INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 18, 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.
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Plan of Correction
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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 records.
The findings include:
Seven personnel records were reviewed on October 2-3, 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 3, 2012 and confirmed the findings
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Plan of Correction
Project Manager will complete 12 hours of training by 11/30/12. Human Resource Cooridnator will ensure completion |
709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to display the facility's hours of operation that can be accessed by the general public in case of an emergency.
The findings include:
A physical plant inspection was conducted on October 18, 2012. The facility's hours of operation that is conspicuously displayed to the general public is required at all outpatient treatment programs. The facility did not display their hours of operation. An interview with the facility director on October 18, 2012 confirmed the findings.
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Plan of Correction
On 10/19/12 Program Director verbally requested an exception from the Property Management company to display facility hours on exterior door in public sight. Property Management approved request on November 6, 2012. Engraved sign with Hours of operation and phone number was purchased on November 6, 2012 and delivered to Maintenance department of the Property management company on November 7, 2012. Sign will be posted in public vie by November 26, 2012. |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to display a telephone number that can be accessed by the general public in case of an emergency.
The findings include:
A physical plant inspection was conducted on October 18, 2012. A telephone number that is conspicuously displayed to the general public is required at all outpatient treatment programs. The facility did not display an emergency telephone number. An interview with the facility director on October 18, 2012 confirmed the findings.
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Plan of Correction
On 10/19/12 Program Director verbally requested an exception from the Property Management company to display emergency telephone number on exterior door in public sight. Property Management approved request on November 6, 2012. Engraved sign with Hours of operation and phone number was purchased on November 6, 2012 and delivered to Maintenance department of the Property management company on November 7, 2012. Sign will be posted in public vie by November 26, 2012. |
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 a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in seven of eight client records.
The findings include:
Eight client records were reviewed on October 18, 2012. A psychosocial evaluation was review in eight client records, #1, 2, 3, 4, 5, 6, 7 and 8.
The psychosocial evaluations in client records #2, 3, 6, 7 and 8 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #2, 3 and 6 did not include an evaluation of the client's negative factors and how they would impact treatment.
An interview with the facility director on October 18, 2012 confirmed the findings.
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Plan of Correction
Vice President of clinical servcies will retrain clinical staff on the correct completion of the Psychosocial Evaluation including: assets/strengths, coping mechanisms, support systems and negative impacts of use. Program Director will monitor correct completion of Psychosocial Evaluations monthly in Open Chart Monitors. Evaluations will be monitored until 90% compliance is achieved for 3 consecutive months. Monitors will be reviewed by Vice President of Clinical Services. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to display the facility's hours of operation that can be accessed by the general public in case of an emergency.
The findings include:
A physical plant inspection was conducted on October 18, 2012. The facility's hours of operation that is conspicuously displayed to the general public is required at all outpatient treatment programs. The facility did not display their hours of operation. An interview with the facility director on October 18, 2012 confirmed the findings.
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Plan of Correction
On 10/19/12 Program Director verbally requested an exception from the Property Management company to display facility hours on exterior door in public sight. Property Management approved request on November 6, 2012. Engraved sign with Hours of operation and phone number was purchased on November 6, 2012 and delivered to Maintenance department of the Property management company on November 7, 2012. Sign will be posted in public vie by November 26, 2012. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to display a telephone number that can be accessed by the general public in case of an emergency.
The findings include:
A physical plant inspection was conducted on October 18, 2012. A telephone number that is conspicuously displayed to the general public is required at all outpatient treatment programs. The facility did not display an emergency telephone number. An interview with the facility director on October 18, 2012 confirmed the findings.
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Plan of Correction
On 10/19/12 Program Director verbally requested an exception from the Property Management company to display telephone numbers on exterior door in public sight. Property Management approved request on November 6, 2012. Engraved sign with Hours of operation and phone number was purchased on November 6, 2012 and delivered to Maintenance department of the Property management company on November 7, 2012. Sign will be posted in public vie by November 26, 2012. |