INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 23-24, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc, Transitions 2 was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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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
Based on a review of staff records, the facility failed to document a mechanism to collect feedback on completed training, as required by regulation.
The findings include:
Employee records were reviewed on October 2 -3 and 23, 2012. The facility failed to document the submission of feedback forms after the completion of employee training in employee records # 3, 4, 5, 6, 7, 8, 9, 10 and 11. Although there was documentation that the employees reviewed had attended training in both 2011 and 2012, there was no documentation provided that the employees completed feedback evaluations on the completed training documented in the personnel or training records.
The Facility Director was interviewed on October 24, 2012 and confirmed the findings.
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Plan of Correction
Beginning November 22, 2012, Human resource coordinators will ensure that training evaluations for all trainings are placed in each individual's employee file. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project director in one of one personnel record.
The findings include:
Six personnel records were reviewed on October 2-3 and 23, 2012. One personnel record pertained to the project director. The facility's training year is January- December. The facility's 2011 training year was reviewed. One personnel record required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 has been the project director since July 1999. There were no training hours documented for the 2011 training year.
Human resources personnel were interviewed on October 5, 2012 and confirmed the findings
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Plan of Correction
Project Manager will complete 12 hours of training by November 30, 2012. Human Resource Coordinator will ensure completion and monitor that this continues in subsequent years. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on the review of the fire drill logs, the facility failed to document that a fire drill was conducted during sleeping hours at least every 6 months.
The findings include:
The fire drill logs were reviewed on October 24, 2012. Sleeping hours are from 10:30 P.M. to 6:30 A.M. Sunday thru Thursday and from 12:00 A.M. to 6:30 A.M. on Friday and Saturday. Fire drill logs were reviewed for the months of December 2011- September 2012. During this time frame, the facility had no documented a fire drill during sleeping hours.
The Facility Director was interviewed on October 24, 2012 and confirmed the findings.
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Plan of Correction
Maintenance staff will conduct fire drills during sleeping hours at a minimum of every 6 months. Director of Physical Plants will monitor that process. Reports confirming the fire drills will be reviewed at monthly facility risk meetings by the risk committee to ensure compliance. This system will be in effect by 12-31-12. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on the review of client records, the facility failed to ensure that staff physicians signed verbal orders within 24 hours in two of two client records.
The findings include:
Twelve client records were reviewed on October 23-24, 2012. Client records # 1 and 3 contained documentation of verbal medication orders that were not signed by the prescribing physician within 24 hours.
Client # 1 was admitted on October 18, 2012. A verbal order contained in the client record dated October 19, 2012 at 1 P.M. was signed by the prescribing physician, but did not contain the date of the signature. A verbal order dated October 20, 2012 at 1:25 A.M. was signed, but the signature was not legible and it could not be be determined if the signature was that of the prescribing doctor.
Client # 3 was admitted on September 7, 2012. A verbal order contained in the client record dated September 7, 2012 did not have a physician signature.
The Facility Director and Clinical Supervisor were interviewed on October 24, 2012 and confirmed the findings.
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Plan of Correction
All physicians will include signature, date and time in their documentation. This task will be monitored through monthly chart monitors conducted by the medical administrative assistant. This system will be in effect by 12-31-12. |
709.63(a)(6) LICENSURE Aftercare plan
709.63. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on the review of client records, the facility failed to document an aftercare plan in one of one client record.
The findings include:
Twelve client records were reviewed on October 23-24, 2012. Four client records were reviewed as detoxification clients. Two client records were reviewed as discharged clients. One discharged client required documentation of an aftercare plan. The facility did not document an aftercare plan in client record # 8.
Client # 8 was admitted on July 31, 2012 and was successfully discharged on August 5, 2012. There was no documentation of an aftercare plan.
The Clinical Supervisor was interviewed on October 24, 2012 and confirmed the findings.
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Plan of Correction
The detoxification behavioral health specialist will set up appropriate aftercare for the detox client and will document this appointment on the aftercare form. This aftercare form will be given to the receptionist within 2 days of the client's discharge. The receptionist will be responsible for making follow-up calls within 7 days of that client's discharge from the detoxification unit. The receptionist will document all follow-up contact on the aftercare form. This procedure will be monitored weekly by the program director. This system will be in effect by 12-31-12. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on the review of client records, the facility failed to document a discharge summary in one of two client records.
The findings include:
Twelve client records were reviewed on October 23-24, 2012. Four client records were reviewed as detoxification clients. Two client records were reviewed as discharged clients. Two discharged clients required documentation of a discharge summary. The facility did not document a discharge summary in client record # 8.
Client # 8 was admitted on July 31, 2012 and was discharged on August 5, 2012. There was no documentation of a discharge summary.
The Clinical Supervisor was interviewed on October 24, 2012 and confirmed the findings.
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Plan of Correction
Program Director will train current staff on the completion of the discharge summary. Clinical Supervisor will monitor compliance through monthly chart monitors. Compliance will be by 12/31/12. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in one of two client records.
The findings include:
Twelve client records were reviewed on October 23-24, 2012. Four client records were reviewed as detoxification clients. Two client records were reviewed as discharged clients. Per agency policy, follow-up is to be completed within seven days. Two discharged clients required documentation of follow-up information. The facility did not document follow-up information in client record # 8.
Client # 8 was admitted on July 31, 2012 and was discharged on August 5, 2012. There was no documentation of follow-up information.
The Clinical Supervisor was interviewed on October 24, 2012 and confirmed the findings.
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Plan of Correction
Program Director will instruct secretary to complete follow up calls accordingly to our company policy. Compliance will be monitored through monthly chart monitors done by Clinical Supervisor. This process will start December 3, 2012. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in two of four client records.
The findings include:
Twelve client records were reviewed on October 23-24, 2012. Eight client records were reviewed as inpatient clients. Four client records were reviewed as discharged clients. Per agency policy, follow-up is to be completed within seven days. Four discharged clients required documentation of follow-up information. The facility did not document follow-up information in client records # 9 and 12.
Client # 9 was admitted on August 2, 2012 and discharged on August 20, 2012. There was no documentation of follow-up information.
Client # 12 was admitted on April 23, 2012 and discharged on May 21, 2012. There was no documentation of follow-up information.
The Clinical Supervisor was interviewed on October 24, 2012 and confirmed the findings.
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Plan of Correction
Program Director will instruct secretary to complete follow up calls accordingly to our company policy. Compliance will be monitored through monthly chart monitors done by Clinical Supervisor. This system will be in effect by December 3, 2012. |