This report is a result of an on-site licensure renewal inspection conducted on August 27, 2018 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, Inc was found to not 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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Observations
The facility failed to review and update treatment plans at least every sixty days in three out of seven records reviewed. Client #1 was admitted on February 8, 2018 and was still active at the time of inspection. There was a treatment plan update completed on May 23, 2018 with the next being due no later than July 23, 2018, however there was no treatment plan update on file at the time of inspection. Client # 4 was admitted on February 12, 2018 and was discharged on May 4, 2018. There was an initial comprehensive treatment plan completed on February 12, 2018 with the next being due no later than April 12, 2018, however the update was not completed until May 1, 2018. Client #7 was admitted on January 15, 2018 and was discharged on July 16, 2018. There was an initial comprehensive treatment plan on March 6, 2018 with the next being due no later than May 6, 2018, however the update was not completed until May 15, 2018. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the licensing inspection dated September 27, 2017.
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Plan of Correction
Clinical Supervisor retrained all clinical staff on treatment plan update requirements on 9/6/18. Clinical Supervisor and Executive Director reviewed report of all outstanding treatment plan updates and all charts will be compliant as of 9/21/18. Ongoing, clinical supervisor will monitor treatment plan update report weekly and utilize Lead Counselor to ensure compliance. Complete compliance will be by 10/1/2018. |