INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 18 and 19, 2010 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 30, 2010.
|
Plan of Correction
|
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included the client's problems/needs that can or cannot be resolved in treatment, assets/strengths that can contribute to the resolution of client's problems, support systems, coping mechanisms, negative factors that might affect the client's treatment, client's attitude toward treatment, and counselor's conclusion/impressions regarding client's attitude toward treatment in five of six inpatient records reviewed.
The findings include:
Seven inpatient client records were reviewed on October 26, 2010 for psychosocial evaluations. Five client records did not include a clinical assessment of the client; and/or only included client reported historical information.
Client # 1 was admitted on September 29, 2010. The psychosocial evaluation was completed on September 30, 2010 and did not include the client's assets/strengths, support systems, and coping mechanisms.
Client # 3 was admitted on September 22, 2010. The psychosocial evaluation was completed but was undated, and did not include the client's assets/strengths, support systems, coping mechanisms, and negative factors that might affect the client's treatment.
Client # 5 was admitted on July 8, 2010. The psychosocial evaluation was completed on July 28, 2010 and did not include the client's assets/strengths, support systems, coping mechanisms, and negative factors that might affect the client's treatment.
Client # 6 was admitted on June 23, 2010. The psychosocial evaluation was completed on June 24, 2010 and did not include the client's assets/strengths and coping mechanisms.
Client # 7 was admitted on June 16, 2010. The psychosocial evaluation was completed on June 16, 2010 and did not include the client's composite picture and support systems.
|
Plan of Correction
709.51(b)(6) Psychosocial Evaluations
The Electronic Health Medical Record version of the Psycho-social Evaluation will no longer be utilized. The agency will implement the paper version of the Psycho-social Evaluation that will include the assessment of the client, identify assets/strengths, support systems, coping mechanisms, negative factors that might affect client's treatment, their attitude toward treatment, and the counselor's overall conclusion/impressions regarding the client. The clinical supervisor will monitor by signing off on the psycho-social evaluations during biweekly supervision as well as through monthly chart auditing. Target date for completion is 11/18/10.
|
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on the review of the facility's policies and procedures and client records, the facility failed to timely document a preliminary treatment and rehabilitation plan in seven of seven client records.
The findings include:
Seven client records were reviewed on October 26, 2010.
The facility's policy under "Treatment Planning" states:
During the assessment and intake process, problems are identified that require immediate action; those problems are identified in a preliminary treatment plan...The clinical staff completes a preliminary treatment plan within 24 hours for residential programs.
Preliminary treatment and rehabilitation plans were required in seven client records. The facility failed to document the date in which the preliminary treatment and rehabilitation plans were completed in client records #1, 2, 3, 4, 5, 6 and 7.
Client # 1 was admitted on September 29, 2010. The preliminary treatment plan was completed for this client but it was undated and unsigned, therefore, the licensing specialist was unable to determine when it had been completed.
Client # 2 was admitted on October 19, 2010. The preliminary treatment plan was completed for this client but it was undated and unsigned, therefore, the licensing specialist was unable to determine when it had been completed.
Client # 3 was admitted on September 22, 2010. The preliminary treatment plan was completed for this client but it was undated and unsigned, therefore, the licensing specialist was unable to determine when it had been completed.
Client # 4 was admitted on September 22, 2010. The preliminary treatment plan was completed for this client but it was undated and unsigned, therefore, the licensing specialist was unable to determine when it had been completed.
Client # 5 was admitted on July 8, 2010. The preliminary treatment plan was completed for this client but it was undated and unsigned, therefore, the licensing specialist was unable to determine when it had been completed.
Client # 6 was admitted on June 23, 2010. The preliminary treatment plan was completed for this client but it was undated and unsigned, therefore, the licensing specialist was unable to determine when it had been completed.
Client # 7 was admitted on June 16, 2010. The preliminary treatment plan was completed for this client but it was undated and unsigned, therefore, the licensing specialist was unable to determine when it had been completed.
|
Plan of Correction
709.51(b)(7) Preliminary Treatment Plan
The signature verification form of the client's chart will include the addition of the preliminary treatment plan along with date of completion. The clinical supervisor will sign off on the signature verification form to ensure determination of the completion dates. Target date for completion is 11/18/10.
|
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.
|
Observations
Based on a review of the facility's policies and procedures and client records, the facility failed to document treatment plans to include proposed types of supportive services in seven of seven client records.
Findings:
Seven outpatient client records were reviewed on October 26, 2010. Treatment plans with proposed types of supportive services were required in seven client records. The facility did not document treatment plans to include proposed types of supportive services in client records # 1, 3, 4, 5, 6, and 7.
The facility's policy on Treatment Planning states:
Treatment plans are individualized and include the following:
1. Long-term goals...
2. Type and frequency of services...
3. Proposed type of support service required including
a. Vocational/Occupational Rehabilitation Services
b. Creative Arts Services
c. Physical Therapy Services
e. Educational Services
f. Family Services
h. MH/MR Services
Client # 1 was admitted on September 29, 2010. The comprehensive treatment plan was completed on September 30, 2010 and did not include proposed support services.
Client # 2 was admitted on October 19, 2010. The comprehensive treatment plan was completed on October 21, 2010 and did not include proposed support services.
Client # 3 was admitted on September 22, 2010. The comprehensive treatment plan was undated and did not include proposed support services.
Client # 4 was admitted on September 22, 2010. The comprehensive treatment plan was completed on September 23, 2010 and did not include proposed support services.
Client # 5 was admitted on July 8, 2010. The comprehensive treatment plan was completed on July 28, 2010 and did not include proposed support services.
Client # 6 was admitted on June 23, 2010. The comprehensive treatment plan was completed on June 24, 2010 and did not include proposed support services.
Client # 7 was admitted on June 16, 2010. The comprehensive treatment plan was completed on June 16 , 2010 and did not include proposed support services.
|
Plan of Correction
709.52(a)(3) Support Service Type
Clinical supervisor will provide treatment plan training to all clinical staff outlining the significance of documenting all clients' identified support services as part of their treatment plan. The clinical supervisor will monitor that clinicians' are documenting proposed support services through monthly chart auditing. Target date for completion is 12/15/10.
|
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a treatment plan update in three of six client records.
Findings:
The facility's policy states:
The treatment plan is to be conducted within 5 days of admission and updated every 14 days after the initial case consultation for the adolescent short-term residential program.
Six inpatient client records requiring treatment plan updates were reviewed on October 26, 2010. The facility did not document a treatment plan update at least every fourteen days after the initial case consultation in client records # 4, 5, and 6.
Client # 4 was admitted on September 22, 2010. The case consult was completed on September 22, 2010, a treatment plan update was completed on October 5, 2010. An additional treatment plan update was due on October 19, 2010 and had not been completed as of the date of inspection.
Client # 5 was admitted on July 8, 2010. Treatment plans had been completed on July 22, 2010 and August 8, 2010. The August 8, 2010 treatment plan update did not have a clinician signature.
Client # 6 was admitted on June 23, 2010 and discharged on August 6, 2010. The case consult was completed on June 30, 2010. A treatment plan update should have been completed by July 14, 2010. As of the date of inspection, a treatment plan update had not been completed.
|
Plan of Correction
709.52(b) Treatment Plan Update
The clinical supervisor will facilitate individual and group supervision with all clinical staff on a bi-weekly basis regarding the required development of the initial treatment plan within five days and the subsequent treatment plan reviews every fourteen days. The clinical supervisor will monitor timely completion of treatment plan reviews through bi-weekly supervision and monthly chart auditing. Target date for completion is 11/31/10.
|
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.
|
Observations
Based on the review of the facility's policies and procedures and client records, the facility either failed to document case consultations which included a date and staff members present during the consult or failed to complete a case consultation at all in three of seven inpatient client records.
The findings include:
The facility's policy states:
Case consultations are held for every client. The following information is to be documented and maintained in the client's record:
a. The date of the consultation
b. Names and disciplines of attendees
c. Client name
d. Disposition
A case consultation shall be completed within 7 days of admission then every 90 days thereafter for residential programs. The case consultation is to be signed by the counselor and the clinical supervisor.
Seven outpatient client records were reviewed for case consultations on October 26, 2010.
Client # 2 was admitted on October 19, 2010. A case consultation had been completed but it was unsigned and undated and therefore the inspector was unable to determine if it had been completed within 7 days of admission.
Client # 3 was admitted on September 22, 2010. A case consultation had been completed but it was unsigned and undated and therefore the inspector was unable to determine if it had been completed within 7 days of admission.
Client # 5 was admitted on July 8, 2010 and discharged on August 18, 2010. A case consultation was due to be completed by July 15, 2010. As of the date of inspection there was no documentation of a case consultation.
|
Plan of Correction
709.53(a)(8) Case Consultation Notes
The clinical supervisor will ensure compliance through individual and group supervision that all case consultations are completed within the seven days of admission and that counselor and clinical supervisor are signing the case consultation upon completion. The clinical supervisor will ensure compliance regarding case consultation notes through individual and group supervision along with monthly chart auditing. Target date for completion is 11/18/10.
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position of counselor in one personnel record.
The findings include:
On October 25, 2010 four counselor's personnel records were reviewed. The facility failed to provide documentation of counselor qualifications in personnel record # 6.
Employee #6 was hired as a counselor on March 22, 2010 and has a Bachelor of Science degree in Community Health. The degree was not listed on licensing alert 03-10 nor was included in the standards.
|
Plan of Correction
704.7(b) Counselor Qualifications
The staff member's position in question has been changed from counselor to counselor assistance status. This staff member will begin the process of obtaining her CAC certification in order to meet the educational requirements of counselor set forth in the regulations. The clinical supervisor will provide bi-weekly, individual documented supervision of this staff member until eligibility for status change to counselor and staff members obtains CAC certification. Target date for completion is 4/1/11.
|