INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 24, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Ridgeview Adolescent Behavioral Health Center at Pittsburgh 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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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
One personnel record was reviewed for the counselor assistant position on October 11, 2017. The facility failed to document the provision of direct observation for employee record # 5.
Employee # 5 was hired on 3/21/17 as a Bachelor's level counselor assistant, and was promoted to the counselor position on 6/18/17. The employee required close supervision while employed in the counselor assistant position, and weekly supervision notes were reviewed for that period. The facility failed to provide documentation of weekly supervision for the weeks within the period of 3/21/17 - 5/6/17. Weekly supervision notes were provided for the period of 5/10/17 - 6/6/17. For these supervision notes, the facility failed to demonstrate that weekly close supervision included an additional hour of direct observation at least once a week.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Beginning 11/17/2017, all future counselor assistant weekly supervision notes will be forwarded to Pyramid Healthcare's Human Resources department by Ridgeview's Clinical supervisor or program director and placed in that employee's personnel file.
The information provided in the supervision note will include the client ID# receiving treatment during that direct observation. This process will be monitored throughout the counselor assistant's required supervision process through a log. |
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
Nine personnel records were reviewed on October 11, 2017. The facility failed to provide documentation of TB/STD training for employee record # 9.
Employee # 9 was hired as a counselor on 9/28/16. The TB/STD training was due to be completed by no later than 9/28/17. Completion of this training was not documented in the employee's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee completed the training 10/26/2017. Beginning 11/17/2017 all new hire direct staff will have mandatory trainings listed on their initial training plan for the upcoming year. A copy his training plan will be given to the employee, one in their employee file and one send to their employment location. The progress of completing their required trainings will be monitored quarterly of the course of their initial year of employment.
Pyramid healthcare will be willing to send out the employee to another location in the state if a specific training is not available locally in order for compliance to be met. |
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.
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Observations
Eight client records were reviewed on October 24, 2017. The facility failed to obtain a valid informed and voluntary consent for client record # 8.
Client # 8 was admitted into outpatient treatment on 12/29/16 and was discharged on 4/10/17. Documentation in the client's record indicated that a letter dated for 4/10/17 was forwarded to two district justices, reporting the client's discharge from the facility. Consents to release information to the district justices were not documented in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective immediately, client charts will be inspected for consents by the Lead Counselor and Clinical Supervisor for any outside organization requesting information for clients. Counselors will not release information until this procedure is followed. If no consent exists, the client will be notified immediately and given the option to sign that consent if they choose to do so. This will be monitored weekly during treatment team through March 31, 2018 and will continue to be a part of daily procedure. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Four client records were reviewed for the inpatient rehabilitation activity on 10/24/17. The facility failed to document a complete personal history for client records # 1, 2, and 3.
Client # 1 was admitted into treatment on 8/23/17 and was discharged on 10/23/17.
Client # 2 was admitted into treatment on 8/17/17 and was discharged on 10/20/17.
Client # 3 was admitted into treatment on 5/17/17 and was discharged on 7/14/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective immediately, all new admit client charts will be monitored within the first 48-72 hrs. of admission by the lead counselor of that team or lead counselor. Any incomplete documentation in the personal history will be required to be completed within 24-48 hours of that review. This will be monitored through March 31, 2018 and will continue to be a standard practice of monitoring for all new client admits. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Four client records were reviewed for the inpatient rehabilitation activity on October 24, 2017. The facility failed to document a complete client record for client records # 1, 3, and 4.
Client # 1 was admitted into treatment on 8/23/17 and was discharged on 10/23/17. Documentation in the client's record indicated that the client attended group counseling sessions on 10/16/17 and 10/18/17. Progress notes for these counseling sessions were not documented in the client's record.
Client # 3 was admitted into treatment on 5/17/17 and was discharged on 7/14/17. Follow-up information was not documented in the client's record.
Client # 4 was admitted into treatment on 3/21/17 and was discharged on 6/6/17. Follow-up information was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective immediately, all open client charts will be monitored by clinical supervisor and or lead counselors on a bi-weekly basis to ensure all required documentation is in place. All charts for discharged clients will be completed within 7 days and monitored for completion by the clinical supervisor or lead counselor. Any and all documentation including follow-up information will be monitored and completed (if necessary) by the appropriate responsible party. This will be monitored through March 31, 2018. |
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
Four client records were reviewed for the outpatient activity on October 24, 2017. The facility failed to document a treatment plan update at least every 60 days in one of two client records, # 5.
Client # 5 was admitted into treatment on 6/21/17 and was still active in treatment. A comprehensive treatment plan was completed for the client on 7/17/17. A treatment plan update was due to be completed by 9/17/17, and one was not found in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor will address treatment plan updates during weekly supervision as well as weekly treatment team. Clinical Supervisor will be responsible to complete a monthly chart monitoring process for all current clients in order to review and ensure all treatment plan updates are completed with the client in the time frame specified by the licensing process. This process will continue to ensure that all current and future client treatment plan updates are completed in a timely manner. |