INITIAL COMMENTS
|
This report is a result of an onsite follow-up inspection regarding the plans of correction for the July 2 - 3, 2011 licensure renewal inspection. The follow-up inspection was conducted on February 6, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Pyramid Healthcare Chambersburg 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.
|
Plan of Correction
|
704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
|
Observations
Based on the review of the facility's policy and procedure manual, the project failed to demonstrate that the project director assisted the governing body in formulating facility
policy and procedures.
The findings include:
The facility's policies and procedures were reviewed on February 6, 2012. The project director failed to document the annual update of the written project's policies and procedures, as required by regulation.
An interview with the facility director/clinical supervisor on February 6, 2012 confirmed the findings.
|
Plan of Correction
Effective immediately the Project Director will ensure that the board meeting minutes reflect active board participation in approving written plans and policies for the project at least annually. Board meeting minutes will reflect such approval, and policy signature sheets will be placed in all P&P manuals. The Facility Director will ensure compliance by submitting P&P signature sheets, and relevant board meeting minutes during DOH site visits. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on a discussion from the facility director/clinical supervisor, the facility failed to ensure that staff to client ratios remained at or under 35:1.
The findings included:
Based on the number of hours the employee worked at this facility, and the number of clients on the counselors' caseload, all employees who provided counseling exceeded the maximum ratio of 35:1. The facility director/clinical supervisor represented as employee # 1 had a caseload of 240:1. The counselor represented as employee # 2 had a caseload of 37:1.
On February 6, 2012, the facility director/clinical supervisor reported that the employee #1 had 18 clients and employee #2 had 35 clients. The facility director/clinical supervisor also reported the employee #1 dedicated 3 hours to the drug and alcohol clients and employee #2 dedicated 38 hours to the drug and alcohol clients. The work week according to the facility director/clinical supervisors is 40 hours per week.
Based on the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week (40), and the total number of clients assigned to the following employees on February 6, 2012, 18 to employee #1 and 35 to employee #2, #1 and 2 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by the facility's standard workweek.
The number of hours per week devoted by Employee # 1 to client treatment, as reported by the facility director/clinical supervisor, was 3 hours per week. The facility director/clinical supervisor reported that Employee # 1 had 18 active clients on February 6, 2012.
Employee # 1 (3/40 = 0.075 FTE 18 clients/0.075 FTE = 240:1 caseload)
The number of hours per week devoted by Employee # 2 to client treatment, as reported by the facility director/clinical supervisor, was 38 hours per week. The facility director/clinical supervisor reported that Employee # 2 had 35 active clients on February 6, 2012.
Employee # 2 (38/40 = 0.95 FTE 35 clients/0.95 FTE = 37:1 caseload)
|
Plan of Correction
Effective 2/8/12 employee #1 has no clinical hours as program director. Effective 2/10/12 employee #2 has a ratio of 30:1. Clinical hours were transferred to employee #3 who now has a ratio of 25:1. Program Director will ensure via weekly staff meetings and daily case management that ratios do not exceed standard of 35:1.The Facility Director will ensure that all counselors meet the required counselor to client ratio through scheduled monthly (at minimum) supervisions with counselors. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the fire drill record, the facility failed to conduct fire drills monthly.
The findings include:
The fire drill record was reviewed on February 6, 2012. The following months were reviewed, November 2011, December 2011 and January 2012 and the facility failed to provide documentation that fire drills were conducted November 2011 and January 2012.
An interview with the facility director/clinical supervisor on February 6, 2012 confirmed the findings.
|
Plan of Correction
Effective February 29, 2012, the Facility Director will ensure that all fire drills are conducted monthly according to policy and results are properly documented. Compliance will be ensured through monthly random compliance and facility audits facilitated by the Director of Pharmacotherapy and/or Risk Safety Officer. |
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.
|
Observations
Based on a review of the fire drill record, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill record was reviewed on February 6, 2012. The following months was reviewed, November 2011, December 2011 and January 2012. The facility failed to document that each drill included the activation of the fire alarm or smoke detector . An interview with the facility director/clinical supervisor on February 6, 2012 confirmed the findings.
|
Plan of Correction
Effective February 28, 2012 all fire drills will involve activation of the fire alarm within the facility. The Facility Director will ensure that this is completed monthly and documented accordingly. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
|
Observations
Based on the review of the facility's policy and procedures, the project failed to demonstrate that the project director assisted the governing body in formulating facility
policy and procedures.
The findings include:
The facility's policies and procedures were reviewed on February 6, 2012. The project director failed to document the annual update of the written project's policies and procedures, as required by regulation.
An interview with the facility director/clinical supervisor on February 6, 2012 confirmed the findings.
|
Plan of Correction
Effective immediately the Project Director will ensure that the board meeting minutes reflect active board participation in approving written plans and policies for the project at least annually. Board meeting minutes will reflect such approval, and policy signature sheets will be placed in all P&P manuals. The Facility Director will ensure compliance by submitting P&P signature sheets, and relevant board meeting minutes during DOH site visits. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
|
Observations
Based on a review of administrative documentation, the project failed to present for review the goals and objectives for the fiscal year July 1, 2011 through June 30, 2012 .
The findings were:
A review of administrative documents on February 6, 2012 indicated that the annual goals and objectives for the fiscal year of July 1, 2011 through June 30, 2012 was not presented for reviewed during the follow-up inspection.
An interview with the facility director/clinical supervisor on February 6, 2012 confirmed that the annual goals and objectives for the fiscal year of July 1, 2011 through June 30, 2012 were not presented for review during the follow-up inspection.
|
Plan of Correction
Program specific goals and objectives will be created annually by the Facility Director, in conjunction with the Director of Pharmacotherapy and approved by the Board of Directors through regularly scheduled meetings. The Facility Director will ensure that program goals and objectives are presented during DOH site visits. Random audits conducted by the Corporate Compliance Officer will ensure compliance. |
709.24(a) 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:
|
Observations
Based on the review of the facility's policy and procedure manual, the project failed to demonstrate that the project director assisted the governing body in formulating
a written plan for coordination of client treatment and rehabilitation services..
The findings include:
The facility's policies and procedures were reviewed on February 6, 2012. The project director failed to document the annual update of the project's written policies and procedures, as required by regulation.
An interview with the facility director/clinical supervisor on February 6, 2012 confirmed the findings.
|
Plan of Correction
Effective immediately the Project Director will ensure that the board meeting minutes reflect active board participation in approving written plans and policies for the project at least annually. Board meeting minutes will reflect such approval, and policy signature sheets will be placed in all P&P manuals. The Facility Director will ensure compliance by submitting P&P signature sheets, and relevant board meeting minutes during DOH site visits. |
709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
|
Observations
Based on the review of the facility's policy and procedure manual, the facility failed to present updated letters of agreements.
The findings include:
The facility's policy and procedures were reviewed on February 6, 2012, revealing that there were no current agreements in place for Pyramid Healthcare Chambersburg. The facility still maintains the letters of agreements under the prior facility name, which is not valid since ownership changed November 7, 2011. An interview with the facility director on February 6, 2012 confirmed the findings.
|
Plan of Correction
Letters of agreement will be initiated by the Director of Pharmacotherapy with providers by March 30, 2012. Copies of request will be kept onsite until signed agreements are received at the facility. In the event signed copies are not received, the Facility Director will make documented attempts to contact the provider of service. Compliance will be monitored through random audits and conducted by the Director of Pharmacotherapy in conjunction with the Facility Director. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
|
Observations
Based on the review of the facility's policy and procedure manual, the facility failed to present the updated letters of agreements.
The findings include:
The facility's policy and procedures were reviewed on February 6, 2012, revealing that there were no current agreements in place for Pyramid Healthcare Chambersburg as the facility continued to still have the letter of agreements for NTP, which is not valid since they changed ownership November 7, 2011. An interview with the facility director on February 6, 2012 confirmed the findings.
|
Plan of Correction
On February 21, 2012, a letter of agreement was sent to the local hospital requesting 24 hour medical and psychiatric services. Copy of the request will be kept onsite until signed agreement is received. In the event signed copies are not received by the facility within 2 weeks of sending them, the Facility Director will make documented attempts to contact the provider of service. Compliance will be monitored through random audits and conducted by the Director of Pharmacotherapy in conjunction with the Facility Director. |
709.26(a) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
|
Observations
Based on the review of the facility's policy and procedure manual, the project failed to demonstrate that the project director assisted the governing body in formulating facility
policy and procedures.
The findings include:
The facility's policies and procedures were reviewed on February 6, 2012. The project director failed to document the annual update of the written project's policies and procedures, as required by regulation.
An interview with the facility director/clinical supervisor on February 6, 2012, confirmed the findings.
|
Plan of Correction
Effective immediately the Project Director will ensure that the board meeting minutes reflect active board participation in approving written plans and policies for the project at least annually. Board meeting minutes will reflect such approval, and policy signature sheets will be placed in all P&P manuals. The Facility Director will ensure compliance by submitting P&P signature sheets, and relevant board meeting minutes during DOH site visits. |
709.26(b) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
|
Observations
Based on the review of the facility's policy and procedure manual, the project failed to demonstrate that the project director assisted the governing body in formulating facility
policy and procedures.
The findings include:
The facility's policies and procedures were reviewed on February 6, 2012. The project director failed to document the annual update of the written project's policies and procedures, as required by regulation.
An interview with the facility director/clinical supervisor on February 6, 2012 confirmed the findings.
|
Plan of Correction
Effective immediately the Project Director will ensure that the board meeting minutes reflect active board participation in approving written plans and policies for the project at least annually. Board meeting minutes will reflect such approval, and policy signature sheets will be placed in all P&P manuals. The Facility Director will ensure compliance by submitting P&P signature sheets, and relevant board meeting minutes during DOH site visits. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include a composite picture of the client, client problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor conclusions and or impressions of the client in eight of eight client records.
The findings include:
Fifteen client records were reviewed on February 6, 2012. A psychosocial evaluation was required in eight of those records, #1, 2, 3, 4, 5, 6, 7 and 8. An interview with the facility director/clinical supervisor on February 6, 2012 confirmed the findings.
Client records #1,7 and 8 did not include a documented a composite picture of the client.
Client records #1, 2, 3, 4, 6, 7 and 8 did not include a documented evaluation of the client's problems/needs and how they would impact treatment.
Client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include a documented evaluation of the client's assets/strengths and how they would impact treatment.
Client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include a documented evaluation of the client's support systems and how they would relate to treatment.
Client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include a documented evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
Client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include a documented evaluation of the client's negative factors and how they would impact treatment.
Client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include a documented evaluation of the clients response to treatment and how it would effect their treatment.
Client records #2, 3, 4, 5, 6, 7 and 8 did not include a documented evaluation of the counselor's conclusion and impression of the client.
|
Plan of Correction
Staff will be trained on completing clinically based psychosocials. Training will be facilitated by the Facility Director in conjunction with the Director of Pharmacotherapy by March 30, 2012. Random monthly chart audits conducted by the Facility Director will ensure compliance in meeting this standard. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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:
(3) Proposed type of support service.
|
Observations
Based on the review of client records, the facility failed to document support services in seven of eight client records reviewed.
The findings include:
Fifteen client records were reviewed on February 6, 2012. Eight client records were reviewed for documentation of proposed support services on the client's treatment plan. Client records # 2, 3, 4, 5, 6, 7 and 8 had no documentation of proposed support services on the comprehensive treatment plan. An interview with the facility director/clinical supervisor on February 6, 2012 confirmed the findings.
|
Plan of Correction
Staff will be trained on the use of Pyramid Healthcare, Inc. comprehensive treatment plans which satisfies DOH requirements of identifying client supports/services. Training will be conducted by the Facility Director in coordination with the Director of Pharmacotherapy by March 30, 2012. Random monthly chart audits conducted by the Facility Director will ensure compliance in meeting this standard. |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document a case consultation within the 90 day time frame in two of two client records.
The findings include:
Fifteen client records were reviewed on February 6, 2012. Per agency policy, case consultations shall be completed every 90 days. Case consultations were required in two client records. The facility did not document a case consultations within the 90 day time frame in client records #3 and 5.
Client #3 was admitted on November 4, 2011. The case consultations were due by February 4, 2012. As of February 6, 2012 there was no documentation of a case consultation in record #3.
Client #5 was admitted on November 4, 2011. The case consultations were due by February 4, 2012. As of February 6, 2012 there was no documentation of a case consultation in record #5.
An interview with the facility director/clinical supervisor on February 6, 2012 confirmed the findings.
|
Plan of Correction
The Facility Director will ensure that all client case consults are completed every 90 days. Staff will be retrained on this standard by March 15, 2012. Each counselor will identify all clients on their caseload that are out of compliance [verified by the Facility Director] and submit reviews to the Facility Director by March 30th. Compliance will be monitored through staff meetings and random monthly chart audits conducted by the Facility Director. |
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.
|
Observations
Based on a review of client records, the facility failed to document an aftercare plan in seven of seven client record.
The findings include:
Fifteen client records were reviewed on February 6, 2012. Per the facility policy, the counselor and client will complete an aftercare plan prior to discharge. The aftercare must include goals with time frames, support services, contact person and reentry process. An aftercare plan was required in four client records, #9, 10, 11, 12, 13, 14 and 15. The facility did not document an aftercare plan in client records #9 and 11.
In client record # 9, the client was admitted on December 8, 2011 and was discharged on January 20, 2012. There was no documentation of an aftercare plan.
In client record # 11, the client was admitted on September 22, 2011 and was discharged on December 6, 2011. There was no documentation of an aftercare plan.
In client records #10, 12, 13, 14 and 15 failed to document goals with time frames in aftercare plans reviewed.
In client records #12, 14 and 15 failed to document support services in aftercare plans reviewed.
This was discussed and confirmed with the facility director/clinical supervisor on February 6, 2012.
|
Plan of Correction
The agency policy will be revised by the Corporate Compliance Officer by March 1, 2012. The revision will indicate that only successful discharged clients will complete aftercare plans. Until policy is changed staff is completing the aftercare form for every client as stated in the policy. Staff was trained on 2/10/12 in reference to adding time frames to action plans when appropriate and to document if client is unable to make a determination of a time frame. Chart audits conducted by the Facility Director on all discharges will ensure compliance in meeting this standard, as well as follow up during staff meetings and clinical supervisions. |
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.
|
Observations
Based on a review of client records, the facility failed to document follow-up attempts in seven of seven required records.
The findings include:
Fifteen client records were reviewed on February 6, 2012. Seven of the fifteen client records were required to document follow-up attempts. Follow up was not documented in seven required client records. Per the facility's policy and procedures, follow-ups will be conducted 7 days after discharge if not being referred. An interview with the facility director/clinical supervisor on February 6, 2012 confirmed the findings.
Client # 9 was admitted on December 8, 2011 and discharged on January 20, 2012. The follow up attempt was due on January 27, 2012. The follow-up was not documented in client record #9 as of February 6, 2012.
.
Client # 10 was admitted on November 8, 2012 and discharged on January 19, 2012. The follow up attempt was due on January 26, 2012. The follow-up was not documented in client record #10 as of February 6, 2012.
.
Client # 11 was admitted on September 22, 2011 and discharged on December 6, 2011. The follow up attempt was due on December 13, 2011. The follow-up was not documented in client record #11 as of February 6, 2012.
Client # 12 was admitted on October 17, 2011 and discharged on December 26, 2011. The follow up attempt was due on January 2, 2012. The follow-up was not documented in client record #12 as of February 6, 2012.
Client # 13 was admitted on September 29, 2011 and discharged on December 6, 2011. The follow up attempt was due on December 13, 2011. The follow-up was not documented in client record #13 as of February 6, 2012.
Client # 14 was admitted on September 30, 2011 and discharged on December 5, 2011. The follow up attempt was due on December 12, 2011. The follow-up was not documented in client record #14 as of February 6, 2012.
Client # 15 was admitted on August 16, 2011 and discharged on December 29, 2011. The follow up attempt was due on January 5, 2012. The follow-up was not documented in client record #15 as of February 6, 2012.
|
Plan of Correction
Staff will be trained on the use of the discharge summary form that includes a prompt for the 7 day follow-up call by March 15, 2012. The Facility Director is required to review all discharge summaries within 7 days and as such, documentation of the follow-up call will be included. The Facility Director will ensure compliance through random monthly discharge chart audits. |