INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 13-14, 2009 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 November 13, 2009.
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
A review of the fire drill logs was conducted on October 14, 2009. Documentation of a fire drill conducted during sleeping hours is required once every six months. The only fire drill conducted during sleeping hours in the past twelve months was conducted on January 20, 2009. Another fire drill during sleeping hours was required to be conducted by July 20, 2009.
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Plan of Correction
Program Director and Maintenance Supervisor will provide in service with the on site Maintenance Worker regarding fire drill standards to ensure the sleeping hours fire drill is completed once every six months. Program Director and Maintenance Supervisor will monitor compliance of this standard via regular monthly reviews of the fire drill log. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in accordance with agency policy of three days after admission in three of four client records.
The findings include:
Eight client records were reviewed on October 13-14, 2009. Psychosocial evaluations were required in four client records. The facility failed to document the date the psychosocial evaluation was completed in client records # 1 and 4. The facility failed to document the psychosocial evaluation within three days of admission in client record #2.
In client record #1 the client was admitted on August 12, 2009. The psychosocial evaluation was due on August 15, 2009. The psychosocial evaluation was not dated therefore compliance with agency policy cannot be verified.
In client record #2 the client was admitted on June 24, 2009. The psychosocial evaluation was due on June 27, 2009, but was not completed until June 30, 2009.
In client record #4 the client was admitted on August 6, 2009. The psychosocial evaluation was due on August 9, 2009. The psychosocial evaluation was not dated therefore compliance with agency policy cannot be verified.
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Plan of Correction
Program Director will conduct an in service with all clinical staff regarding the completion and dating of psychosocial histories and evaluations within three days of client's admission date. Program Director will monitor compliance of this standard via monthly chart monitors. |
709.52(a)(3) LICENSURE Support service type
709.52. 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 on the review of client records, the facility failed to document support services in the individual treatment and rehabilitation plan in three of four client records.
The findings include:
Eight client records were reviewed on October 13-14, 2009. Support services were required in the individual treatment and rehabilitation plan in four client records. The facility did not document support services in the individual treatment and rehabilitation plan in client records #1, 3 and 4.
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Plan of Correction
Program director will conduct an in service with all clinical staff regarding the inclusion of support services in the individual treatment plan and rehabilitation plan of all clients. Program Director will ensure compliance of this standard via monthly chart monitors. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document that work done by the client at the project is an integral part of the treatment and rehabilitation plan in three of four client records.
The findings include:
Eight records were reviewed on October 13-14, 2009. Verification of work as an integral part of the treatment and rehabilitation plan was required in four client records. The facility did not document work as an integral part of the treatment and rehabilitation plan in client records #1, 3 and 4.
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Plan of Correction
Program Director will conduct an in service with all clinical staff regarding the inclusion of work as an integral part of the treatment plan and rehabilitation plan of all clients. Program Director will ensure compliance of this standard via monthly chart monitors. |