INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc- Transitions 2 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Reports, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Reports for the project's 14 facilities were reviewed on October 15, 2013. The project employed the equivalent of 105.275 full-time counselors, which would require the project to have at least 13 full-time clinical supervisors. The project failed to employ a full-time clinical supervisor for every eight full-time counselors as the project only employed 7 full-time clinical supervisors as of October 15, 2013.
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Plan of Correction
The Vice President of Clinical Services will ensure that the ratio of Clinical Supervisors for the project is within the defined regulation of 1 fulltime clinical supervisor for every 8 fulltime counselors or counselor assistants. The Project will re-evaluate its current system and restructure the project to include the appropriate number of clinical supervisors. Human Resources coordinators will identify the number of clinical supervisors, counselors, and counselor assistants within the system on a quarterly basis. Vice President of Clinical Services will be responsible to review staffing hours quarterly to ensure that ratio is maintained. Program Directors will notify the Vice President of Clinical Services should any changes in the ratio per site occur during the quarter. Restructuring of the Clinical Supervisor ratio will begin December 1, 2013. Clinical Supervisor ratio will be in 100% compliance by January 1, 2014. |
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 employee records, the facility failed to document the completion of 12 clock hours of annual training required for project directors in one of one employee records.
The findings include:
The facility training year runs from July 1 through June 30.
Ten employee records were reviewed on October 25, 2013. One employee record pertained to the project director and required the documentation of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in employee record # 1.
Employee # 1 has been the project director since July 1, 1999. The facility failed to document 12 clock hours of annual training for employee # 1 for the July 2012 - June 2013 training year as the record only contained documentation of 10.5 hours of training.
This is repeat citation from the 2012 licensing inspection.
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Plan of Correction
Project Manager will complete 12 hours of training annually. Project Manager will ensure needed documentation of completed trainings is presented to Human Resources to be recorded in Personnel File. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance. |
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.
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Observations
Based on the review of personnel records, the facility failed to document that each counselor completed at least 25 clock hours of training annually in one of one personnel record.
The findings include:
Ten personnel records were reviewed on October 25, 2013. Six personnel records were reviewed as counselors. One counselor record reviewed required 25 clock hours of annual training. The facility failed to document 25 clock hours of training for the 2012 training year in personnel record # 4.
Employee # 4 was hired as a counselor on November 2, 2009. The facility failed to ensure that employee # 4 completed at least 25 clock hours of training for the 2012 training year.
The Facility Director and Clinical Supervisor were interviewed on October 25, 2013 and confirmed the findings.
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Plan of Correction
Counselors will complete required 25 hours of training per year. Clinical Supervisors and Program Directors will be responsible for tracking counselors' training hours as part of clinical supervision monthly. HR coordinators will audit completed training hours quarterly and supply Program Directors with results to ensure training hours are being met. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of the patient records, the facility failed to ensure that verbal medication orders were put in writing and signed with 24 hours thereafter by the prescribing physician in two of three patient records.
The findings include:
Ten patient records were reviewed on October 25, 2013. Six patient records were reviewed as inpatient records. The facility failed to ensure that verbal medication orders in patient records # 2 and 3 were signed by the prescribing physician within 24 hours.
Patient # 2 was admitted into inpatient on August 27, 2013. There was no documentation provided that a verbal order that was dated August 27, 2103, was signed within 24 hours by the prescribing physician.
Patient # 3 was admitted into inpatient on September 17, 2013. There was no documentation provided that a verbal order that was dated September 17, 2013 at 1:50 P.M., was signed within 24 hours by the prescribing physician.
The Facility Director and Clinical Supervisor were interviewed on October 25, 2013 and confirmed the findings.
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Plan of Correction
All physicians will include signature, date and time in their documentation. Director of Nursing will monitor through monthly chart monitors conducted by the medical administrative assistant. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of patient records, the facility failed to document that the patient was notified, in writing, of a decision to involuntarily terminate the patient's treatment at the project in one of one patient records.
The findings include:
Ten patient records were reviewed on October 25, 2013. Four patient records were reviewed as discharged patients. One patient was involuntarily terminated from the project. The facility failed to document that patient # 7 was notified, in writing, of a decision to involuntarily terminate the patient's treatment at the project.
Patient # 7 was admitted on May 25, 2013 and involuntarily discharged on July 31, 2013. The facility failed to provide documentation that the patient had been notified, in writing, of a decision to involuntarily terminate the patient's treatment at the project.
The Facility Director and Clinical Supervisor were interviewed on October 25, 2013 and confirmed the findings.
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Plan of Correction
Program Director will conduct a training regarding termination policy and necessary forms with all staff prior to January 1, 2014. Clinical Supervisor will monitor completion of from through the use of Chart monitors monthly until 100% completion is achieved. |
709.62(c)(4) LICENSURE Consent to TX
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(4) Consent to treatment.
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Observations
Based on the review of patient records, the facility failed to document a consent to treatment in one of three patient records.
The findings include:
Ten patient records were reviewed on October 25, 2013. Four patient records were reviewed as detoxification records. Three were reviewed for a consent to treatment. The facility failed to document a consent to treatment in record # 9.
Patient # 9 was admitted on August 31, 2013. The facility failed to document a consent to treatment in record # 9 as of October 25, 2013.
The Facility Director and Clinical Supervisor were interviewed on October 25, 2013 and confirmed the findings.
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Plan of Correction
All Intake staff will have client complete consent to treatment paperwork immediately. Director of Nursing will oversee this process and assure completion through monthly chart monitoring. The goal is 100% compliance. |
709.63(a) LICENSURE Client record
709.63. 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:
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Observations
Based on the review of patient records, the facility failed to document a complete client record, to include follow-up information, in two of two patient records.
The findings include:
Follow-up information is to be completed within 7 days of discharge.
Ten patient records were reviewed on October 25, 2013. Four patient records were reviewed as detoxification records, two of which were discharged patients and required follow-up information. The facility failed to document follow-up information in patient records # 9 and 10.
Patient # 9 was admitted on May 29, 2013 and discharged on June 13, 2013. There was no documentation of follow-up information as of October 21, 2013.
Patient # 10 was admitted on August 31, 2013 and discharged on September 5, 2013. There was no documentation of follow-up information as of October 21, 2013.
The Facility Director and Clinical Supervisor were interviewed on October 25, 2013 and confirmed the findings.
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Plan of Correction
The aftercare coordinator and all other designated staff responsible for completing follow-up calls will be retrained on the protocol for completing follow-up calls by December 31,2013. Clinical supervisor will monitor completion of all follow-up calls through monthly closed chart monitors. |