INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 30-31, 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:
|
Plan of Correction
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
The faciltiy failed to ensure that counselors had 25 hours of training.
Staff #5 had eleven hours for the training year, January 1, 2017-December 31, 2017.
These findings were reviewed with faciltiy staff during the licensing process.
|
Plan of Correction
Clinical Supervisor will develop a staff spreadsheet to more accurately schedule and monitor staff training hours. |
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.
|
Observations
The facility failed to conduct fire drills at least once a month.
The facility did not have documented fire drills for the months of December 2017 and February 2018.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Outpatient Office has identified a RISK Leader who will monitor and track all monthly fire drills. Quarterly safety inspections will continue to be reviewed and monitored by the maintenance department and include physical plant as well as the review of monthly fire drills. |
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 obtain release forms for funding sources within the parameters of 255.5(b) in thirteen out of twenty one client records reviewed.
Client #3 was admitted on June 18, 2018 and was still active at the time of the survey. A release of records to Magellan-Northampton was signed by the client on June 6, 2018 for the five points outlined in 255.5(b) plus general progress updates and general treatment updates.
Client #5 was admitted on October 10, 2017 and was discharged November 21, 2017. A release for records to Magellan-Lehigh was signed by the client on October 10, 2017 for the five points outlined in 255.5(b) plus general progress updates.
Client #6 was admitted on January 15, 2018 and was discharged on 2/20/2018. A release for records to Independence BC of PA was signed by the client on January 15, 2018 for the five points outlined in 255.5(b) plus general progress updates.
Client #7 was admitted on June 6, 2018 and was discharged on July 13, 2018. A release for records to Magellan-Lehigh was signed by the client for the five points outlined in 255.5(b) plus general progress updates, medication administration record, psychological assessment, medical history and physical and treatment progress update.
Client #10 was admitted on March 17, 2018 and was still active at the time of the survey. A release of records to Magellan-Lehigh was signed on March 17, 2018 for the five points outlined in 255.5(b) plus general progress updates, medication administation record, psychological assessment, medical history and physical and treatment progress updates.
Client #11 was admitted on May 15, 2018 and was discharged on July 4, 2018. A release of records to Magellan-Lehigh was signed on May 15, 2018 for the five points outlined in 255.5(b) plus general progress updates, medication administration record, psychological assessment, psychiatric evaluation, medical history and physical, and treatment progress updates.
Client #12 was admitted on January 15, 2018 and was discharged April 6, 2018. A release of records to Capital Blue Cross was signed on January 15, 2018 for the five points outlined in 255.5(b) plus general progress updates, medication administration record, psychological assessment, medical history and physical and treatment progress update.
Client #13 was admitted on May 15, 2018 and was discharged on July 13, 2018. Releases of records to Magellan-Lehigh and Lehigh County Drug and Alcohol Abuse Services signed on May 11, 2018 for the five points outlined in 255.5(b) plus general progress updates.
Client #14 was admitted on December 22, 2017 and was discharged on March 10, 2018. A release was signed to Magellan-Lehigh for the five points outlined in 255.5(b) plus general progress updates, medication administration record, psychological assessment, medical history and physical, psychiatric evaluation and treatment progress updates.
Client #16 signed a release to SCA-Lehigh County on February 21, 2018 for the five points outlined in 255.5(b) plus general progress updates.
Client #21 signed a release to Magellan Behavioral Helath on November 9, 2017 for the five points outlines in 255.5(b) plus general progress updates, medication administration record, psychological assessment, psychiatric evaluation, medical history and physical and treatment progress updates.
These findings were reviewed with facility staff during the licensing process.
This was a repeat citation from licensing inspection November 13, 2017.
|
Plan of Correction
A process guide will be developed by the Clinical Supervisor detailing the parameters contained in 255.5 (b) and how it is applied to the completion of releases during the informed consent process. This process guide will be developed and reviewed with the clinicians, assessors and certified recovery specialists during a team meeting by 9/30/18. |
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.
|
Observations
The facility failed to ensure that clients had individual counseling at least twice weekly.
Client #1 was admitted on June 14, 2018 and was still active at the time of the inspection. Treatment plan dated 6/14/2018 indicated individual therapy weekly.
Client #4 was admitted on January 16, 2018 and discharged on February 30, 2018. The treatment plan dated January 18, 2018 indicated individual counseling once a week.
Client #5 was admitted on October 10, 2017 and discharged 1/30/2018. Treatment plan dated 1/2/2018 indicated individual counseling bi-weekly.
These findings were reviewed with facility staff during the licensing process.
This was a repeat citation from licensing inspection 11/13/2017.
|
Plan of Correction
Clinical Supervisor will develop an auditing tool for the Partial program counselors which will track all clinical documentation including two 30minute individual counseling sessions per week. The partial program counselors will meet with the Clinical Supervisor weekly in an effort to carefully schedule and monitor all client individual sessions. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
|
Observations
The facility failed to provide client orientation to the project in four out of seven records.
Client # 8 was admitted on June 22, 2018 and was still active at the time of inspection. There was no signed client orientation to the project polices.
Client #9 was admitted on January 9, 2018 and was still active at the time of inspection. There was no signed client orientation to the project policies.
Client #10 was admitted on March 17 and was still active at the time of inspection. There was no signed client orientation to the project policies
Client #13 was admitted on May 15, 2018 and discharged on July 13, 2018. There was no signed client orientation to the project policies.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A client orientation process is already part of our intake and assessment process. A re-training of this process will be reviewed with all clinicians, assessors and certified recovery specialists will occur by 9/30/18.
Ongoing audits will be completed monthly by the clinical supervisor in an effort to verify that the client has signed the orientation completion form within the electronic medical record. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
The facility failed to obtain a consent to treat in three out of seven records reviewed.
Client # 8 was admitted on June 22, 2018 and was still active at the time of inspection. The client did not have a signed consent to treatment.
Client #9 was admitted on January 9, 2018 and was still active at the time of the inspection. The client did not have a signed consent to treatment.
Client #10 was admitted on March 17, 2018 and was still active at the time of inspection. The client did not have a signed consent to treatment.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The consent to treat form and the importance of completing it during the initial contact will be reviewed with all clinicians, assessors and certified recovery specialists during an all staff training on 9/30/18.
Ongoing chart audits will be conducted monthly by the clinical supervisor. |