INITIAL COMMENTS
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This report is a result of an on-site licensure follow up inspection conducted on February 20, 2009 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 March 23, 2009.
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Plan of Correction
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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 a client record review, the facility failed to document follow up within seven days in two of two client records.
The findings include:
Three short term detoxification client records were reviewed on February 20, 2009. Documentation of follow up was required in two client records. The facility did not document follow up within seven days in client record # 2 and # 3.
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Plan of Correction
The Receptionist will be responsible for follow-up calls for Short and Long term Rehabilitation clients, as well as Detoxification clients. The receptionist will receive the completed aftercare plans from either the primary counselor or the detox technician. 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 their home, within 7 days following discharge. The receptionist will keep a follow-up call log, which will be reviewed periodically by the clinical supervisor, who will oversee the follow-up care process. The facility will be in compliance with this standard by 5-1-09. |
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 a review of the policy and procedure manual, the facility failed to document a current referral agreement for client legal support services.
The findings include:
A review of the policy and procedure manual was held on February 20, 2009. The facility failed to document a current legal support service agreement.
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Plan of Correction
The Program Director assigned the task of updating and maintaining all referral agreements to the Administrative Assistant. Referral agreements will be updated every two years by the Administrative Assistant. This task will be overseen by the Clinical Supervisor. The facility will be in compliance with this standard by 5-1-09. |
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 a client record review, the facility failed to document an individualized treatment plan in one of five client records.
The findings include:
Five client records were reviewed on February 20, 2009. An individualized treatment plan was required in five client records. The facility did not document an individualized treatment plan in client record # 1. A generalized, standardized treatment plan form was used but no individualized goals were added for this particular client.
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Plan of Correction
The Program Director made revisions to the treatment plan forms and held an inservice training on 9-26-08 to address improving treatment planning. Transitions began utilizing the revised treatment plans on 9-29-08. Another inservice training, on treatment planning, was conducted by Pyramid Healthcare's Director of Performance Improvement on 3-06-09 from 9:00am-12:00pm. This training focused on the proper format for writing problem statements, goals, and objectives. The Clinical Supervisor is responsible for ensuring ongoing compliance with this standard through regular supervision with counselors and chart monitoring. |
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 a client record review, the facility failed to document individualized treatment goals in one of five client records.
The findings include:
Five client records were reviewed on February 20, 2009. Individualized treatment goals were required in five client records. The facility did not document individualized treatment goals in client record # 1. A generalized, standardized form was used but no individual goals were added for this particular client.
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Plan of Correction
The Program Director made revisions to the treatment plan forms and counseling staff participated in an in-service training on 9-26-08. Another in-service training was conducted, by the Director of Performance Improvement, on 3-6-09. This training included, but was not limited to the following: Problem Statements should be based on priority needs; Goals should address the problem statements; Goals should be attainable during the active treatment phase; The client should be able to understand the goals as written; The client's stage of readiness to change should be considered while writing the treatment plan; Objectives should address the goals; Objectives should be specific, realistic, measurable, and attainable; Interventions should address the objectives; Interventions should be measurable, attainable, realistic, and specific; The treament plan should be individualized to fit the client based on their unique abilities, goals, lifestyle, etc; Client strengths should be incorporated in the treatment plan; and The client should participate in developing his/her own treatment plan. The Clinical Supervisor is responsible to ensuring the ongoing compliance with this standard via regular supervision with counselors and by chart monitoring. |
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 a review of the policy and procedure manual, the facility failed to document a current referral agreement for client legal support services.
The findings include:
A review of the policy and procedure manual was conducted on February 20, 2009. The facility failed to provide documentation of its ability to assist the clients in obtaining legal support services.
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Plan of Correction
A referral agreement between Pyramid Healthcare, Inc. and Neighborhood Legal Services, Assoc. will be renewed by the Administrative Assistant. All referral agreements, including a current referral agreement for client legal support services, will be updated every two years by the Administrative Assistant. This process will be monitored by the Clinical Supervisor. The facility will be in compliance with this standard by 5-1-09. |
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 client record review, the facility failed to document a case consultation within seven days of admission, as is required by facility policy and procedure, in one of five client records.
The findings include:
Five client records were reviewed on February 20, 2009. Facility policy and procedure requires that a case consultation be documented in each client record within seven days of admission. Case consultations were required in five client records. The facility did not document a case consultation within seven days of admission in client record #5. Client #5 was admitted to treatment on 12/31/08 and the first case consultation occurred on January 9, 2009.
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Plan of Correction
A case consultation will be completed within seven days of a client's admission. Any members of the clinical team, who are present for the case consult, will sign their initials on a Treatment Plan Review/Update and Case Consultation Attendance Sheet, which is placed in the client chart. The Clinical Supervisor will ensure compliance with completion of Case Consultation forms and Case Consultation Attendance Sheets through chart monitoring. The facility will be in compliance with this standard by 5-01-09. |
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 client record review, the facility failed to document attempts to follow up on clients within seven days of the discharge date, as required by facility policy and procedure, in two of two client records.
The findings include:
Two inpatient client records were reviewed on February 20, 2009. Documentation of follow up was required in two client records. The facility did not document follow up attempts within seven days of the discharge date in client records # 4 and # 5.
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Plan of Correction
The receptionist is assigned the task of providing follow-up calls. The inpatient counselors will complete the Aftercare Plan and will give it to the receptionist. 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 their home)within 7 days following discharge. The receptionist will keep a follow-up call log, which will be reviewed periodically by the Clinical Supervisor. The facility will be in compliance with this standard by 5-1-09. |