INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15-17, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc-Transitions 2 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 17, 2008.
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Plan of Correction
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709.82(e)(3) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on the review of administrative documentation on October 15-16, 2008, the facility failed to provide documentation that facility staff were able to assist the client in obtaining legal support services.
Findings:
There was no documentation provided that indicated that there were legal support services available to clients.
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Plan of Correction
Program Director will initiate a referral service agreement with legal services within the community and will send two copies of the referral agreement to said agency. Upon signature and return of referral agreement, the agreement will be placed in the Referral Agreement Binder. This will be in compliance by November 30, 2008. Compliance will be indicated by the properly completed, signed, and dated referral agreement for legal services in the Referral Agreement Binder. |
709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on the review of eleven client records on October 15-16, 2008, two were reviewed as partial hospitalization clients. The facility failed to document case consultation notes per policy in two of two records where required.
Findings:
Policy states that a case consultation will be completed within 7 days. Although consultation forms, completed within 7 days, were found in client records #10 and 11, the forms were incomplete and contained only the therapist's signature. There was no documentation that any additional staff had consulted on the case.
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Plan of Correction
The Program Director will hold an in-service training, on November 21st, from 12:00pm?3:00pm, to discuss the importance of properly completing case consultation forms within 7 days. The
members of the clinical team signatures are documented on a separate document entitled Treatment
Plan Review/Update and Case Consultation Attendance Sheet, which is filed after the Case Consultation
Sheet. The Clinical Supervisor will ensure compliance with completion of Case Consultation forms and
Case Consultation Attendance Sheets by monthly chart monitoring.
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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 eleven client records on October 15-16, 2008, two were reviewed as partial hospitalization records. The facility failed to document complete progress notes in two of two records where required.
Findings:
The group progress notes were missing data as there were no group topics identified in the group progress notes in client records # 10 and 11.
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Plan of Correction
Program Director will initiate a training plan on 11/3/2008 for current staff to address the completion of group progress notes that will include complete data of group topics identified in the group progress notes. This will be in compliance on or before 11/28/08 and compliance will be monitored through regular monthly chart monitors by the Program Director or Clinical Supervisor.
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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 eleven client records on October 15-16, 2008, two were reviewed as partial hospitalization records. The facility failed to document follow up information in two of two client records where required.
Findings:
There was no documentation that follow up had been completed in client records # 10 and 11.
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Plan of Correction
The Program Director will assign the task of follow-up calls to Transitions Receptionist. The inpatient counselors will complete the Aftercare Plan and will give it to the Receptionist.
The Clinical Supervisor will have oversight to ensure compliance with this standard. The Receptionist
will attempt to contact the client or the client's aftercare provider within 7 days following his/her initial
scheduled aftercare appointment or the Receptionist will call the client (at home) within 7 days following discharge. The purpose of this follow-up contact is to see how the client is doing and, if necessary, to provide support. The Receptionist will keep a follow-up call log, which will be reviewed monthly by the Clinical Supervisor. The facility will be in full compliance with this standard beginning December 1, 2008.
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on the review of eleven client records on October 15-16, 2008 , two were reviewed as short-term detoxification records. The facility failed to document a psychosocial evaluation in one of two client records where required.
Findings:
There was no documentation that a psychosocial evaluation was completed in client record # 9.
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Plan of Correction
We have reviewed the identified record and have concluded that the psychosocial evaluation is complete and is documented at the end of the nursing assessment. The nursing supervisor will remind nursing staff of the importance of doing a thorough psychosocial evaluation, as part of the nursing assessment. We have determined that no action plan is necessary at this time.
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709.63(a)(8) LICENSURE Follow-up Information
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:
(8) Follow-up information.
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Observations
Based on the review of eleven client records on October 15-16, 2008, two were reviewed as short-term detoxification records. The facility failed to document follow up in one of one client record where required.
Finding:
There was no documentation that follow up had been completed in client record # 9.
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Plan of Correction
The Program Director will assign the task of follow-up calls to Transitions Receptionist. The Detox Technician will complete the Aftercare Plan and will give it to the Receptionist. The Clinical Supervisor will have oversight to ensure compliance with this standard. The Receptionist will attempt to contact the client or the client's aftercare provider within 7 days following his/her initial scheduled aftercare appointment or the Receptionist will call the client (at home) within 7 days following
discharge.The purpose of this follow-up contact is to see how the client is doing and, if necessary, to provide support. The Receptionist will keep a follow-up call log, which will be reviewed monthly by the Clinical Supervisor. The facility will be in full compliance with this standard beginning December 1, 2008.
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709.64(c)(3) LICENSURE Legal support service
709.64. Project management services.
(c) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on the review of administrative documentation on October 15-16, 2008, the facility failed to provide documentation that facility staff could assist clients in obtaining legal support services.
Findings:
There was no documentation provided that indicated that legal support services were available to clients and/or that facility staff could assist clients in obtaining legal support services.
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Plan of Correction
A referral agreement is in place between Pyramid Healthcare, Inc. and Neighborhood Legal Services, Assoc. However, this referral agreement has since expired as of March 2008. The
Program Director will assign the Administrative Assistant the task of updating this referral agreement,
and any others which may be out of date. Referral agreements will be updated every two years by the
Administrative Assistant. The facility will be in full compliance with this standard by January 1, 2009.
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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 eleven client records on October 15-16, 2008, seven were reviewed as in patient non-hospital records. The facility failed to document a complete psychosocial evaluation in six of seven client records where required.
Findings:
In client records # 2, 3, and 7 the assets/strengths component was client reported and not a clinical evaluation. In client records # 2, 4 and 6, the conclusions/impressions were either historical information or addressed only the clients' readiness for treatment. The conclusion/impressions were not clinically evaluative.
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Plan of Correction
The Program Director will hold an in-service training with the counseling staff to address ways to improve clinical documentation, especially relating to the psychosocial evaluation (assets /strengths and conclusion/impressions). This training will be scheduled for November 21, 2008, from 12:00pm -3:00pm. The Clinical Supervisor will be responsible for ensuring ongoing compliance with this standard through monthly group and individual supervision. Ongoing compliance will also be monitored through the completion of chart monitors on a monthly basis. The facility will be in full compliance with this standard by December 1, 2008.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of eleven client records on October 15-16, 2008, seven were reviewed as in patient non-hospital records. The facility failed to document an individualized treatment and rehabilitation plan in seven of seven client records where required.
Findings:
The treatment plans were standardized, pre typed plans that listed the same short and long term goals for each client. There were no individualized goals or support services listed on the individual treatment plans. The plans were not individualized in client records # 1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
The Program Director made revisions to the treatment plans that were being used. All clinical staff participated in an in-service training, which was held on Sept. 26, 2008. This
in-service training was conducted by the Program Director. This training included the following: the need to individualize treatment plans, the need to make goals measurable, the need for mental health issues to be addressed, the need for the client to fully participate in the development of his/her treatment plan, the need for treatment plan updates to include detailed client progress in treatment,
and the need for client progress to be reflected in the progress note. Transitions began utilizing these
new forms on Sept. 29, 2008. The Clinical Supervisor is responsible for ensuring ongoing compliance with this standard via regular supervision with the clinical staff and monthly chart monitoring.
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709.52(a)(1) LICENSURE Short/Long term TX Goals
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of eleven client records on October 15-16, 2008, seven were reviewed as in patient non-hospital records. The facility failed to document an individualized treatment and rehabilitation plan goals and objectives in seven of seven client records where required.
Findings:
The treatment plans goals and objectives were standardized, pre typed goals and objectives that listed the same short and long term goals for each client. There were no individualized goals listed on the individual treatment plans. The goals and objectives were not individualized in client records # 1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
The Program Director made revisions to the treatment plans that were being used. All clinical staff participated in an in-service training, which was held on Sept. 26, 2008. This
in-service training was conducted by the Program Director. This training included the following: the need to individualize treatment plans, the need to make goals measurable, the need for mental health issues to be addressed, the need for the client to fully participate in the development of his/her treatment plan, the need for treatment plan updates to include detailed client progress in treatment,
and the need for client progress to be reflected in the progress note. Transitions began utilizing these
new forms on Sept. 29, 2008. The Clinical Supervisor is responsible for ensuring ongoing compliance with this standard via regular supervision with the clinical staff and monthly chart monitoring.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of eleven client records on October 15-16, 2008, seven were reviewed as in patient non-hospital records. The facility failed to document that counseling services were provided according to the individual treatment and rehabilitation plan in two of seven client records where required.
Findings:
The clients were not receiving individual counseling sessions one time a week as required by the treatment plans in client records #4 and 6. In client record # 4, there was no individual counseling session documented for the week of October 5, 2008. In client record #6, there were no individual counseling sessions documented for the weeks of April 13, April 27, May 17 and June 1, 2008.
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Plan of Correction
Clients #4 and 6 were involved in Long-term inpatient rehabilitation (3C Level of Care). Despite the fact that clients are in Short-term inpatient treatment, or Long-term(3C) inpatient
treatment, Pyramid Healthcare policy states that the minimum requirements for frequency of documentation are weekly. The Program Director will discuss this policy, in an in-service training scheduled on November 21, 2008, from 12:00pm-3:00pm. In regards to the missing individual progress
notes, The Program Director will discuss the importance of the notes matching the record of service
forms. In client record #6, there was an individual note for the week of April 13th (note is dated 4-17-08). An individual note is present for the week of May 17th (note is dated 5-12-08 and 5-19-08).
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709.52(e)(3) LICENSURE Legal support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on the review of administrative documentation on October 15-16, 2008, the facility failed to provide documentation that facility staff were able to assist the clients in obtaining legal support services.
Findings:
There was no documentation provided that indicated that the staff were able to assist clients in obtaining legal support services.
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Plan of Correction
A referral agreement is in place between Pyramid Healthcare, Inc. and Neighborhood Legal Services, Assoc. However, this referral agreement has since expired as of March 2008. The
Program Director will assign the Administrative Assistant the task of updating this referral agreement,
and any others which may be out of date. Referral agreements will be updated every two years by the
Administrative Assistant. The facility will be in full compliance with this standard by January 1, 2009.
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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 eleven client records on October 15-16, 2008, seven were reviewed as in patient non-hospital records. The facility failed to document complete progress notes in six of seven client records where required.
Findings:
The group progress notes were missing the data as there were no group topics identified in the group progress notes in client records # 1, 2, 3, 4, 5 and 6.
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Plan of Correction
The Program Director will hold an in-service training with the counseling staff, on November 21, 2008, from 12:00pm-3:00pm. During this training, we will discuss the importance of
adding group topics to the data section on the group note. We will also discuss the need for the
counselors to improve on the quality of their documentation and expand on the clinical content in the
client record.
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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 the review of eleven client records on October 15-16, 2008, seven were reviewed as in patient non-hospital records. The facility failed to document case consultation notes in accordance with facility policy in three of seven records where required.
Findings:
Facility policy states that a case consultation will be completed within 7 days. Although consultation forms, completed within 7 days, were found in client records # 2 and 4, the forms were incomplete and contained only the therapist's signature. There was no documentation that any additional staff had consulted on the case.
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Plan of Correction
The Program Director will hold an in-service training, on November 21st, from 12:00pm ?3:00pm, to discuss the importance of properly completing case consultation forms within 7 days. The
members of the clinical team signatures are documented on a separate document entitled Treatment
Plan Review/Update and Case Consultation Attendance Sheet, which is filed after the Case Consultation
Sheet. Both client records #2 and 4 contained this Case Consultation Attendance Sheet. We believe that we do need to address the issue of how to properly complete a Case Consultation form, however, no action plan is needed to address the reported lack of evidence of additional staff consulting on the case. The Clinical Supervisor will ensure compliance with completion of Case Consultation forms and Case Consultation Attendance Sheets by monthly chart monitoring.
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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 the review of eleven client records on October 15-16, 2008, seven were reviewed as in patient non-hospital records. The facility failed to document follow up information in three of three records where required.
Findings:
There was no documentation that follow up had been completed in client records # 5, 6 and 7.
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Plan of Correction
The Program Director will assign the task of follow-up calls to Transitions Receptionist. The inpatient counselors will complete the Aftercare Plan and will give it to the Receptionist.
The Clinical Supervisor will have oversight to ensure compliance with this standard. The Receptionist
will attempt to contact the client or the client's aftercare provider within 7 days following his/her initial
scheduled aftercare appointment or the Receptionist will call the client (at home) within 7 days following discharge. The purpose of this follow-up contact is to see how the client is doing and, if necessary, to provide support. The Receptionist will keep a follow-up call log, which will be reviewed monthly by the Clinical Supervisor. The facility will be in full compliance with this standard beginning December 1, 2008.
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