INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 30-31, 2008 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 and a plan of correction is due on December 1, 2008.
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Plan of Correction
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709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on the review of eleven client records on October 30-31, 2008, the facility failed to inform the client of the right to appeal a decision limiting access to his records to the project director in eleven of eleven client records where required.
Findings:
There was no documentation that the client was informed of this right in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11.
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Plan of Correction
Client Rights form will be updated with a statement concerning 709.30 regarding appeal of limited access to records. This form will be reviewed with all clients upon admission and client signature will be obtained to verify client understanding of this appeal process. COO Jim Vernarsky will update Client Rights form and Pyramid Policy and Procedure according to these regulations by January 31, 2009. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the client record reviews, the facility failed to include evaluations on the psychosocial documents in six of eleven records.
The findings include:
Eleven client records were reviewed on October 30-31, 2008. The facility did not document evaluative statements for all required areas in client records #2, 4, 5, 8, 9 and 10.
There was no evaluation documented for client record # 2 for assets/strengths; support systems;coping mechanisms; negative factors and counselor conclusions/impressions
There was no evaluative documentation for client records # 4, 5, 8, 9 and 10 for composite picture; client problems/needs; assets/strengths; support system; coping mechanisms; negative factors and counselor conclusions/impressions.
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Plan of Correction
All Counselors will be re-trained on completion of Psychosocial evaluation by January 31, 2009 by Von Wade, Clinical Supervisor. The training will be specifically geared toward a comprehensive, evaluative summary of client strengths, support systems, coping mechanisms etc. Von Wade will track compliance through ongoing monthly chart audits. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on the review of client records, the facility failed to document complete progress notes in nine of eleven client records.
The findings included:
Eleven client records were reviewed on October 30-31, 2008. The facility did not document complete data in that the theme or topic of the group was not documented in the group progress notes in client records #2, 3, 5, 6, 7, 8, 9, 10 and 11.
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Plan of Correction
All Counselors will be re-trained on completion of Group Therapy notes by January 31, 2009 by Von Wade, Clinical Supervisor. The training will be specifically geared toward identification and documentation of themes and/or topics in the data section of the note on group process.
Von Wade will track compliance through ongoing monthly chart audits.
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