INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 22-24, 2012, by staff from the Division of Drug and Alcohol 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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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ensure that each bathroom has a working exhaust fan or window to provide adequate ventilation.
The findings include:
An licensure renewal inspection was conducted on May 22-24, 2012. There was one unisex bathroom in the suite of offices which is designated for staff use. There were two bathrooms outside the suite which were designated for use by clients and the public.
The bathrooms located outside the suite which were intended for use by facility clients and the public did not have working exhaust fans or windows at the time of the inspection.
The finding was reviewed with the facility director and was not disputed.
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Plan of Correction
705.24(5) The unisex bathroom located within the suite has been designated for client use. This location has a working exhaust fan. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the fire drill log, the facility failed to document the exits used for each fire drill.
The findings included:
The licensure renewal inspection was conducted on May 22-24, 2012. The fire drill log did not include documentation of which exits were used during each fire drill. Fire drills documented on 11/8/11, 12/15/11, and 3/12/12 did not include documentation of the exits used during the drill.
The findings were reviewed with the Facility Director and were not disputed.
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Plan of Correction
705.28(d)(5): Staff responsible for conducting fire drills and maintaining fire drill logs will be re-trained by the Program Director by 5/25/12. Compliance will be reviewed on at least a monthly basis at the monthly facility meeting of the Risk Committee. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on the review of the fire drill log, the facility failed to set off a fire alarm or have an approved alternative method of announcing fire drills.
The findings included:
The fire drill log presented for review on May 22, 2012 did not include documentation of the activation of fire alarms during the fire drills conducted on 12/15/11, 1/20/12. 2/23/12, 3/12/12, and 4/9/12. The facility did not have any documentation of a Division approved alternative procedure to use if the fire alarms could not be activated during fire drills.
The finding were reviewed with the Facility Director and were not disputed.
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Plan of Correction
705.28(d)(7): The program Diretcor will draft a letter requesting an exception from DOH in regards to activating alarm during fire drills. Due to the office being based in a complex where the fire alarm system is universal to all offices, we are requesting the use of hand operated air horns to initiate fire drills. Should this letter of exception be approved, we will monitor the use of the alternative procedure through documentation on the fire drill logs monthly. Should the exception not be approved, Maintenance will purchase an internal fire/smoke detecting system to utilize within the specific office space. This plan will be implemented no later than 15 days after receiving denial of exception. |
709.28(c) 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 shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to obtain informed, written consents to release client identifying information from the client in 5 of 8 client records.
The findings include:
Eight client records were reviewed during the licensing renewal inspection conducted on May 22-24, 2012. Consent to release information forms signed by clients and staff in 5 of 8 client records were incomplete and, therefore, not informed consents to release information.
Client record # 1 - The client was admitted 4/12/12 and was last seen on 5/17/12. There were three consents to release information to funding agencies, a consent to release information to a probation officer and a consent to release information to a testing lab dated 4/12/12. The consents to release information did not include a purpose for the release of information. An expiration date was missing from the consent to release information to the probation officer.
Client record # 2, The client was admitted on 5/1/12 and was last seen on 5/21/12. The documentation in the record contained consents to release information executed on 5/1/12 to family members, the Single County Authority, a probation officer and a testing lab. The consents to release information did not include the expiration dates of the consents.
Client record # 4 - This client was admitted on 2/12/12 and was last seen on 5/17/12. A consent to release information form for a release of information to the Office of Vocational Rehabilitation was executed with the client on 3/15/12. The purpose for the release of information was not documented on the consent.
Client record # 5 - This client was admitted on 3/20/12 and was last seen on 5/18/12. A consent to release information was executed with this client for a release to another agency in the area on 5/12/12. The specific information to be released was not identified on the consent from.
Client record # 6- This client was admitted on 1/31/12 and was last seen on 3/9/12. Consents to release information to the he Single County Authority, a probation officer, a family member and a testing lab which were dated 1/31/12 did not include documentation of an expiration date.
The findings were reviewed with the Facility Director and were not disputed.
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Plan of Correction
709.28(c): The Program Director will review the procedure for obtaining informed and voluntary consent at staff meeting on 6/1/12 and 6/15/12. Counselors will ensure that every consent is complete including purpose and information to be released. The Program Director will ensure 100% compliance in monthly open chart audits. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to document psychosocial evaluations within timeframes specified in facility policy in six of eight client records.
The findings included:
Eight client records were reviewed during the licensure renewal inspection of May 22-24, 2012. Facility policy and procedure required documentation of a psychosocial evaluation by the fifth treatment session. Six of eight client records included documentation demonstrating that the facility failed to complete psychosocial evaluations within the five sessions required by facility policy.
Client record # 1 - the client was admitted on 4/12/12 and was last seen on 5/17/12. The psychosocial evaluation was not documented until the ninth treatment session.
Client record # 2 - the client was admitted on 5/1/12 and was last treated on 5/21/12. The client was seen for a total of seven treatment sessions at the time of the record review on 5/22/12, but the psychosocial evaluation was not completed.
Client record # 3 - the client was admitted on 3/23/12 and was last seen on 5/18/12. The client had been seen for 9 sessions as of the time the record was reviewed on 5/23/12. The psychosocial evaluation was not completed.
Client record # 4 - the client was admitted on 2/12/12 and was last seen on 5/17/12. The psychosocial evaluation was not documented until the sixth treatment session in this record.
Client record # 5 - the client was admitted on 3/20/12 and was last seen on 5/18/12. The fifth treatment session was completed on 4/10/12. The psychosocial evaluation was not completed until 4/13/12.
Client record # 6 - the client was admitted on 1/31/12 and was last seen on 3/9/12. At the time of the record review on 5/23/12 the client had attended eight treatment sessions. The psychosocial evaluation was not completed as of 5/23/12.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
709.91(b)(6): The Program Director will revisit designated time lines for documentation in staff meeting by June 15, 2012. Program Director will continue to monitor the plan of correction through monthly chart audits. Counselors will complete all psychosocial evaluations by the 5th treatment session. Program Director will monitor open and closed charts monthly to ensure 100% compliance. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and the facility policy manual, the facility failed to document an aftercare plan in three of four client records.
The findings include:
The annual onsite licensure renewal inspection was conducted May 22-24, 2012. Eight client records were reviewed. Four records were those of discharged clients. Documented facility policy states that the continuing care plan (aftercare plan) is initiated by the counselor following admission and that a plan is developed with each client.
Client record # 5 - the client was admitted on 3/20/12 and discharged on 5/18/12. There was no documentation included in the record to indicate that a continuing care plan had been initiated with the client.
Client record # 6- the client was admitted on 1/31/12 and discharged on 3/9/12. There was no documentation included in the record to indicate that a continuing care plan had been initiated with the client.
Client record # 7- The client was admitted on 1/9/12 and discharged on 3/12/12. There was no documentation included in the record to indicate that a continuing care plan had been initiated with the client.
The findings were reviewed with the Facility director and were not disputed.
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Plan of Correction
709.93(a)(9): VP of Clinical Services will revise the aftercare form to include continuing care goals with measureable expectations by June 15, 2012. VP of Clinical Services will revise Policy to reflect protocol instituted with form. Program Director will train staff on appropriate use of new form and review policy with staff by June 22, 2012. Completion of appropriate form will be monitored in monthly closed chart audit conducted by PD or VP of Clinical Services. |