INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 7 & 12, 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 9, 2008.
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Plan of Correction
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based upon observation on 12/12/2007, the facility failed to maintain unobstructed access to exits.
The facility recently made renovations in areas of the building which resulted in changes in exiting for the first floor and the ground floor. Due to these renovations the secondary exit access for these two levels would be through a staff bathroom and then through a large group room. The bathroom may be locked against egress thus eliminating the second exit route.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 upon review of client records on 12/7/2007, the facility failed to develop individualized treatment plans with the clients. Two of four client records reviewed, #1 & 2, were identical preprinted plans without any additional plans or individualized plans and/or goals for the different clients.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.82(a)(1) 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:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
Based upon review of client records on 12/7/2007, the facility failed to develop individualized treatment plans with short and long term goals with the clients. Two of four client records reviewed, #1 & 2, were identical preprinted plans without any additional plans or individualized plans and/or goals for the different clients.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.82(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based upon review of client records on 12/7/2007, the facility failed to develop individualized treatment plans with the clients indicating the type and frequency of treatment and rehabilitation services to be provided. Two of four client records reviewed, #1 & 2, were identical preprinted plans without any additional plans or individualized plans indicating the type and frequency of treatment and rehabilitation services to be provided.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.82(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based upon review of client records on 12/7/2007, the facility failed to develop individualized treatment plans with the clients indicating the proposed type of support services. Two of four client records reviewed, #1 & 2, were identical preprinted plans without any additional plans or individualized plans indicating the proposed type of support services.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.83(a)(9) LICENSURE Client records
709.83. 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:
(9) Progress notes.
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Observations
Based upon client records reviewed on 12/7/2007, the facility failed to provide assessments appropriate to the individual sessions. The progress notes for the individual counseling sessions in two of four client records reviewed, #1 & 2, contained assessments that simply stated the client was compliant in all groups and functions.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based upon an interview with employee #2 on 12/7/2007, the facility failed to secure client records within locked storage containers on site. The facility was storing clinical records at the correctional facility for those clients in the Partial Hospitalization program located at the correctional facility.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 upon review of client records on 12/7/2007, the facility failed to ensure that consents to release information were voluntary and informed. The consent to release information in four of six records reviewed, #1, 2 ,3 & 4, did not permit the client to revoke the consent verbally.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(c)(2) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(2) Drug storage areas.
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Observations
Based upon observation on 12/12/2007, the facility failed to adhere to their policy regarding the storage of methadone and how access would be regulated so that it would require both the nursing staff and the client to open the storage box. The client did not have his key to the locked box as per policy, the nursing staff had it locked in a drawer at the nurses ' station thus enabling the nursing staff full access to the methadone.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |