INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 16, 2018 at the Pyramid Healthcare Bartonsville facility by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Pyramid Healthcare Bartonsville facility 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:
|
Plan of Correction
|
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.
|
Observations
The facility failed to document that employee #5 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training within a year of hire.
Employee # 5 was hired on May 15, 2017 and was due to have the communicable disease trainings no later than May 15, 2018.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee #5 completed HIV/ AIDS training on 7/25/2018 and training certificate has been submitted to HR.
Employee #5 Completed TB/ STD training 2/23/2017 in his previous role and it was accepted into his new role. Certificate was submitted to HR.
|
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.
|
Observations
The Staffing Requirements Facility Summary Report was completed and reviewed on August 16, 2018. Employee #6 was hired as a counselor on May 6, 2015 and was still acting in that position. Employee #6 was reported to have 25 hours per week devoted to their 26 clients on their caseload. The FTE counselor's caseload calculation is as follows: 25/35 = .7142(FTE); 26/.7142 = 37, which equals to a client/counselor ratio of 37:1.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee # 6 Caseloads was reduced to the appropriate ratio of 35:1 as of August 13, 2018 to reflect the appropriate amount of clients she is able to have on her caseload for working 40 hours per week. This was corrected as it was reviewed in the audit exit interview. |
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.
|
Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 in client record # 1, 3, and 4.
Client #1 was admitted on May 14, 2018 and was still an active client at the time of the inspection. A consent to release form was signed and dated on May 1, 2018 to a funding source releasing prognosis, psychiatric assessment, psychological evaluation, medication administration record, history and physical, and treatment progress update
Client # 3 was admitted on May 18, 2018 and was still an active client at the time of the inspection. A letter dated July 16, 2018 releasing client information to an unknown source was in the client records. A letter dated August 1, 2018 containing discharge information to an unknown source was in the client records.
Client # 4 was admitted on April 9, 2018 and was still an active client at the time of the inspection. A letter dated July 23, 2018 releasing client information to an unknown source was in the client records. A letter dated May 24, 2018 releasing client information to an unknown source was in the client records.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Releases of information and 255.5 guidelines will be reviewed with counselors during staff meeting on 10/1/18 by the Program Director and Clinical Supervisor.
Examples will be provided to show counselors how 255.5 releases should be completed and they will be given a process guide to help with future consents.
Program Director will conduct monthly chart audits in which releases will be reviewed during this process. Any releases found not to be in compliance, will need to be replaced by counselor and client.
|
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.
|
Observations
The facility failed to document in 6 of 7 client records, counseling services being provided according to the comprehensive treatment plan.
Client # 1 was admitted on May 14, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan dated May 14, 2018 indicated 1 individual session bi-weekly and 3 group sessions weekly. The chart's record of service and progress notes indicated that the client did not receive individual treatment the week of July 1 through July 7, 2018 and only received 2 group sessions the week of June 3-9 and June 17-23, 2018.
Client # 2 was admitted on April 18, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan dated April 18, 2018 indicated 1 individual session bi-weekly and 3 group sessions weekly. The chart's record of service and progress notes indicated that the client did not receive individual treatment the week of April 22 through April 28, 2018 and the week of June 24-30, 2018. The chart's record of service and progress notes indicated that the client did not receive group sessions the week of June 17-23, 2018 and only received 1 group session the weeks of June 24-30, July 1-7, July 8-14, July 15-21, July 22-28, July 29-August 4, and August 5-11.
Client # 3 was admitted on May 18, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan dated May 18, 2018 indicated individual sessions weekly and group sessions three times weekly. The chart's record of service and progress notes indicated that the client did not receive individual treatment the week of May 20-26, May 27-June 2, June 10-16, July 1-7, July 8-14, July 22-28.
Client # 4 was admitted on April 9, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan dated April 20, 2018 indicated individual sessions bi-weekly and group sessions three times weekly. The chart's record of service and progress notes indicated that the client did not receive individual treatment from April 15 through May 25, 2018, July 29- August 4.
Client # 5 was admitted on June 12, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan dated June 26, 2018 indicated individual sessions bi-weekly and group sessions weekly. The chart's record of service and progress notes indicated that the client did not receive individual treatment from June 12 until July 11, 2018. The chart's record of service and progress notes indicated that the client did not receive group sessions June 12 through July 3, 2018.
Client # 6 was admitted on December 19, 2017 and was discharged on March 6, 2018. The comprehensive treatment plan dated December 21, 2017 indicated individual sessions bi-weekly and group sessions weekly. The chart's record of service and progress notes indicated that the client did not receive individual treatment from December 31-January 6 and February 11-17.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Treatment plans will be reviewed with counselors during Group Supervision on 9/20/2018 by Clinical Supervisor.
Clinical Supervisor will review the process sheet that was created to break down the frequency of group and individual sessions.
Program Director will also complete monthly chart audits and treatment plans will be reviewed during this process and review the Type and Frequency of Services and compare to the scheduled and completed sessions.
Clinical Supervisor will also complete case reviews with counselors during monthly group supervision to ensure that clients are receiving the correct individual sessions needed for the program they are assigned to.
|
709.93(a)(3) LICENSURE Client records
709.93. 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:
(3) Record of services provided.
|
Observations
The facility failed to document a record of service for 2 out of 7 client records viewed.
Client # 2 was admitted on April 18, 2018 and was still an active client at the time of the inspection. Client record had a progress note indicating a group session on May 3 but session was not recorded on the record of service.
Client # 4 was admitted on April 9, 2018 and was still an active client at the time of the inspection. Client record had a progress note indicating a group sessions on April 17, August 7, 9, and 14 but sessions were not recorded on the record of service.
Client # 7 was admitted on November 22, 2017 and was discharged on January 26, 2018. Client record had a progress note indicating an individual sessions on November 29 but session was not recorded on the record of service.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Program Director will review in Staff Meeting on 10/1/2018 with all staff the need to complete notes associated with the history of service.
Program Director and Clinical Supervisor will continue to monitor this with monthly chart audits that check both the corresponding service history and notes.
Program Director will continue to also check weekly of the reconciliation using the failed activities report and the service history report. |