INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 18, 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., Erie Outpatient 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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709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of partial client records, the facility failed to obtain a completed informed and voluntary consent which included the dated signature of client in one out of seven records reviewed.
Client # 13 was admitted on March 18, 2024, and discharged on June 17, 2024. A consent form for a pharmacy was completed on February 12, 2024, during the pre-admission process, but it did not contain a client signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will ensure all ROI's have been signed by both client and counselors. ROI's will be monitored by supervisors at time of admission/assessment for compliance. Supervisors will also review with counselors during supervision sessions.
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of partial client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of six applicable records reviewed.
Client #9 was admitted on April 30, 2024, and was still active at the time of the inspection. A treatment plan update was completed on May 28, 2024, and the next update was due no later than June 28, 2024; however, the next update was completed on July 2, 2024.
Client #14 was admitted on November 30, 2023 and discharged on March 11, 2024.A treatment plan update was completed on January 29, 2024 and the next update was due no later than February 29, 2024; however, it was completed on March 1, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors will ensure all treatment plan updates occur within 60 days of existing treatment plan. All treatment plans will be forwarded to a supervisor and physician for review and signature. Component of the supervisor's signature will be to monitor compliance through review that the update occurred within a 60 day time frame. Counselors will maintain a weekly case load tracker for all clients to ensure compliance. Case load trackers will also be reviewed during supervision sessions. |
709.93(a)(8) LICENSURE Client records
709.93. 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 outpatient client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in five of six applicable records reviewed. The facility's policy is that case consultations must be completed within ninety-days of admission.
Client #1 was admitted on January 8, 2024, and was still active at the time of the inspection. A case consultation was due no later than April 8, 2024; however, the initial case consultation was dated April 12, 2024.
Client #3 was admitted on April 11, 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 #4 was admitted on March 13, 2024, and discharged on June 20, 2024. A case consultation was due no later than June 13, 2024; however, the initial case consultation was completed on June 19, 2024.
Client #5 was admitted on January 26, 2024, and discharged on April 30, 2024. There was no documentation of a completed case consultation in the client record.
Client #7 was admitted on January 6, 2024, and discharged on May 20, 2024. 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
Counselors will ensure all case consults occur within 90 days of client's admission. Component of two other staff signatures, one being a supervisor's signature, will serve as communication and compliance monitoring. All staff were educated on the importance of signing documents daily, specifically case consults, in staff meeting on 7/26/24. Counselors will maintain a weekly case load tracker for all clients that highlight upcoming due dates for documentation to ensure compliance. Case load trackers will be reviewed with counselors each week by supervisors. |