INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 18, 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., 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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709.92(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 two of five applicable outpatient client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records # 10 and # 13.
Client # 10 was admitted on February 16, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on February 21, 2023. A treatment and rehabilitation plan update was due no later than April 21, 2023. A treatment and rehabilitation plan update did not occur until May 3, 2023.
Client # 13 was admitted on January 18, 2023 and was discharged June 9, 2023. A treatment and rehabilitation plan was developed on January 25, 2023. A treatment and rehabilitation plan update was due no later than March 25, 2023. A treatment and rehabilitation plan update did not occur until April 17, 2023.
These findings were reviewed with facility staff during the licensing process.
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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)(11) 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:
(11) Follow-up information.
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Observations
Based on two of three applicable outpatient client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur seven days from discharge.
Client # 13 was admitted on January 18, 2023 and was discharged on June 9, 2023.
There was no follow-up information available in the client record.
Client # 14 was admitted on December 13, 2022 and was discharged on May 24, 2023.
There was no follow-up information available in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pyramid Healthcare's written policy for client discharge from the program is that all clients will be called within 7 days of the discharge date. To ensure compliance with completing follow up calls is occurring the following will happen. Clinical Supervisor will run a weekly report of clients who have been discharged the week prior and monitor discharge documentation for completion of follow up call within 7 days and compliance. Routine monitoring will also be conducted on a monthly basis by Pyramid's quality and compliance team by reviewing a minimum of 5 treatment records per month which include both active and discharged charts. One of the monthly indicators that is monitored is that follow up calls are made in accordance with applicable licensing and funding requirements. Quality and Compliance team meets with site leadership monthly to review key performance indicators. If an indicator falls below the 80% benchmark, areas of opportunity are identified and discussed during these meetings. |