INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 6 and 7, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on April 9, 2007.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Employee # 55 had documentation in his personnel file indicating he was being supervised and he was working with clients. A degree was noted in his file, but it failed to include the specific major. It could not be determined if the employee met qualifications for counselor.
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Plan of Correction
In preparation for future licensing visits once the visit schedule has been published the Human Resource Coordinator will have available all necessary personnel material available for review during at the time scheduled. The Human Resource Coordinator will monitor the timeline in preparation for the licensing visit. |
704.8(a)(1) - (5) & (b) LICENSURE Qualification Level
704.8. Qualifications for the position of counselor assistant.
(1) A Master's Degree in a human service area.
(2) A Bachelor's Degree in a human service area.
(3) Licensure in this Commonwealth as a registered nurse.
(4) An Associate's Degree in a human service area.
(5) A high school diploma or General Education Development (GED) equivalent.
(b) A counselor assistant shall also complete the training requirements in 704.11 (relating to staff development program).
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Observations
Employee # 54 had a degree in his personnel file, but the degree was not related to human services. Employee's # 56 and #57 did not have degrees or transcripts in their files. The inspector was unable to determine what level of counselor assistant the employees are. All required information should be in the personnel files at the time of the licensing visit.
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Plan of Correction
The Human Resource Coordinator will insure that staff performing a clinical role irregardless of their status as an employee or student intern will be listed as either a counselor or a counselor assistant with all credentials documented. This will be monitored by both the Program Director and Human Resource Coordinator at the time of hire/commencement of duties. As of this writing the facility has no student interns and all other staff performing clinical duties are currently listed as counselor or counselor assistant. The facility is currently in compliance with this requirement.
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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Employee # 55 did not have a a counselor assistant semiannual performance evaluation.
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Plan of Correction
The performance evaluation will be completed by Alicia Fairman, Director of Outpatient Services, the appropriate supervisor within the next 90 days from today's date. We will be in compliance by 6/29/2007. Jill Wharrey, Human Resource Coordinator will montior when evalutations are due for this employee in the future and will communicate that information to the appropriate supervisor. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Licensing staff were unable to determine if credentials for employee's # 54 and 55 meet the requirements for their respective positions because the credentials did not include transcripts. Employee's # 56 and 57 did not have documentation in their personnel files of any degrees. All clinical personnel files must include documentation of degrees and or transcripts if specific major or field of study cannot be found on the degree.
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Plan of Correction
Jill Wharrey, Human Resource Coordinator, is in the process of obtaining employee #55's transcripts. These will be placed in her personnel file within the next 90 days. We will be in compliance by June 29, 2007.
Transcripts on enployee #54 were faxed to Harrisburg by Jill Wharrey. This employee was approved for his position by Mr. Ron Young. Jill Wharrey, Human Resource Cordinaator, will place degrees and transcripts for employee's 56 and 57 in their personnel files by June 29, 2007. We will be in complaince by June 29, 2007. This will be monitored by Jill Wharrey at the time of hire and at the time of 90 day performance evaluation. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Feedback forms were not consistently documented for all staff reviewed.
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Plan of Correction
Jill Wharrey, Human Resource Coordinator will instruct all employees to complete traning evaluations upon completion of each training that they attend. We will be in compliance by 3/30/2007. This will be monitored by Jill Wharrey on an annual basis. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
The credentials for one employee, ( # 54), were not available for review therefore his time could not be included in the ratios, causing the facility to exceed the ratio requirement.
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Plan of Correction
Transcripts on enployee #54 were faxed to Harrisburg by Jill Wharrey. This employee was approved for his position by Mr. Ron Young. As a result of this we are within the appropriate staff to client ratios. Compliance will be monitored by Bill Dorn, Program Director on a monthly basis. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
One out of two client records reviewed had a psychosocial evaluation completed beyond the administrative procedure timeline of 3 sessions. The psychosocial evaluation was not completed until after the fourth session.
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Plan of Correction
The timeline for completion of a psychosocial evaluation is 5 sessions, not three. This was maintained in all of the facility P & P manuals, but this policy was missing from the corporate manual, so the reviewer counted the brief psychosocial policy time frames instead. All outpatient facility psychosocial evaluations will be completed in 5 sessions. The policy has been placed in the corporate P & P manual by Jason Hendricks. We are in compliance. Compliance will be monitored by Bill Dorn, Program Director, on a monthly basis through chart monitors. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The counseling services were not provided according to the individual treatment plan.
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Plan of Correction
Program Director, Bill Dorn, will train staff to include treatment plan progress information in weekly group notes and individual sessions notes. Compliance will be by June 29, 2007. Compliance will be monitored through monthly chart monitors. |
709.83(a)(9) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(9) Progress notes.
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Observations
Progress notes did not consistently contain data and topic and/or did not consistently reflect the goals and objectives listed on the comprehensive treatment plan.
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Plan of Correction
Bill Dorn, Program Director, will train staff to describe data that consistently reflects the goals and objectives of the comprehensive treatment plan in the weekly group notes and individual session notes. This will require a form change which will be in place by June 29, 2007. Compliance will be by June 29, 2007. Compliance will be monitored by Bill Dorn through monthly chart monitors. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
The manual at the main administrative office and the manuals at the various locations reviewed were not consistent with regard to policies and procedures. The general organization of the manual made the review difficult and increased the potential for misunderstanding the intent of various procedures.
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Plan of Correction
All policies and procedures are submitted to the policy review committee by Jason Hendricks, JCAHO Staff Coordinator, for approval and distribution. All new or revised policies are distributed to all program directors and reviewed at the monthly Performance Improvement Committee meetings. The program director is responsible for training all staff on the new or revised policy. The Performance Improvement Committee will be responsible for the oversight of the implementation of all policies. The Performance Improvement will immediately begin auditing program policy and procedure manuals to ensure consistency between all manuals. Compliance is current |
709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
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Observations
In employee records # 54 and 55 educational degrees were documented, but transcripts were not provided in the personnel records. No degrees or transcripts were provided in employee records # 56 and 57.
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Plan of Correction
Jill Wharrey, Human Resource Coordinator, is in the process of obtaining employee #55's transcripts. These will be placed in her personnel file within the next 90 days. We will be in compliance by June 29, 2007. Transcripts on employee #54 were faxed to Harrisburg by Jill Wharrey. This employee was approved for his position by Mr. Ron Young. Jill Wharrey, Human Resource Coordinator, will place degrees and transcripts for employee's 56 and 57 in their personnel files by June 29, 2007. We will be in compliance by June 29, 2007. This will be monitored by Jill Wharrey at the time of hire and at the time of 90 day performance evaluation. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
The HIPAA Notice of Privacy Practices form has errors in sections III L.and O.; IV. F; V. A and C.; VI E and H and VII. In addition, in all outpatient client records reviewed, no individual therapy sessions were documented beyond the initial intake session. The confidentiality of each client's individual treatment plans cannot be maintained when those plans are developed during group treatment sessions. The development of individual treatment plans and the treatment plan updates must be addressed in individual sessions. Failure to do so breaches a client's right to confidentiality.
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Plan of Correction
The HIPAA Notice of Privacy Practices Policy was revised on April 2nd, 2007 by Pam Ashburn, Director of Medical Records. All observations noted in section 0277 of the Southside deficiency listing have been corrected. The revised policy has been approved by the policy review committee and will be distributed to all programs immediately. The revised policy will be reviewed at the monthly Performance Improvement Committee meeting. The Program Director will be responsible for training all staff on the revised policy. The Performance Improvement Committee will be responsible for the oversight of the implementation of the new policy. The revised HIPAA Notice of Privacy Practices Policy is available for review upon request.
Pyramid Healthcare maintains that clients can and do receive individualized treatment in a group setting. Treatment plans are not formulated in a group setting. Bill Dorn, Program Director, will train staff to document all client contact, including individual sessions, in a progress note. Compliance will be by June 29, 2007. Compliance will be monitored through monthly chart monitors.
Program Director, Bill Dorn, will train staff to include treatment plan progress information in weekly group notes and individual session notes. Compliance will be by June 29, 2007. Compliance will be monitored through monthly chart monitors.
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709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
A release for "ACT 126" was completed for an insurance carrier that exceeded the limits imposed at 4 Pa. Code 255.5(b) in listing the comprehensive treatment plan in client record # 1. In client record #2, the "other" category was checked off and no designated information was documented. In client record # 4 a release to DUI court exceeded the limits imposed at 4 Pa. Code Subsection 255.5(b) by listing the psychosocial evaluation, the MARS assessment, the history and the physical. All specific information disclosed on releases must fall within regulations and should not exceed what is allowed by law.
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Plan of Correction
Program Director, Bill Dorn, will train clinical and assessment staff on the proper use of the Act 126 release. Compliance will be by June 29, 2007. Compliance will be monitored through monthly chart monitors. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Per the administrative policy a physical examination should be conducted on all clients. No physical examinations were completed.
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Plan of Correction
Section IV of the Pyramid Healthcare History and Physical Policy states that:
A History and Physical is not required for admission to the outpatient program.
- A risk assessment is performed upon initial intake.
- If the risk assessment indicates a need, the client is referred to their PCP or another physician for a complete history and physical examination.
In response to the deficiency listing the above items were removed from the History and Physical policy ( by Jason Hendricks) and a History and Physical-Outpatient Policy was created on March 5th, 2007. The policy was distributed to all programs by the JCAHO Staff Coordinator on March 7th, 2007. The Program Director will be responsible for training all staff on the revised policy. The Performance Improvement Committee will be responsible for the oversight of the implementation of the new policy. Both policies are available for review upon request. Training will be completed by June 29, 2007.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations were documented and complete and contained all required areas. However, the administrative procedure states that they must be completed within 3 sessions, and they were not completed within the stipulated time frame.
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Plan of Correction
The timeline for completion of a psychosocial evaluation is 5 sessions, not three. This was maintained in all of the facility P & P manuals, but this policy was missing from the corporate manual, so the reviewer counted the brief psychosocial policy time frames instead. All outpatient facility psychosocial evaluations will be completed in 5 sessions. The policy has been placed in the corporate P & P manual by Jason Hendricks. We are in compliance. Compliance will be monitored by Bill Dorn, Program Director, on a monthly basis through chart monitors. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
All clients files contained individualized treatment plans. The practice of formulating treatment plans during group sessions with no individual sessions documented beyond the initial assessment does not meet the Department of Health's interpretation of individualized treatment.
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Plan of Correction
Pyramid Healthcare maintains that clients can and do receive individualized treatment in a group setting. Treatment plans are not formulated in a group setting. Bill Dorn, Program Director, will train staff to document all client contact, including individual sessions, in a progress note. Compliance will be by June 29, 2007. Compliance will be monitored through monthly chart monitors. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Long term goals were consistently documented in all client records reviewed. Short term goals were not consistently documented in client records # 2, 3 and 4. In these client records the short term goal section contained statements that appear to be objectives rather than short term goals that are realistic and measurable.
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Plan of Correction
Program Director, Bill Dorn will review and amend the current comprehensive treatment plan form to include a clearer listing of short term goals with accompanying objectives and interventions that are realistic and measurable. This will be in compliance by June 29, 2007. This will be monitored on a monthly basis through chart monitors. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Counseling services were not provided according to the individual treatment and rehabilitation plan.
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Plan of Correction
Pyramid Healthcare maintains that clients can and do receive individualized treatment in a group setting. Treatment plans are not formulated in a group setting. Bill Dorn, Program Director, will train staff to document all client contact, including individual sessions, in a progress note. Compliance will be by June 29, 2007. Compliance will be monitored through monthly chart monitors. |