INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 20-23,2008 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 24, 2008.
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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 the review of twelve employee training and personnel records on October 20-22, 2008, the facility failed to ensure that all applicable staff persons received the required mandatory communicable disease training within one year of the hire date for clinical staff and two years of the hire date for support staff in three of four employee training records where required.
FINDING:
Employee training record # 8 had no documentation of TB/STD and other communicable disease training; employee # 11 had no documentation of TB/STD and other communicable disease training; employee # 12 had no documentation of HIV/AIDS training.
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Plan of Correction
All staff who had not taken the STD/TB training attended it on 10/16/08, since the inspection in October. On an ongoing basis the Clinical Supervisor will ensure compliance with regard to meeting staff training requirements through individual and group supervision monthly with all staff not yet trained, and quarterly reviews of training records with Human Resources staff.
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705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection which included inspection of mattresses and pillows throughout the facility as part of the onsite licensing inspection of October 20 - 22, 2008, the facility failed to ensure that all mattresses were in good condition.
FINDING:
Mattresses were randomly spot checked for cleanliness and good repair during the physical plant inspection . Two types of mattresses are used . One type is newer and has a shiny blue mattress cover made of durable fabric , the older type of mattress has a green vinyl/plastic cover. These latter mattresses were generally in worn condition. Tears were noted in mattress covers as follows: room 103 - one torn mattress cover; room 104 - one torn mattress cover; rooms # 203, 207, 209, 213 and 223 each had an older type mattress with a cracked or torn mattress cover.
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Plan of Correction
Maintenance Supervisor has begun examining the mattresses on each floor and ordered a supply to begin replacement by the end of December. Program Director will ensure compliance with this standard through regular walk-through inspections and supervision of mattress replacement, as needed.
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709.81(a)(1) LICENSURE Intake and admission
709.81. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
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Observations
Based on the review of seventeen client records from October 20 to 22, 2008, the facility failed to provide treatment at the partial hospital level of care in two of four client records where required.
FINDING:
Clients admitted to the partial hospital level of care outside of the prison setting, specifically client records # 6 and 12, actually received treatment with the clients in the residential level of care and participated in the residential rehabilitation activities. The partial hospital activity was not managed as a separate level of care outside the prison setting.
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Plan of Correction
A Request for an Exception regarding this standard was submitted by the COO for Adolescent Services to be able to integrate Partial level of care with Residential programming at several facilities due to historically low referrals for this level of care. Because we do not expect this trend to change significantly, if we are not granted an exception, we will offer a short-term Partial program on at least 2 occasions per year. When we have a sufficient number of clients (minimum 5) to be able to conduct effective group therapy sessions, we will run the program for a 2-3 week period, offering a minimum of 10 hours of programming, to include psychoeducation, group therapy (minimum 2x weekly) and individual therapy (minimum 2x weekly). We will not integrate these clients into our residential program. Additionally, we will continue to operate our satellite Partial Program in the Blair County Prison. The Program Director will be responsible for oversight of the Partial Program and ensuring compliance with this standard.
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709.83(a)(8) 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:
(8) Record of services provided.
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Observations
Based on the review of seventeen client records on October 20 through 22, 2008, the facility failed to consistently document records of services that contained the provider of the services in four of four client records where required.
FINDING:
The provider of the educational activities and other support activities was not listed on the records of services in client records # 6, 10, 11 and 12.
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Plan of Correction
The Record of Service is currently being revised, and will be in use by the end of December, to include the initials of each staff member who provides or facilitates support treatment sessions such as lectures, life skills activities, AA/NA meetings, and other group activities other than those done specifically by counseling staff. Program Director will ensure compliance with this standard through staff training, individual and group supervision monthly with the clinical supervisory staff, and monthly chart monitors.
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709.83(a)(9) 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:
(9) Progress notes.
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Observations
Based on the review of seventeen client records on October 20 through 22, 2008, the facility failed to document progress notes which contained data, assessments and plans in 4 of 4 client records where required.
FINDING:
Group treatment progress notes did not include the assessments of the group dynamics and individual interactions in the group treatment process in client records # 6, 10, 11 and 12.
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Plan of Correction
The Clinical Supervisor will conduct an inservice training with the clinical team, providing instruction on clinical documentation of the interactions among peers and group dynamics during each group therapy session. The Clinical Supervisor will follow up with regular individual and group supervision with the clinical staff. The Clinical Supervisor will be responsible for ongoing compliance with this standard via monthly chart monitors. |
709.83(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of seventeen client records on October 20 through 22, 2008, the facility failed to document follow up attempts in two of four client records where required.
FINDING:
Follow up attempts were not documented in client records # 11 and 12.
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Plan of Correction
The current policy and procedure addresses follow-up activities on all clients discharged from each level of care, regardless of discharge status, within seven days of the appointment. The evening shift receptionist will continue to be responsible for implementing this action. Program Director will ensure compliance with this standard through monthly chart monitors.
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709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of seventeen client records on October 20 through 22, 2008, the facility failed to adhere to the requirements specified at 4 PA. Code subsection 255.5(b) by failing to identify the specific information to be disclosed on each consent to release information form in three of four client records where required.
FINDING:
Client record # 6 had documented consents to release information to government agencies which exceeded the five areas permitted under this regulation ( presence in treatment, progress, nature of the program, relapse and prognosis). The specific information to be released was not stated on consents to release information documented in client records # 6, 10 and 12. The information to be released was listed as "other" with no information defining what the nature of the other information to be released would be.
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Plan of Correction
The Clinical Supervisor and Director of Nursing will conduct an in-service training with their staff regarding the use of proper releases and the appropriate completion of consents. In-services will include education on the meaning of "informed" consent, importance of completing all sections of each consent, and the appropriate use of the line item "Other". Clinical Supervisor and Director of Nursing will ensure compliance with this standard through ongoing monthly clinical supervision with the secretaries and direct care staff in addition to monthly chart monitors.
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709.63(a)(5) LICENSURE Record of Services
709.63. 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:
(5) Record of services provided.
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Observations
Based on the review of seventeen client records on October 20 through 22, 2008, the facility failed to document records of service in three of five client records where required.
FINDING:
The records of services were not documented in client records # 3, 4 and 5.
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Plan of Correction
Previously counselors have been marking areas of the Record of Service conducted by staff other than themselves with a yellow marker. This was not noted during this inspection, and therefore was seen as "not completed". The Record of Service is currently being revised, and will be in use by the end of December, to include the initials of each staff member who provides or facilitates support treatment sessions such as lectures, life skills activities, AA/NA meetings, and other group activities other than those done specifically by counseling staff. Program Director and clinical supervisors will ensure compliance with this standard through staff training, individual and group supervision monthly with the clinical supervisory staff, and monthly chart monitors.
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709.64(b) LICENSURE Promoting treatment
709.64. Project management services.
(b) The project shall develop a written plan that delineates specific service planning and counseling approaches used to promote client interest in participating in necessary treatment, following the detoxification process.
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Observations
Based on the reviewed of seventeen client records on October 20 through 22, 2008, the facility failed to document efforts to promote client interest in participating in necessary treatment following the detoxification process in five of five client records where required.
FINDING:
The facility did not document efforts to promote client interest in participating in ongoing treatment following the detoxification process in client records # 1, 2, 3, 4 and 5.
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Plan of Correction
Though clients are encouraged to continue treatment by all staff in the detox area, those conversations have not been documented regularly or in an organized manner. The Director of Nursing will conduct an inservice on clinical documentation in the Nurses Notes related to therapeutic conversations with clients, including efforts to promote interest in participating in ongoing treatment following the detoxification process, and will ensure ongoing compliance with this standard through monthly chart monitors. In addition, we are preparing to bring on counseling staff assigned primarily to the detox unit to more consistently offer recovery treatment programming to clients at this level of care.
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709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on the review of seventeen client records on October 20 through 22, 2008, the facility failed to consistently document records of service identifying the provider of the services in eight of eight client records where required.
FINDING:
The provider of the service was not identified on the records of services documented in client records # 1, 2, 3, 4, 5, 7, 8, and 9.
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Plan of Correction
Previously counselors have been marking areas of the Record of Service conducted by staff other than themselves with a yellow marker. This was not noted during this inspection, and therefore was seen as "not completed". The Record of Service is currently being revised, and will be in use by the end of December, to include the initials of each staff member who provides or facilitates support treatment sessions such as lectures, life skills activities, AA/NA meetings, and other group activities other than those done specifically by counseling staff. Program Director and clinical supervisors will ensure compliance with this standard through staff training, individual and group supervision monthly with the clinical supervisory staff, and monthly chart monitors.
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709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on the review of 17 client records on October 20 through 22, 2008, the facility failed to document progress notes consisting of data, assessments and plans in eight of eight client records where required.
FINDING:
Group treatment progress notes did not provide an assessment of the group dynamics and interaction in client records # 1, 2, 3, 4, 5, 7, 8, and 9.
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Plan of Correction
The Clinical Supervisor will conduct an inservice training with the clinical team, providing instruction on clinical documentation of the interactions among peers and group dynamics during each group therapy session. The Clinical Supervisor will follow up with regular individual and group supervision with the clinical staff. The Clinical Supervisor will be responsible for ongoing compliance with this standard via monthly chart monitors.
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