INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20, 2023 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(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
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that the employee #12 received at least 4 hours of TB/STD and other health related topics within the regulatory timeframe of two years for support staff.
Employee #12 was hired as support staff on November 2, 2016 and was due to have the communicable disease trainings no later than November 2, 2018. There was no documentation of the completion of the TB/STD training as of the date of the inspection.
The finding was discussed with facility staff during the licensing inspection.
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Plan of Correction
Employee #12 will complete TB/STD training before the next inspection. This will be monitored by the assessment supervisor and the executive director quarterly. This will ensure that all staff are registered and completing required trainings within the regulatory time frames for their position. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
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Observations
Based on a review of outpatient client records, the facility failed to complete a comprehensive treatment plan within the guidelines established in the facility's policy and procedures manual which is 14 days after admission in four out of seven records reviewed.
Client #1 was admitted on April 19, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due on May 3, 2023; however, it was not completed until May 10, 2023.
Client #2 was admitted on April 10, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due on April 24, 2023; however, it was not completed until May 11, 2023.
Client #3 was admitted on April 13, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due on April 27, 2023; however, it was not completed until June 21, 2023.
Client #6 was admitted on March 14, 2023 and discharged on June 12, 2023. A comprehensive treatment plan was due on March 28, 2023; however, it was not completed until May 2, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Comprehensive treatment plan will be completed by counselor in the first individual session scheduled within 14 days of admission. Counselors monitor treatment plan due dates and new clients using their case trackers daily to ensure that they are adding new starts and scheduling them for individual session to complete their comprehensive treatment plan. Clinical supervisor will check that this is updated on the case tracker twice weekly
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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 four out of six applicable records.
Client #1 was admitted on April 19, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 10, 2023 and an update was due no later than July 10, 2023; however, it was not completed until July 19, 2023.
Client #2 was admitted on April 10, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 11, 2023 and an update was due no later than July 11, 2023; however, it was completed on July 19, 2023.
Client #5 was admitted on October 12, 2022 and discharged on February 17, 2023. A comprehensive treatment plan was completed on October 20, 2022 and an update was due no later than December 20, 2022; however, it was completed on January 19, 2023.
Client #7 was admitted on February 24, 2023 and discharged on May 30, 2023. A comprehensive treatment plan was completed on March 7, 2023 and an update was due no later than May 7, 2023; however, it was completed on May 9, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors will monitor that are treatment plans are being scheduled to be completed within the regulatory time frame of 60 days. Counselors will update case trackers daily to ensure that they are updating when treatment plans are due for their caseload and noting in the EHR when to complete reviews on their schedule. Clinical supervisor will check that case trackers and treatment plan reviews are up to date twice weekly |
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 comprehensive treatment plan in three out of seven records reviewed.
Client #1 was admitted on April 19, 2023 and was still active at the time of the inspection. A comprehensive treatment plan dated May 10, 2023 indicated individual sessions monthly. There was no documentation of an individual session occurring in June 2023.
Client #2 was admitted on April 10, 2023 and was still active at the time of the inspection. A comprehensive treatment plan dated May 11, 2023 indicated individual sessions monthly. There was no documentation of an individual session occurring in June 2023.
Client #5 was admitted on October 12, 2022 and discharged on February 17, 2023. A comprehensive treatment plan dated October 20, 2022 indicated group sessions weekly and individual sessions monthly. There was no documentation of group sessions between November 18, 2022 - December 14, 2022 and December 30, 2022 - January 18, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clients will receive counseling services according to their individual comprehensive treatment plan. All active clients will be scheduled for individual sessions during the month prior, this will be monitored on their case trackers as well to ensure that all clients are actively attending and have an upcoming individual. Clinical supervisor will check that these are up to date twice weekly |