INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 20 through 21, 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 25, 2008.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to insure TB/STD training was obtained in four of eleven records reviewed, # 5, 6, 7, and 8.
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Plan of Correction
704.11(c) Mandatory Communicable Disease Training
Counselors will attend the next TB/STD training available, tentatively scheduled for 3/4/08. On an ongoing basis the Program Director will ensure that all department supervisors monitor compliance with regard to meeting staff training requirements through individual and group supervision monthly with the clinical staff, and quarterly reviews of training records with the Human Resources staff.
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709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
Based on a December 20 through 21, 2007 review of client records, the facility failed to document an accurate record of services in three of nine client records, #5, 7 and 8. Client records #5 and 8 had pre-dated dates of service for group sessions and client record #7 was missing for the month of December.
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Plan of Correction
709.53(a) Record of Service
Clinical Supervisor will be responsible for ensuring that a record of service is completed for every client record. The Clinical Supervisor will review with each staff during clinical supervision the proper procedure for completing the record of service. The Clinical Supervisor will ensure compliance by doing monthly chart audits, as well as following up with the counselor in regularly scheduled supervision sessions. Target date for final completion of this target is 2/1/08.
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 a December 20 and 21, 2007 review of client records, the facility failed to document case consultations in three of nine records reviewed, #1, 2 and 5. Client records #1 and 2 were not dated. Therefore, the facility's compliance with time frame requirements could not be determined. Client record #5 was missing the seven day case consultation as required by facility policy.
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Plan of Correction
709.53(a)(8) Case Consultation Notes
Clinical Supervisor will conduct individual clinical supervision with current and new counselors regarding appropriate documentation on case consultation notes. Supervision will focus on the quality of the documentation of the data collected in the case consult. New counselors will receive orientation and training regarding the same. The Program Director and Clinical Supervisor will ensure compliance with this standard through ongoing clinical supervision and monthly chart monitors. Target date for final completion of this project is 2/1/08.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on a December 20 through 21, 2007 review of client records, the facility failed to document follow-up information in five of six client records, # 9, 10, 12, 13 and 14.
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Plan of Correction
709.53(a)(11) Follow-up Information
The current policy and procedure addresses follow-up contact on all clients discharged from each level of care, regardless of discharge status, and requires documentation of the follow-up attempt which is to be made within seven days of the appointment date. Clinical Supervisor will review the policy and procedure with the counselors and monitor for compliance by completing monthly chart audits. Target date for final completion of this project is 3/1/08.
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