INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16, 2014 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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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on the review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis which included individual counseling, at least twice weekly in two of four client records.
The findings include:
Eleven client records were reviewed on September 16, 2014. Four client records were reviewed as partial hospitalization clients and required documentation of individual counseling, at least twice weekly. Clients # 4 and # 6 did not document individual counseling, at least twice weekly.
Client # 4 was admitted on July 7, 2014. There was one individual counseling session documented for the week of July 20, 2014. There were no individual counseling sessions documented for the weeks of August 31 and September 7, 2014.
Client # 6 was admitted on February 19, 2014 and discharged on April 3, 2014. There were no individual counseling sessions documented for the weeks of February 23 and March 2, 2014. There was one individual counseling session per week documented for the weeks of March 9 and March 23, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be trained by October 15, 2014 and all individual counseling sessions will be scheduled in the electronic clinical record for twice per week, and a note recorded for each session, or a note indicating that the client did not attend the session with a reason wny and an indication of the rescheduled day with time.
Chart monitors done by the Clinical Supervisor each month will include this item beginning with the November 2014 open and closed chart monitors. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to document that the treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of four client records.
The findings include:
Eleven client records were reviewed on September 16, 2014. Five client records were reviewed as outpatient client records. The treatment and rehabilitation plans were not reviewed and updated at least every 60 days in client records # 10 and 11.
Client # 10 was admitted on January 6, 2014 and discharged on June 9, 2014. A treatment and rehabilitation plan was completed on February 1, 2014. There was no documentation of treatment plan updates due April 1 and June 1, 2014.
Client # 11 was admitted on May, 2014 and discharged on September 2, 2014. A treatment and rehabilitation plan was completed on June 17, 2014. There was no documentation of a treatment plan update due August 17, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be retrained by the Clinical Supervisor on the documentation of the treatment and rehabilitation plans that are to be reviewed and updated at least every 60 days. This retraining will be complete by October 15, 2014. Chart Monitors done by the Clinical Supervisor each month will include this item beginning with the November 2014 open and closed chart monitors. |