INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26, 2022 through July 27, 2022 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. 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to maintain documentation that counselor assistants receive direct observation of the provision of counseling services as part of their close supervision, in two of three applicable records reviewed.
Employee # 9 was hired as a high school level counselor assistant by the facility on April 18, 2022. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision for the weeks of June 27, 2022, June 20, 2022, June 13, 2022, or June 6, 2022.
Employee # 11 was hired as an Associate ' s degree level counselor assistant by the facility on March 28, 2022. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #9 no longer works for Pyramid Healthcare. Employee #11's supervision will be reviewed and documented correctly in the supervision notes.
The Regional Quality Manager will meet with the Clinical Director to review the process of supervising a counselor assistant. Target date is 9/15/2022. The CS will ensure the Lead Counselor is meeting the requirements and is documenting properly direct and close supervision of a CA. This will occur in monthly supervision. The Executive Director will monitor in the CS monthly supervision to ensure this is occurring. This process will start immediately.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of thirteen personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that two applicable employees received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a counselor on August 3, 2020 and was due to have the communicable disease trainings no later than August 3, 2021. However, there was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #5 was hired as a counselor on April 12, 2021 and was due to have the communicable disease trainings no later than April 12, 2022. However, there was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 9, 2021, July 14, 2020, August 8, 2019, and August 29, 2018 annual licensing inspections.
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Plan of Correction
The Clinical Supervisor will ensure the two counselor that were indentified as delinquent will complete the DDAP course on September 8-9 2022 or October 11-12 2022. The Clinical Supervisor and the BHT Manager as well as the rest of the leadership team will meet on a monthly basis and track/ monitor all completion of staff trainings. Pyramid had created a position of staff trainer whose main objective is to train all new employees and to track all required trainings. He will report to leadership in the monthly meeting the progress of all trainings for new and existing employees.
Executive Director will ensure that all Department Managers monitor their assigned staff for compliance of Communicable Diseases training attendance through supervision. Human Resource Coordinator to complete quarterly reviews of employee files for facility staff to ensure 100% compliance. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of thirteen personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two applicable records reviewed.
Employee # 4 was hired as a counselor on August 31, 2015 and has remained in that position. The facility's training year that was reviewed was from January 2021 through December 2021. Employee #4's personnel record only documented 15 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director for the facility will track/monitor completion of staff training hours for all employees.CD will review with HR the policy of using college courses as training hours as Empoyee #4 was in his Doctorate Program, to ensure that all employee that are currenlty in school recieve credit. Program Director will ensure that all Department Supervisors monitor their assigned staff for compliance of annual required training attendance through supervision. Human Resource Coordinator to complete quarterly reviews of employee files for facility staff to ensure 100% compliance. Target date for completion is 10/15/2022. |
705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a physical plant inspection on July 27, 2022, the facility failed to ensure that bunk beds were equipped with securely attached railings as the bunk bed in Bedroom #4 of the Farmhouse did not have a railing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A security bar was placed on the bunk bed immediately. Monthly walk through will occur with the Executive Director and a member of maintenance to ensure all clients living quarters are safe. Person responsible is Maintenance and ED. This will be documented an reviewed in the monthly PI Meeting. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection on July 27, 2022, the facility failed to ensure exits from the facility were unobstructed as the second and third floor exits of the Lakehouse were obstructed by a low hanging wire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/24/2022 The policy for fire drill was reviewed with Leadership staff, Risk Management Committee, and Administrative Coordinator. Moving forward the fire drills are to be performed on all shift including hours the clients are sleeping and will alternate exits doors.
While conducting fire drills all exits will be un- obstructed.
On 8/16/2022 the low hanging wire were fixed.
Maintenance supervisor and Executive Director will conduct monthly walkthroughs to ensure the safety of the units and the clients This will be documented and reviewed in the Risk/PI meeting 1x per month. Administrative Assistant will oversee this task.
All the fire drills are documented in a smartsheet by maintenance director. The smart sheet will be reviewed by the administrative assistant and the program director on a monthly basis to ensure the fire drills are completed as required. The Risk Lead will also monitor the smartsheet and keep track of the fire drills to ensure they are occurring on second shift, while clients are sleeping and using alternate exits. Also during the drill and monthly reviews all exits will remain unobstructed. Target date for completion is 9/1/2022.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of facility fire drill logs from October 2021 through June 2022, the facility failed to conduct fire drills during sleeping hours at least every 6 months, as no fire drills were conducted during sleeping hours in any of the four buildings where clients reside.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/24/2022 The policy for fire drill was reviewed with Leadership staff, Risk Management Committee, and Administrative Coordinator. Moving forward the fire drills are to be performed on all shift including hours the clients are sleeping and will alternate exits doors.
While conducting fire drills all exits will be un- obstructed.
On 8/16/2022 the low hanging wire were fixed.
Maintenance supervisor and Executive Director will conduct monthly walkthroughs to ensure the safety of the units and the clients This will be documented and reviewed in the Risk/PI meeting 1x per month.
All the fire drills are documented in a smartsheet by maintenance director. The smart sheet will be reviewed by the administrative assistant and the program director on a monthly basis to ensure the fire drills are completed as required. The Risk Lead will also monitor the smartsheet and keep track of the fire drills to ensure they are occurring on second shift, while clients are sleeping and using alternate exits. Also during the drill and monthly reviews all exits will remain unobstructed. Target date for completion is 9/1/2022.
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of facility fire drill logs from October 2021 through June 2022, the facility failed to prepare alternate exit routes to be used during fire drills, as all drills in the Lakehouse, Farmhouse, and Detox buildings only used the front exit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/24/2022 The policy for fire drill was reviewed with Leadership staff, Risk Management Committee, and Administrative Coordinator. Moving forward the fire drills are to be performed on all shift including hours the clients are sleeping and will alternate exits doors.
While conducting fire drills all exits will be un- obstructed.
On 8/16/2022 the low hanging wire were fixed.
Maintenance supervisor and Executive Director will conduct monthly walkthroughs to ensure the safety of the units and the clients This will be documented and reviewed in the Risk/PI meeting 1x per month.
All the fire drills are documented in a smartsheet by maintenance director. The smart sheet will be reviewed by the administrative assistant and the program director on a monthly basis to ensure the fire drills are completed as required. The Risk Lead will also monitor the smartsheet and keep track of the fire drills to ensure they are occurring on second shift, while clients are sleeping and using alternate exits. Also during the drill and monthly reviews all exits will remain unobstructed. Target date for completion is 9/1/2022.
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705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on a review of facility fire drill logs from October 2021 through June 2022, the facility failed conduct fire drill son different staffing shifts as no fire drills were conducted during second shift.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/24/2022 The policy for fire drill was reviewed with Leadership staff, Risk Management Committee, and Administrative Coordinator. Moving forward the fire drills are to be performed on all shift including hours the clients are sleeping and will alternate exits doors.
While conducting fire drills all exits will be un- obstructed.
On 8/16/2022 the low hanging wire were fixed.
Maintenance supervisor and Executive Director will conduct monthly walkthroughs to ensure the safety of the units and the clients This will be documented and reviewed in the Risk/PI meeting 1x per month.
All the fire drills are documented in a smartsheet by maintenance director. The smart sheet will be reviewed by the administrative assistant and the program director on a monthly basis to ensure the fire drills are completed as required. The Risk Lead will also monitor the smartsheet and keep track of the fire drills to ensure they are occurring on second shift, while clients are sleeping and using alternate exits. Also during the drill and monthly reviews all exits will remain unobstructed. Target date for completion is 9/1/2022.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of three applicable records reviewed.
Client #5 was admitted on February 16, 2022 and discharged Against Medical Advice (AMA) on February 21, 2022. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
All clients that AMA or AFA will have their emergency contact called with in 12 hours. Executive Director will meet with the Leadership team and review the expectation of contacting the emergency contact one 8/24/2022. Clinical supervisor and Nurse Manager will follow up in group supervision and in the nurses meeting on 9/15/2022 to ensure that all staff understand the proper protocol for contacting emergency contacts throughout treatment. Follow up will be completed in chart audits by Leadership monthly. Person responsible is nurse manager and clinical supervisor. |
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.
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Observations
Based on a review of fourteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client #7 was admitted to the Detox activity on May 20, 2022 and was discharged on May 23, 2022. The record contained documentation that an emergency contact was contacted on May 23, 2022, to whom there was no client signed consent to release information form.
Client #9 was admitted to the Rehab activity on March 22, 2022 and was discharged on April 30, 2022. The record did not contain a current client signed consent to release information form to the funding source during the time period reviewed, and the record contained evidence of billing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will review with the Clinical Supervisor and Nurse Manager on 8/24/2022 in supervision about disclosure of information and consent. The supervisors of each team will meet with their employees before 10/1/2022 and discuss the importance of confidentiality. All new employees will be trained by the onsite trainer and the on-site trainer will set up a department specific training on confidentiality. The Clinical Supervisor and Nurse manager will continue to complete chart audits on a monthly basis. Quality Manager will also camplete random chart audits to ensure compliancance. Completion on training will be 10/1/2022 for all departments. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of fourteen client records, the facility failed to document that the client was given the opportunity to request reconsideration of a decision terminating treatment in two of two applicable records reviewed.
Client #3 was admitted to the Detox activity on October 2, 2021 and was behaviorally discharged on October 4, 2021.
Client #8 was admitted to the Rehab activity on December 23, 2021 and was behaviorally discharged on February 25, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review with clinical staff in group supervision on 8/25/2022 how to fill out a discharge letter in the discharge bundle in Care logic. The discharge letter would include the need to notify a client and document the decision to involuntarily terminate the client from treatment at the facility. The written notice will include the reasons for the termination. Clinical Supervisor will monitor compliance in this area through bi-weekly or monthly documented supervision and completion of monthly open and closed chart audits. The Quality Managment Team will also follow up with monthly chart audits. Target date for completion is 9/30/2022 |
709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of seven client records, the facility failed to include documentation of client personal histories in four of six applicable records reviewed.
Client #2 was admitted on July 21, 2022 and was active at the time of the inspection. The record did not include documentation of a personal history.
Client #4 was admitted on December 24, 2021 and was discharged on December 28, 2021. The record did not include documentation of a personal history.
Client #5 was admitted on February 16, 202 and was discharged on December 21, 2022. The record did not include documentation of a personal history.
Client #7 was admitted on May 20, 2022 and was discharged on May 23, 2022. The record did not include documentation of a personal history.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
Personal History: Intake and Admission
1. Clinical Director was hired
2. Implemented a counselor in Withdrawal Management occurred immediately.
3. Hired another intake worked
4. Implemented group supervision weekly with day and evening intake workers until KPI scores are above 80% person responsible for supervision is clinical supervisor or executive director. Start date will be Sept.15 2022.
5. Weekly supervision will also occur with assign supervisor to ensure all documents are complete. Person responsible is Clinical Supervisor/ Lead counselor
6. RQM will continue to review and complete chart audits.
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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 a review of seven client records, the facility failed to include documentation of a psychosocial evaluation in five of six applicable records reviewed.
Client #1 was admitted on July 19, 2022 and was active at the time of the inspection.
Client #2 was admitted on July 21, 2022 and was active at the time of the inspection.
Client #4 was admitted on December 24, 2021 and was discharged on December 28, 2021.
Client #5 was admitted on February 16, 202 and was discharged on December 21, 2022.
Client #7 was admitted on May 20, 2022 and was discharged on May 23, 2022.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
1. Clinical Director was hired
2. Implemented a counselor in Withdrawal Management occurred immediately.This will ensure that LOCA's will be completed durning the client stay in detox, or prior to the step down.
3. Hired another intake worker.
4. Implemented group supervision weekly with the day intake worker and evening intake workers until KPI scores are above 80%, the person responsible for supervision is clinical supervisor or executive director. Start date will be Sept.15 2022. The focus of supervision will be on intial documentation inculding psychosocial evauations.
5. Weekly supervision will also occur with assign supervisor to ensure all documents are complete. Person responsible is Clinical Supervisor/ Lead counselor
6. RQM will continue to review and complete chart audits |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 15 days in four of five applicable records reviewed.
Client #8 was admitted on December 23, 2021 and discharged on February 25, 2022. A treatment plan update was completed on January 6, 2022 and another treatment plan update was due to be completed by January 21, 2022; however, the next treatment plan update was not completed until January 25, 2022.
Client #10 was admitted on February 10, 2022 and discharged on March 24, 2022. The treatment and rehabilitation plan was completed on February 11, 2022 and a treatment plan update was due to be completed by February 26, 2022; however, the next treatment plan update was not completed until March 4, 2022.
Client #12 was admitted on June 9, 2022 and was active at the time of the inspection. A treatment plan update was completed on June 23, 2022 and another treatment plan update was due to be completed by July 8, 2022; however, the next treatment plan update was not completed until July 13, 2022.
Client #14 was admitted on June 20, 2022 and was active at the time of the inspection. A treatment plan update was completed on July 5, 2022 and another treatment plan update was due to be completed by July 20, 2022; however, no additional treatment plan updates were completed prior to the inspection.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
1. Clinical Director will meet with the counselor and review the expectation of treatment plans and treatment plan updates. They will review the expected timeframe all treatment plan updates. This will occur on 9/8/2022.
2. The executive director will meet with the new counselors 1x per week to review documentation including treatment plan and treatment updates to ensure they have an understanding of the DDAP expectations. Started on 8/5/2022
3. The Clinical Supervisor will support the counselor that are struggling with time management and documentation and provide supervision in both individual and group sessions. 1x month.
4. Regional Quality Managers will continue to complete chart audits on a monthly basis and RQMs will meet with the clinical supervisor once a month to offer support on increasing KPI with clinical documentation.
5. Executive Director will random chart audit to ensure documentation of treatment plan updates are occurring.
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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 a review of seven client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in three of seven records reviewed.
Client #10 was admitted on February 10, 2022 and discharged on March 24, 2022. The treatment and rehabilitation plan completed on February 11, 2022 indicated the client was to receive one individual session per week. The record of service and progress notes indicated that the client did not receive an individual session between February 18, 2022 and March 4, 2022.
Client #13 was admitted on June 27, 2022 and was active at the time of the inspection. The treatment and rehabilitation plan completed on July 13, 2022 indicated the client was to receive one individual session per week. The record of service and progress notes indicated that the client did not receive an individual session between July 5, 2022 and the date of the inspection.
Client #14 was admitted on June 20, 2022 and was active at the time of the inspection . The treatment and rehabilitation plan completed on June 21, 2022 indicated the client was to receive one individual session per week. The record of service and progress notes indicated that the client has only received individual counseling on July 5, 2022 and July 14, 2022.
These findings were discussed with facility staff during the licensing process.
This is a repeat citation from the September 9, 2021 annual licensing inspection.
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Plan of Correction
1. Clinical Director was replaced
2. CD will continue to complete chart audits and discuss in individual supervision monthly.
3. The new Clinical Director will discuss in group supervision the importance of completing treatment expectations and documentation in a timely manner. Due 9/1/2022
4. All new counselor under 6 months will meet with Executive Director 1x week to review documentation, new counselor issues, time management, topic related groups. This group will ensure the counselors have the opportunity to ask question and focus on any issues they are struggling with including documentation.
5. Regional Quality Managers will hold monthly meeting with the ED and CD to ensure the progress of documentation is progressing.
6. RQM will continue to monitor the charts on a monthly basis.
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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 a review of seven client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include documentation that the clients received case consultations within seven days of admission per the facility policy in three records reviewed.
Client #10 was admitted on February 10, 2022 and discharged on March 24, 2022.
Client #13 was admitted on June 27, 2022 and was active at the time of the inspection.
Client #14 was admitted on June 20, 2022 and was active at the time of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will train the clinical team on 8/26/22 in group supervision about documentation and timeframes and case consults for all clients.
Clinical Director will ensure that all documentation including case consults are included in charts by conducting monthly chart audits.
CD will review in staff meeting the expectation of completing case consults within seven days of admissionfor client in residential and in withdrawal managament.
Target date of 9/26/22
RQM will continue to audit the charts monthly to ensure all documentations present.
Executive Director will conduct random chart audits to ensure all documentation is completed.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of thirteen personnel records and fourteen client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing communicable disease trainings within regulatory times for staff was submitted and approved by the Department for the September 9, 2021, July 14, 2020, August 8, 2019, and August 29, 2018 annual licensing inspections. Completing communicable disease trainings within the regulatory timeframes was again found to be a deficiency in the July 26, 2022 through July 27, 2022 licensing inspection.
A plan of correction for providing counseling services according to the treatment plan for clients in the Rehab activity was submitted and approved by the Department for the September 9, 2021 annual licensing inspection. Providing counseling services according to the treatment plans was again found to be a deficiency in the July 26, 2022 through July 27, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure the plans of correction are followed as approved:
1. The Facility Director will meet with the Clinical Supervisor and Behavior Health Manager on the 1st Monday of each month to ensure that all staff members are up to date on all trainings. First Meeting will be Septeber 12, 2022
a. Any staff member identified as delinquent in trainings will be require to complete within one month/ or sign up for the next avaiable training. Staff responsible for documentation are the BHT manager and Clinical Supervisor.
b. Human Resources will review with Facility Director on a quarterly basis all staff training reports.
2. The Facility Director will meet with the Clinical Supervisor in monthly supervision to review Monthly Quality Compliance scores and in house chart audits to ensure that we are following the corrective action plan.
3. Clinical Supervision/Leadership will incorporate a training with staff about required treatment services and documentation.(9-15-2022) Any counselors that are identified as struggling, will increase their supervision to a group on Thursdays at 11am-12 until progress shown improvement and therefore aligns with the corrections plan.
Regional Quality Managers/ will meet with the Clinical Supervisor and Facility Director monthly to discuss Chart audits to ensure all treatment services are documented and that Langhorne is following the plan of correction.
Executive Director will report to Vice President of Operation the progress of the plans for managing training of staff. This will occur in monthly supervision.
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