INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 20-21, 2007 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 January 25, 2008.
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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
Based on a review of staff training records during the on site inspection of December 20 and 21 , 2007 the facility failed document the required communicable disease training for all staff. Employee # 4 did not receive the training within the required timeframe.
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Plan of Correction
Effective immediately, all facility staff will receive HIV/AIDS training and STD/TB training within required timeframe. Employee #4 has had HIV/AIDS training on 6/26/06. She is enrolled in STD/TB training on 2/12/08. The HR Coordinator, Jill Wharrey will track and monitor completed trainings and work with Program Director, Marnie Hall to ensure compliance with all training requirements. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection during the on site inspection of December 20 and 21, 2007 the facility failed to comply with the regulation because of the absence of slip resistant surfaces in the shower stalls.
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Plan of Correction
Effective immediately, slip resistant surfaces will be present in all shower stalls. Facility Maintenance Director,Peter Roy will ensure compliance through the purchase and installation. Program Director, Marnie Hall, will provide oversight of installation. Installation has been completed. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant review during the on site inspection of December 20 and 21, 2007 the facility did not comply with this regulation as evidenced by improper storage of cooking utensils in an open container.
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Plan of Correction
Effective immediately, all cooking utensils will be stored in a clean, closed container. Lead Cook, Barry McMillan will ensure compliance. Food Services Coordinator, Angela Case will monitor through monthly inspection of the kitchen. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records during the on site inspection held December 20 and 21, 2007 the facility failed to comply with this regulation as evidenced by documentation in the one active (#1) and one closed client(#2) record reviewed (2 of 2 in the sample). Individual treatment plans were not developed at the time the clients moved from the residential program to the partial hospitalization program. Each level of care must be viewed as separate from another. When clients move from one level of care to another a new treatment plan must be developed.
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Plan of Correction
Effective immediately, all clients moved from residential program to the partial hospitalization program will participate in the development of a new treatment plan for the new level of care, partial hospitalization. The Clinical Supervisor, Von Wade will train all counselors on this expectation and will monitor partial hospitalization charts to ensure compliance. |
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 client records during the on site inspection held December 20 and 21, 2007 the facility failed to comply with this regulation as evidenced by documentation in the one active file reviewed (#1). During one of two weeks in treatment at the partial hospitalization level of care the client did not receive the required two individual counseling sessions per week.
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Plan of Correction
Effective immediately, all clients will receive counseling on a regular and scheduled basis and within required timeframe. All partial hospitalization clients will receive two individual sessions weekly. Clinical Supervisor, Von Wade will ensure compliance through training all clinical staff on this requirement and through review of documentation during chart monitoring. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records during the on site inspection held December 20 and 21, 2007 the facility failed to comply with this regulation as evidenced by use of consent to release information forms permitting Ridgeview staff to release to and receive information from the home school district of each client. The forms utilized failed to meet the requirements for an appropriately executed, informed consent for the following reasons: the parents co- signed each form despite the stipulations in Commonwealth law at Act 63 of 1972 (71 P.S. Subsection 1690.112) and the directive in the federal regulation at 42 CFR Part 2, Subpart B, Subsection 2.14(b) relating to the consent of a minor; the language in the consent to release information form does not clearly identify the specific information to be released; and there is no expiration date on the consent to release information form. The client record sample consisted of six client records.
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Plan of Correction
Following the approval of Forms Review Committee, by February 1, 2008 a revised consent to release and receive information from the home school district will be utilized. This newly revised form will not solicit a parent co-signature and will clearly identify the information to be released. In addition, an expiration date for the release will be added. Medical Records Coordinator has revised and submitted form. Program Director, Marnie Hall will ensure compliance along with Medical Records Coordinator, Cynthia Gazzo through regular Chart Audits. |
709.28(c)(2) 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. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records during the on site inspection held December 20 and 21, 2007 the facility failed to comply with this regulation as evidenced by documentation that specific information released to government agencies and funding entities exceeded limits imposed at 4 Pa. Code subsection 255.5(b) in three of six client records in the sample ( # 1, 3 and 5).
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Plan of Correction
On or before February 15, 2008, all Counselors, Counselor Assistants, Teachers and UR Coordinator will receive training on Confidentiality Code PA 255.5 as conducted by Clinical Supervisor, Von Wade. Clinical Supervisor, Von Wade will track compliance with this code through chart monitoring and clinical supervision on an ongoing basis. Marnie Hall, Program Director will assist in the process. |
709.28(c)(6) 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. The consent shall be in writing and include, but not be limited to:
(6) Expiration date of the consent.
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Observations
Based on a review of client records during the onsite inspection held December 20 and 21, 2007 the facility failed to clearly identify an expiration date for the consent forms in client records # 1, 4 and 5. The client record sample consisted of six client records.
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Plan of Correction
Following the approval of Forms Review Committee by February 1, 2008, a revised consent clearly indicating an expiration date will be utilized. Medical Records Coordinator, Cindy Gazzo has revised and submitted the form. Program Director, Marnie Hall will ensure compliance, along with Medical Records Coordinator, Cynthia Gazzo, through regular chart audits. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records during the onsite inspection held December 20 and 21, 2007 the facility failed to consistently document that client's were offered a copy of each consent. The section of the consent to release information form which documented that the client accepted or refused a copy of the consent was not consistently completed in client records # 1, 4 and 5. The client record sample consisted of six client records.
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Plan of Correction
Effective immediately, Program Director Marnie Hall will train all intake staff, Counselors and Counselor Assistants on the proper completion of consent forms, highlighting the importance of offering copies to clients as evidenced by circling accepted/refected and securing required signatures. Compliance will be monitored through regular and ongoing chart audits conducted by Marnie Hall, Program Director, Von Wade,Clinical Supervisor and Cynthia Gazzo, Medical Records Coordinator. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records during the onsite inspection of December 20 and 21, 2007, the facility failed to meet this requirement because two of the client records reviewed did not document that work done by the clients was included as part of their treatment regimen. This was noted in client records # 3 and 4. The client record sample consisted of six client records.
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Plan of Correction
By February 15, 2008, all Counselor and Counselor Assistants will be trained by Clinical Supervisor, Von Wade on policy that work assignments can only be assigned to clients when they are part of the individualized treatment plan and the goals and objectives of that work assignment are included in the treatment plan. Marnie Hall, Program Director, and Von Wade, Clinical Supervisor, will ensure compliance through monitoring the charts of all clients who have work assignments on a regular basis. |