INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 2, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Thirteen personnel records were reviewed on November 8, 2017, for the licensing renewal inspection that was conducted on November 2, 2017. The facility failed to provide documentation for the completion of HIV/AIDS and TB/STD training within the required time period for employee records # 9, 12, and 13.
Employee # 9 was hired as a counselor on 8/8/16. The employee was required to complete HIV/AIDS and TB/STD training by no later than 8/8/17. Documentation in the employee's record indicated that HIV/AIDS training was completed on 9/28/17 and TB/STD training was completed on 8/31/17.
Employee # 12 was hired as a counselor on 6/20/16. The employee was required to complete TB/STD training by no later than 6/20/17. Provision of this training was not documented in the employee's record.
Employee # 13 was hired as a counselor on 7/6/16. The employee was required to complete TB/STD training by no later than 7/6/17. Documentation in the employee's record indicated that this training was completed on 10/26/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff persons and volunteers shall receive a training minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics using a Department approved training curriculum. Counselors and Counselor Assistants shall complete the training within their first year of employment. All other staff shall complete the training within the first 2 years of employment. The facility director will ensure needed documentation of completed training is presented to Human Resources to be retained in the personnel records. The human resource coordinator will monitor employee files quarterly for 100% compliance with training requirements. Scheduling of department available required training will be completed by January 1, 2018 and monitoring of required hours will be ongoing on a quarterly basis. |
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.
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Observations
Nine client records were reviewed on November 2, 2017. The facility failed to obtain an informed and voluntary consent when consent was applicable for client record # 9.
Client # 9 received an evaluation and referral for treatment services on 9/19/17. Documentation in the client's record indicated that the facility forwarded letters to two magistrate district justices on 9/19/17, reporting the facility completed a drug and alcohol assessment for the client. Consents to release information to the district justices were not documented in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff members involved with informed and voluntary consent will receive additional training on completion and revision of consents. This training will conclude by December 31, 2017. This training will be conducted by the Clinical Supervisor. Ongoing monitoring of compliance with consent requirements will be conducted monthly by the Clinical Supervisor and the Assessment Supervisor. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Four client records were reviewed for the outpatient activity on November 2, 2017. The facility failed to document a treatment plan update at least every 60 days for client records # 6 and 7.
Client # 6 was admitted into treatment on 6/30/15 and was still active in treatment. The first treatment plan update reviewed for this client's record was completed on 11/8/16. A subsequent treatment plan update was then completed on 4/12/17. A following treatment plan update was completed on 6/27/17.
Client # 7 was transferred into outpatient treatment on 2/21/17 and was discharged on 7/25/17. A comprehensive treatment plan was completed for the client on 1/11/17, while the client was in partial hospitalization treatment at the facility. The first treatment plan update documented in the client's record was completed on 5/30/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical staff will be trained by the Clinical Supervisor by 12/31/2017 on the documentation of the treatment and rehabilitation plans that are to be reviewed and updated at least every 60 days. Ongoing monitoring of compliance with treatment plan update requirements will be conducted monthly by the Clinical Supervisor beginning with the January 2018 chart monitor. |
709.42(b)(2) LICENSURE Preliminary Treatment Plan
709.42. Project management.
(b) The intake project or treatment service providers shall have a written procedure for the performance of the following functions:
(2) Preparation of a preliminary treatment plan utilizing appropriate available service resources and listing the services to be provided. This plan shall be developed in cooperation with and agreed to by the intake project or treatment service provider and the client. The service plan shall also include referral to services not specifically for drug and alcohol clients; for example, legal services and dental services for which the client may be eligible.
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Observations
One client record was reviewed for the intake, evaluation, and referral activity on November 2, 2017. The facility failed to document a preliminary treatment plan for client record # 9.
Client # 9 received an evaluation and referral for treatment services on 9/19/17.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Intake, evaluation, and referral staff will be trained by the Assessment Supervisor by December 31, 2017 on the preparation of the preliminary treatment plan developed by the intake provider or treatment service provider and the client, which utilizes the appropriate available service resources, lists the services to be provided, and includes referrals to services not specific to drug and alcohol clients. Ongoing monitoring of compliance with preliminary treatment plan requirements will be conducted monthly by the Assessment Supervisor and the Clinical Supervisor beginning with the January 2018 chart monitor. |
709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
One client record was reviewed for the intake, evaluation, and referral activity on November 2, 2017. The facility failed to document a consent to treatment for client record # 9.
Client # 9 received an evaluation and referral for treatment services on 9/19/17.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Intake, evaluation, and referral staff will be trained by the Assessment Supervisor by December 31, 2017 on the preparation of the consent to treatment form which will be reviewed and completed by the intake provider or treatment service provider and the client at the time of intake, evaluation and referral. Ongoing monitoring of compliance of the consent to treatment requirements will be conducted monthly by the Assessment Supervisor and the Clinical Supervisor beginning with the January 2018 chart monitor |
709.44(a)(3) LICENSURE Psychosocial evaluation
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(3) Psychosocial evaluation.
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Observations
One client record was reviewed for the intake, evaluation, and referral activity on November 2, 2017. The facility failed to document a psychosocial evaluation for client record # 9. The facility also failed to document information pertaining to the referral contact for client record # 9.
Client # 9 received an evaluation and referral for treatment services on 9/19/17.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Intake, evaluation, and referral staff will be trained by the Assessment Supervisor by December 31, 2017 on the documentation of the psychosocial evaluation and the referral contact information which will be completed by the intake provider or treatment service provider at the time of intake, evaluation and referral. Ongoing monitoring of the psychosocial evaluation and referral contact information will be conducted monthly by the Assessment Supervisor and the Clinical Supervisor beginning with the January 2018 chart monitor |
709.44(b)(4) LICENSURE Follow-up Information
709.44. Client records.
(b) If applicable, the project shall also include the following items in the client record:
(4) Follow-up information.
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Observations
One client record was reviewed for the intake, evaluation, and referral activity on November 2, 2017. The facility failed to document follow-up information for client record # 9.
Client # 9 received an evaluation and referral for treatment services on 9/19/17.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Intake, evaluation, and referral staff will be trained by the Assessment Supervisor by December 31, 2017 on the documentation of the follow-up information which will be completed by the intake provider or treatment service provider at the time of intake, evaluation and referral. Ongoing monitoring of the follow-up information documentation will be conducted monthly by the Assessment Supervisor and the Clinical Supervisor beginning with the January 2018 chart monitor. |