INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 10, 2012, 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of staff records, the facility failed to document a mechanism to collect feedback on completed training, as required by regulation.
The findings include:
Employee records were reviewed on October 2 -3 and 10, 2012. The facility failed to document the submission of feedback forms after the completion of employee training in employee records # 4, 5, 6, 7, 8 and 13. Although there was documentation that the employees reviewed had attended training in both 2011 and 2012, there was no documentation provided that the employees completed feedback evaluations on the completed trainings documented in the personnel or training records.
The Facility Director was interviewed on October 10, 2012 and confirmed the findings.
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Plan of Correction
Beginning October 22, 2012, Human resource coordinators will ensure that training evaluations for all trainings are placed in each individual's employee file. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project director in one of one personnel record.
The findings include:
Fifteen personnel records were reviewed on October 4-5, 2012. One personnel record pertained to the project director. The facility's training year is January- December. The facility's 2011 training year was reviewed. One personnel record required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 has been the project director since July, 1999. There were no training hours documented for the 2011 training year.
Human resources personnel were interviewed on October 5, 2012 and confirmed the findings.
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Plan of Correction
Project Manager will complete 12 hours of training by November 30, 2012. Human Resource Coordinator will ensure completion and monitor compliance in subsequent years. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs, the facility failed to conduct unannounced fire drills at least once per month.
The findings include:
Fire drill logs for the months of November 2011 - October 2012 were reviewed on October 10, 2012. Unannounced fire drills are required at least once per month per regulation. The facility did not document unannounced fire drills for the months of July, August, September and October 2012.
The fire drills conducted on July 31, August 30 and October 2, 2012 were announced fire drills. There was no documentation that a fire drill had been conducted in September 2012.
The Facility Director was interviewed on October 10, 2012 and confirmed the findings.
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Plan of Correction
Program Director will insure monthly unannounced fire drills will begin in November, 2012. The Maintenance Supervisor will monitor the log for compliance. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill logs, the facility failed to document that fire drills were conducted at different times of the day and on different staffing shifts.
The findings include:
Fire drill logs for the months of November 2011 - October 2012 were reviewed on October 10, 2012. All fire drills documented were conducted on first shift and between 1:30 and 1:40 P.M.
The Facility Director was interviewed on October 10, 2012 and confirmed the findings.
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Plan of Correction
Program Director will insure fire drills will be conducted each month during a variety of times of day and different staff shifts. The Maintenance Supervisor will monitor the log for compliance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation that was evaluative in four of four client records.
The findings include:
Thirteen client records were reviewed on October 10, 2012. Eight client records were reviewed as outpatient client records. Four client records required documentation of a psychosocial evaluation. The psychosocial evaluations in client records # 1, 2, 3 and 4 did not include an evaluation of the client's assets/strengths, coping mechanisms, support systems, negative factors towards treatment nor did they include the counselors' conclusions and/or impressions regarding the clients' status.
The Facility Director was interviewed on October 5, 2012 and confirmed the findings.
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Plan of Correction
Program Director will insure staff will be trained and retrained by the Vice President of Clinical Services, and the Clinical Supervisor by December 30, 2012 in the correct documentation of psychosocial evaluations and the Clinical Supervisor will continue to conduct open chart monitors. |
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
Based on a review of client records, the facility failed to document a treatment plan update at least every 60 days, which included the client's progress as it related to the goals identified in the individualized treatment and rehabilitation plan, in three of three client records.
The findings included:
Thirteen client records were reviewed on October 10, 2012. Eight client records were reviewed as outpatient client records. Three client records required documentation of a treatment and rehabilitation plan update. The treatment and rehabilitation plan did not include an updated treatment plan in client records # 1, 4 and 8.
Client # 1 was admitted on April 24, 2012. The treatment and rehabilitation plan was completed on May 30, 2012. An treatment and rehabilitation plan update, completed on July 25, 2012 included new goals and did not include an update of the client's progress on the goals identified in the individualized treatment and rehabilitation plan.
Client # 4 was admitted on June 11, 2012. The treatment and rehabilitation plan was completed on June 25, 2012. An update was due to be completed by August 25, 2012. The treatment and rehabilitation plan update was not completed until September 19, 2012. The update included new goals and did not include an update of the client's progress on the goals identified in the individualized treatment and rehabilitation plan.
Client # 8 was admitted on January 2, 2012. The treatment and rehabilitation plan was completed on January 18, 2012. An update was due to be completed by March 18, 2012. The treatment and rehabilitation plan update was not completed until April 21, 2012. The update included new goals and did not include an update of the client's progress on the goals identified in the individualized treatment and rehabilitation plan.
The Facility Director was interviewed on October 10, 2012 and confirmed the findings.
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Plan of Correction
By November 30, 2012, the Program Director will train staff to complete treatment plan updates at least every 60 days, which include the client's progress as it relates to the goals identified in the individualized treatment plan, and addition of any new goals. This will be monitored by monthly chart monitors by the Clinical Supervisor. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document a case consultation note in three of three client records.
The findings include:
Thirteen client records were reviewed on October 10, 2012. Eight client records were reviewed as outpatient client records. Three client records were required to include documentation of a case consultation note. Per agency policy, case consultation are to be completed every 90 days. The facility did not document a case consultation per policy in client records # 1, 3, and 4.
Client # 1 was admitted on April 24, 2012. A case consultation was to be completed by July 24, 2012. There was no documentation that a case consultation had been completed.
Client # 3 was admitted on July 23, 2012. A case consultation was to be completed by October 23, 2012. A case consultation note, completed on September 17, 2012 contained only the signature of the counselor. There was no documentation that the staff member had attended the case consultation.
Client # 4 was admitted on June 11, 2012. A case consultation was to be completed by September 11, 2012. A case consultation note, completed on August 15, 2012 was signed by the counselor on August 15, 2012 and the supervisor on October 8, 2012. There was no documentation that staff members had attended the case consultation.
The Facility Director was interviewed on October 10, 2012 and confirmed the findings.
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Plan of Correction
By November 30, 2012, the Program Director will train staff in the use of the new quantitative audit tool to use on open charts to track the due dates of documentation, and all open charts will be audited using a second quantitative audit tool to insure documentation is done on time.Program Director will insure staff will be trained and retrained by the Vice President of Clinical Services, and the Clinical Supervisor by December 30, 2012 in the correct documentation of case consults and the Clinical Supervisor will continue to conduct open chart monitors. |