INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29-30, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Staff #8 was hired as an assessment counselor on August 26, 2019, and was still in the position as of the date of the onsite inspection. The training year that was reviewed was from January 1, 2023, through December 1, 2023. Staff #8's employee record only documented 13.25 hours of annual training for the 2023 year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will complete required training hours and will track training hours using Relias transcript. ED and CS will utilize training grid to monitor and will run monthly reports to ensure staff are in compliance with needed hours. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document treatment plan updates within the regulatory timeframe in one out of three applicable records reviewed.
Client #13 was admitted on October 23, 2024, and was discharged on March 12, 2024. An updated treatment plan was completed on November 21, 2023, and the next update was due no later than December 21, 2023; however, it was completed January 2, 2024. Additionally, a treatment plan update was completed February 1, 2024, and the next update was due no later than March 2, 2024; however it was completed March 7, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors will monitor due dates of treatment plan reviews with their case trackers daily to ensure that they are completing reviews as needed and by their due dates. CS will check that this is updated and on the case tracker weekly and will also discuss in clinical supervisions. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in one out of two applicable records reviewed. The facility's policy is that case consultations must be completed within ninety-days of admission.
Client #13 was admitted on October 23, 2023, and was discharged on March 12, 2024. A case consultation was due no later than January 23, 2024; however, there was no documentation of a completed case consultation in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors will ensure all case consults occur within 90 days of client's admission. Component of two other staff signatures, one being a supervisor's signature, will serve as communication and compliance monitoring. All staff were educated on the importance of signing documents daily, specifically case consults, in staff meeting on 8/15/2024. Counselors will maintain a weekly case tracker for all clients that highlight upcoming due dates for documentation to ensure compliance. Case trackers will be reviewed with counselors each week by supervisors. |
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
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of six applicable records reviewed.
Client #1 was admitted on May 13, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 20, 2024, and the next update was due no later than July 20, 2024; however, there was no updated treatment plan documented in the client record.
Client #4 was admitted on January 2, 2024, and discharged on May 30, 2024.A treatment plan update was completed on March 8, 2024, and the next update was due no later than May 8, 2024; however, it was completed on May 9, 2024.
Client #6 was admitted on March 14, 2024, and discharged on July 22, 2024. A comprehensive treatment plan was completed on May 9, 2024, and the next update was due no later than July 9, 2024; however, it was completed July 16, 2024.
This is a repeat citation from the July 20, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors will monitor due dates of treatment plan reviews with their case trackers daily to ensure that they are completing reviews as needed and by their due dates. CS will check that this is updated and on the case tracker weekly and will also discuss in clinical supervisions. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of seven applicable records reviewed.
Client #2 was admitted on May 1, 2024, and was still active at the time of the inspection. An updated treatment plan dated June 27, 2024, indicated the client was to receive one individual session per month and one group session per week. There was no documentation to verify that a group session had occurred during the weeks of July 1-July 6, 2024, and July 15-July 20, 2024.
Client #3 was admitted on April 22, 2024, and was still active at the time of the inspection. A comprehensive treatment plan dated May 15, 2024, indicated the client was to receive one individual session per month and one group session per week. There was no documentation to verify that a group session had occurred during the week of June 9-June 15, 2024.
Client #5 was admitted March 7, 2024, and was discharged May 5, 2024. A comprehensive treatment plan dated March 15, 2024, indicated the client was to receive one individual session per week and one group session per week. There was no documentation to verify that an individual session had occurred during the weeks of April 1-April 6, 2024, and April 7-April 13, 2024.
This is a repeat citation from the July 20, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors will utilize their case trackers to identify last and next individual session scheduled. This will ensure clients are receiving individual sessions that align with treatment plan. Counselors will make follow up engagement calls for any missed appointments within 24 hours and document in a call log. |
709.93(a)(8) LICENSURE Client records
709.93. 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 review of outpatient client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in three out of three applicable records reviewed. The facility's policy is that case consultations must be completed within ninety-days of admission.
Client #3 was admitted on April 22, 2024, and was still active at the time of the inspection. A case consultation was due no later than July 22, 2024; however, there was no documentation of a completed case consultation in the client record.
Client #4 was admitted on January 2, 2024, and was discharged on May 30, 2024. A case consultation was due no later than April 2, 2024; however, there was no documentation of a completed case consultation in the client record.
Client #6 was admitted on March 14, 2024, and was discharged on July 22, 2024. A case consultation was due no later than June 14, 2024; however, there was no documentation of a completed case consultation in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors will ensure all case consults occur within 90 days of client's admission. Component of two other staff signatures, one being a supervisor's signature, will serve as communication and compliance monitoring. All staff were educated on the importance of signing documents daily, specifically case consults, in staff meeting on 8/15/2024. Counselors will maintain a weekly case tracker for all clients that highlight upcoming due dates for documentation to ensure compliance. Case trackers will be reviewed with counselors each week by supervisors.
Client 3# has a case consult that has been completed as of 8/15/2024.
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