INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 18, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc., Erie Outpatient 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
A physical plant inspection was conducted on October 18, 2017. Eight counselor offices and three group rooms were observed to not have coverings on the windows, failing to ensure privacy during counseling sessions. In addition, the project director's office, also utilized for clinical services, was observed to have an uncovered window.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The eight counselor offices, three group rooms and the project director's office windows in the doors will be covered with a film that will not be able to see inside the room from the outside. Program Director has contacted cooperate maintenance department who's team will be coming to complete this project. This project will be completed by Pyramid Healthcare's corporate maintenance team by 12/12/17. Program Director and Regional Maintenance Director will continue to monitor this project to ensure compliance going forward. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Five client records were reviewed for the outpatient activity on October 18, 2017. The facility failed to document a treatment plan update at least every 60 days for client records # 7 and 9.
Client # 7 was admitted into treatment on 2/16/17 and was discharged on 8/14/17. A comprehensive treatment plan was completed for the client on 3/9/17. A treatment plan update was due to be completed by 5/9/17, and one was not documented in the client's record.
Client # 9 was admitted into treatment on 4/24/17 and was discharged on 9/8/17. A comprehensive treatment plan was completed for the client on 5/16/17. A subsequent treatment plan update was completed for the client on 8/3/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselor who failed to complete the treatment plan reviews, was placed on a corrective action plan. Clinical Supervisor is monitoring documentation daily to ensure treatment plans are being completed on time. Clinical Supervisor in weekly supervisions ensures compliance of clinical documentation of all clinicians and will continue to implement the corrective action plan of the specific clinician documented in this citation. |