INITIAL COMMENTS
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This report is a result of an on-site provisional licensure follow-up inspection conducted on October 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of residential client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in two of four applicable client records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in DDAP Licensing Alert 02-21.
Client #2 was admitted to the inpatient non-hospital rehabilitation activity on August 6, 2024, and was discharged against medical advice on September 29, 2024. There was no documentation that the emergency contact was notified of the client's discharge.
Client #3 was admitted to the inpatient non-hospital rehabilitation activity on September 30, 2024, and was discharged against medical advice on October 19, 2024. There was no documentation that the emergency contact was notified of the client's discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The previous POC will be maintained albeit with an amendment. Weekly audits by the BHT Manager and Nurse Manager, beginning December 8, 2024, will assess compliance, with findings reviewed in monthly leadership meetings led by the Executive Director, who will also address any issues promptly. Moreover, daily emails to the "shift report" distribution list indicating any issues, opportunities missed, and errors to ensure all departments involved keep the process efficient. Additionally, all attempts to contact EC, whether successful or not, will be documented in a memo-to-chart in our EMR. Starting on December 15, 2024, Executive Director will audit charts randomly choosing discharged clients to ensure compliance in this regard. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in seven out of seven applicable records. The facility's policy is to complete the psychosocial evaluation within twenty-four hours of admission to the non-hospital rehab.
Client #1 was admitted on September 8, 2024, and was discharged on September 11, 2024. A psychosocial evaluation was due to be completed no later than September 10, 2024; however, there was none documented in the client record.
Client #2 was admitted on August 6, 2024, and was discharged on September 29, 2024. A psychosocial evaluation was due to be completed no later than August 8, 2024; however, it was not completed until September 15, 2024.
Client #3 was admitted on September 30, 2024, and was discharged on October 19, 2024. A psychosocial evaluation was due to be completed no later than October 3, 2024; however, there was none documented in the client record.
Client #4 was admitted on August 3, 2024, and was discharged September 16, 2024. A psychosocial evaluation was due to be completed no later than August 5, 2024; however, it was not completed until September 9, 2024.
Client #5 was admitted on September 13, 2024, and was discharged October 20, 2024. A psychosocial evaluation was due to be completed no later than September 15, 2024; however, it was not completed until September 23, 2024.
Client #6 was admitted on September 14, 2024, and was still active at the time of the inspection. A psychosocial evaluation was due to be completed no later than September 16, 2024; however, it was not completed until October 7, 2024.
Client #7 was admitted on October 9, 2024, and was still active at the time of the inspection. A psychosocial evaluation was due to be completed no later than October 11, 2024; however, it was not completed until October 16, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The previous POC will be maintained, but will be amended for greater accountability and support. We will establish a backup system where secondary counselors from the intake department are assigned to cover evaluations, as well as interns as tertiary backup, if primary counselors are unavailable, ensuring no evaluations are missed due to staff absences or unavailability. Starting on December 15, 2024, Executive Director will audit charts randomly choosing active/discharged clients to ensure compliance in this regard. |
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.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in four out of six applicable records reviewed. The facility's policy is that case consultations must be completed within seven days of admission.
Client #4 was admitted on August 3, 2024, and was discharged on September 16, 2024. There was no documentation of a completed case consultation in the client record.
Client #5 was admitted on admitted on September 13, 2024, and was discharged on October 20, 2024. There was no documentation of a completed case consultation in the client record.
Client #6 was admitted on September 14, 2024, and was still active at the time of the inspection. There was no documentation of a completed case consultation in the client record.
Client #7 was admitted on October 9, 2024, and was still active at the time of the inspection. 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
The previous POC will be maintained, but will be amended. Starting on 1/8/2025, Clinical Director will be auditing Clinical Lead's "My Alerts" feature in Carelogic every other Monday to ensure compliance. Additionally, Microsoft Outlook's calendar will be utilized to scheduled reminders to clinical leadership three times a week. Starting on December 15, 2024, Executive Director will audit charts randomly choosing active/discharged clients to ensure compliance in this regard. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of rehab client records, the facility failed to provide a complete client record, which is to include follow-up information in three out of five applicable discharged records reviewed. The facility's policy is to follow-up on discharged clients within seven days of discharge.
Client #2 was admitted on August 6, 2024, and was discharged on September 29, 2024. There was no documentation of a follow-up contact in the client record.
Client #3 was admitted on September 30, 2024, and was discharged on October 19, 2024. There was no documentation of a follow-up contact in the client record.
Client #4 was admitted on August 3, 2024, and was discharged on September 16, 2024. There was no documentation of a follow-up contact in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The previous POC will be maintained, with two slight adjustments. All calls (successful or not) will be documented exclusively in a memo-to-chart in the EMR (to avoid documentation in various places). The Smartsheet will also be monitored by the Case Coordination Manager (as indicated in previous POC), but Intake Supervisor will also be monitoring weekly. Additionally, starting on December 15, 2024, Executive Director will audit charts randomly choosing active/discharged clients to ensure compliance in this regard. |