INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated inspection, client records were reviewed on September 29, 2020 and the physical plant inspection was conducted on October 30, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Pyramid Healthcare, Inc 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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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of seven clients, six out of seven clients did not receive individual counseling twice a week.
Client #8 was admitted on August 12, 2020 and was current at the time of the inspection. Client #8 did not have documentation of individual counseling twice a week. The chart's record of service and progress notes indicated that the client had not received two individual sessions the weeks of August 17-21, August 31-September 4, September 7-September 11, September 14-18 and September 21-25.
Client #9 was admitted on August 27, 2020 and was current at the time of the inspection. Client #9 did not have documentation of individual counseling twice a week. The chart's record of service and progress notes indicated that the client had not received two individual sessions the weeks of August 31-September 4, September 7-September 11, September 14-18 and September 21-25.
Client #10 was admitted on September 4, 2020 and was current at the time of the inspection. Client #10 did not have documentation of individual counseling twice a week. The chart's record of service and progress notes indicated that the client had not received two individual sessions the weeks of September 7-September 11, September 14-18 and September 21-25.
Client #11 was admitted on September 10, 2020 and was current at the time of the inspection. Client #11 did not have documentation of individual counseling twice a week. The chart's record of service and progress notes indicated that the client had not received two individual sessions the weeks of September 7-September 11, September 14-18 and September 21-25.
Client #12 was admitted on December 12, 2019 and was discharged on January 14, 2020. Client #12 did not have documentation of individual counseling twice a week. The chart's record of service and progress notes indicated that the client had not received any individual counseling.
Client #13 was admitted on March 18, 2020 and was discharged on May 21, 2020. Client #13 did not have documentation of individual counseling twice a week. The chart's record of service and progress notes indicated that the client had not received any individual counseling.
These findings were reviewed with facility staff during the licensing process.
This was a repeat citation from the licensing inspections completed on 9/5/19 and 7/31/18.
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Plan of Correction
As of 11/13/2020, we modified our documentation for PHP individual sessions in our EMR system to be on the same form as our standard individual sessions making them easier to track on schedules and access by both staff and auditors.
Beginning 11/20/2020, the PHP group facilitator and Lead Clinician will take on the responsibility of ensuring that clients are seen two times per week for individual sessions. This will be accomplished by clients being assigned to complete sessions with the group facilitator or Lead Clinician only.
To ensure completion of individual sessions, beginning 11/20/2020, Lead Clinician will utilize a tracking sheet to monitor scheduled and completed individual sessions. This sheet will be monitored weekly during staff meeting and will be turned into the Executive Director for review at the end of each week.
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of seven client records, the facility failed to document medical histories in three out of seven clients reviewed.
Client #1 was admitted on April 23, 2020 and was current at the time of the inspection. Client #1 had no documented medical history.
Client #5 was admitted on April 8, 2020 and was discharged on July 20, 2020. Client #5 had no documented medical history.
Client #7 was admitted on January 31, 2020 and was discharged on May 25, 2020. Client #7 had no documented medical history.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identified problem is that charts were missing pre-screens completed before or at time of assessment.
As of 11/24/2020, Lead Assessor has created and will be implementing a check list for assessors and administrative assistants to use in order to audit charts for all documents required at the time of admission / assessment / intake. This check list will be turned in to Lead Assessor for review on each assessment / intake that occurs beginning 11/24/2020.
Lead assessor will then audit 50% of scheduled assessments / intakes at the end of each week to ensure all documents are accounted for during the assessment / intake process.
All staff will receive a training on 11/24/2020 on how to properly find, review, and check Pre-screens for completion as well as how to complete a pre-screen prior to scheduling an assessment.
Executive Director will contact Admissions department on 11/20/2020 to ensure pre-screens are completed and there is a system to ensure these forms are completed prior to assessments being scheduled in additional this site completing weekly audits.
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of seven client records, the facility failed to document drug and alcohol histories in three out of seven clients reviewed.
Client #1 was admitted on April 23, 2020 and was current at the time of the inspection. Client #1 had no documented drug and alcohol history.
Client #5 was admitted on April 8, 2020 and was discharged on July 20, 2020. Client #5 had no documented drug and alcohol history.
Client #7 was admitted on January 31, 2020 and was discharged on May 25, 2020. Client #7 had no documented drug and alcohol history.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identified problem is that charts were missing pre-screens completed before or at time of assessment.
As of 11/24/2020, Lead Assessor has created and will be implementing a check list for assessors and administrative assistants to use in order to audit charts for all documents required at the time of admission / assessment / intake. This check list will be turned in to Lead Assessor for review on each assessment / intake that occurs beginning 11/24/2020.
Lead assessor will then audit 50% of scheduled assessments / intakes at the end of each week to ensure all documents are accounted for during the assessment / intake process.
All staff will receive a training on 11/24/2020 on how to properly find, review, and check Pre-screens for completion as well as how to complete a pre-screen prior to scheduling an assessment.
Executive Director will contact Admissions department on 11/20/2020 to ensure pre-screens are completed and there is a system to ensure these forms are completed prior to assessments being scheduled in additional this site completing weekly audits.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of seven client records, the facility failed to document personal histories in three out of seven clients reviewed.
Client #1 was admitted on April 23, 2020 and was current at the time of the inspection. Client #1 had no documented personal history.
Client #5 was admitted on April 8, 2020 and was discharged on July 20, 2020. Client #5 had no documented personal history.
Client #7 was admitted on January 31, 2020 and was discharged on May 25, 2020. Client #7 had no documented personal history.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identified problem is that charts were missing pre-screens completed before or at time of assessment.
As of 11/24/2020, Lead Assessor has created and will be implementing a check list for assessors and administrative assistants to use in order to audit charts for all documents required at the time of admission / assessment / intake. This check list will be turned in to Lead Assessor for review on each assessment / intake that occurs beginning 11/24/2020.
Lead assessor will then audit 50% of scheduled assessments / intakes at the end of each week to ensure all documents are accounted for during the assessment / intake process.
All staff will receive a training on 11/24/2020 on how to properly find, review, and check Pre-screens for completion as well as how to complete a pre-screen prior to scheduling an assessment.
Executive Director will contact Admissions department on 11/20/2020 to ensure pre-screens are completed and there is a system to ensure these forms are completed prior to assessments being scheduled in additional this site completing weekly audits.
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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
Based on a review of seven client records, the facility failed to document a psychosocial evaluation in three out of seven clients reviewed.
Client #1 was admitted on April 23, 2020 and was current at the time of the inspection. Client #1 had no documented psychosocial evaluation.
Client #5 was admitted on April 8, 2020 and was discharged on July 20, 2020. Client #5 had no documented psychosocial evaluation.
Client #7 was admitted on January 31, 2020 and was discharged on May 25, 2020. Client #7 had no documented psychosocial evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/1/2020 the Psychosocial Evaluations form became a required document in Pyramid Healthcare's Level of Care Assessments.
All Assessors/ Counselors were trained prior to 10/1/2020 and are required to complete the Psychosocial Evaluation form in order to successfully lock and sign the assessment in our electronic charting system.
All assessments are routed to the Clinical Lead or Executive Director for review of completion in which the Psychosocial Evaluation will be checked for completion in its entirety.
Medical Director is also responsible for reading and reviewing all Psychosocial Evaluations once provided with a Justification of Treatment and will sign off for review of completion.
Executive Director will utilize monthly chart audits completed by Pyramid Healthcare's Quality Management team to ensure Psychosocial Evaluations are being completed and of good clinical quality. Executive Director will then use this audit tool to train any additional staff member struggling to complete Psychosocial Evaluations.
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