INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the October 13, 2010 licensure renewal inspection. The follow-up inspection was conducted on April 28, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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704.12(a)(3)(ii) LICENSURE NonHosp Rehab/Adol
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(ii) Projects serving adolescent clients shall have one FTE counselor for every six clients.
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Observations
Based on a review of client records, the facility failed to provide treatment services that are not concurrent with school hours and that do occur during Department of Health approved primary care hours.
The findings include:
Six client records were reviewed on April 28, 2011. Six of the six client records are required to provide treatment services outside of the school hours and during primary care hours approved by the Department. Five of the six client records included therapy documented during school hours.
Client record #1 was admitted on 2-15-11. Documentation of progress notes in the client record confirmed therapy was conducted during the school hours. Individual progress notes were documented on 2-24-11 from 9:45 to 10:45, 3-2-11 from 12:15 to 1:15, 3-9-11 from 11:00 to 12:00, 3-16-11 from 10:10 to 11:10, 4-13-11 from 10:00 to 11:00, and 4-27-11 from 12:15 to 1:15. Family progress notes were documented on 3-16-11 from 12:00 to 1:00, and 4-15-11 from 11:50 to 12:50.
Client record #2 was admitted on 3-21-11. Documentation of progress notes in the client record confirmed therapy was conducted during the school hours. Individual progress notes were documented on 3-22-11 from 10:00 AM to 11:00 AM, 3-31-11 from 11:00 AM to 12:00 PM, and 4-20-11 from 11:00 AM to 12:00 PM. Family progress notes were documented on 4-1-11 beginning at 11:30 AM, but there was no documentation of the completion of session.
Client record #3 was admitted on 3-25-11. Documentation of progress notes in the client record confirmed therapy was conducted during the school hours. Individual progress notes were documented on 4-7-11 from 10:00 AM to 11:00 AM, 4-15-11 from 10:00 AM to 11:00 AM, and 4-20-11 from 9:30 AM to 11:00 PM. A family progress note was documented on 4-20-11 from 12:00 PM to 1:00 PM.
Client record #4 was admitted on 3-8-11. Documentation of progress notes in the client record confirmed therapy was conducted during the school hours. Individual progress notes were documented on 3-9-11 from 12:30 PM to 1:30 PM, 3-18-11 from 11:00 AM to 12:00 PM, 3-25-11 from 9:30 AM to 10:30 AM, 3-31-11 from 10:30 AM to 11:30 AM, and 4-4-11 from 11:30 AM to 1:30 PM.
Client record #5 was admitted on 3-2-11. Documentation of progress notes in the client record confirmed therapy was conducted during the school hours. An individual progress note was documented on 3-25-11, from 9:30 AM to 10:00 AM.
This was discussed with the clinical supervisor and the two lead counselors and was confirmed by the lead counselors that therapy occurs during the school hours.
The facility is to submit a time frame for primary care hours between Monday and Sunday for review by the Department. The Department will not approve primary care hours that are concurrent with school hours.
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Plan of Correction
New daily schedule will reflect the following: 21 hours per week of clinical hours, equaling 10 hours per week per client of D & A treatment, 5.5 hours per day of uninterrupted school. Marnie Hall, Program Director will be responsible for adherence to this plan. New schedule began 10/10/11. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in four of six client records.
The findings include:
Six client records were reviewed on April 28, 2011. Six of the six client records were required to include documentation of an informed and voluntary consent to release information, signed by the client, prior to the disclosure of information.
Client record #1 was admitted on 2-15-11. Documentation in the client record confirmed that information was disclosed to the Single County Authority without a signed consent to release information. Fax forms dated/confirmed the releases of information without written consent on 4-1-11 and 4-8-11. Progress notes documented telephone contact with the Single County Authority on 2-17-11, 3-8-11, 3-17-11, 3-29-11, 4-13-11, 4-19-11, and 4-27-11, but there was no documentation of written consents to release information to the Single County Authority in the client record. The client record also included documentation of a written consent to release information to the client's mother, dated 2-15-11, that did not include documentation of the specific information to be disclosed.
Client record #2 was admitted on 3-21-11. The client record included documentation of a written consent to release information to the client's mother, dated 3-21-11, that did not include documentation of the specific information to be disclosed.
Client record #3 was admitted on 3-25-11. The client record included documentation of a written consent to release information to the client's mother, dated 3-25-11, that did not include documentation of the specific information to be disclosed.
Client record #4 was admitted on 3-8-11. The client record included documentation of a written consent to release information to the client's father, dated 3-8-11, that did not include documentation of the specific information to be disclosed or the purpose for the disclosure of information.
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Plan of Correction
All counselors and intake personnel will be retrained on Confidentiality and proper completion of consents by Pyramid trainer, Kathy Coleman by July 1, 2011. Marnie Hall, Program Director, will be responsible for monitoring the proper completion and use of consents through monthly chart monitoring. |