INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 6-7, 2011 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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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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's policy and procedures manual, the facility failed to document a psychosocial evaluation in accordance with the facility's policy in four of eight client records reviewed.
The findings include:
In reference to biopsychosocial evaluations, the facility's policy states:
The Biopsychosocial Evaluation shall be documented within seven days of admission.
On October 6, 2011 eight client records were reviewed for documentation of a biopsychosocial evaluation. Three client records did not include a dated biopsychosocial evaluation of the client, specifically records # 4,5, and 6. One client record, # 8 did not include a biopsychosocial evaluation at all.
Client # 4 was admitted on August 11, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within seven days.
Client # 5 was admitted on May 5, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within seven days.
Client # 6 was admitted on April 25, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within seven days.
Client # 8 was admitted on April 5, 2011. Documentation of a biopsychosocial evaluation was due by April 12, 2011. As of the date of inspection, there was no documentation of a biopsychosocial evaluation for client # 8.
The facility director confirmed the findings.
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Plan of Correction
Program Director will hold in-service for all counselors to review the inclusion of the date the psychosocial evaluation is completed. This in-service will be conducted by 11/30/2011. Compliance will be ensured by Program Director via open and closed chart monitors monthly. In addition, during this in-service, it will be demanded that counselors ensure a psychosocial evaluation is completed and dated accordingly for every client. This will also be monitored by the Program Director via open and closed chart monitors monthly. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document the frequency of services in the individual treatment and rehabilitation plan in four of seven client records.
The findings include:
On October 6, 2011 seven client records were reviewed for treatment plans that included the frequency of services. The facility did not document the frequency of services in the individual treatment and rehabilitation plans in client records # 4, 5 and 8.
Client # 4 was admitted on August 11, 2011. The treatment plan was completed on August 11, 2011 and did not include documentation of the frequency of treatment and rehabilitation services.
Client # 5 was admitted on May 5, 2011. A treatment plan was documented in the record, but was undated and did not include documentation of the frequency of treatment and rehabilitation services.
Client # 8 was admitted on April 5, 2011. The treatment plan was completed on April 5, 2011 and did not include documentation of the frequency of treatment and rehabilitation services.
The findings were confirmed by the facility director.
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Plan of Correction
Program Director will hold in-service for all counselors to review the inclusion of frequency of treatment and rehabilitation services in the individual treatment plan. This in-service will be conducted by 11/30/2011. Compliance will be ensured by Program Director via open and closed chart monitors monthly. Also included in this in-service will be review of the process of dating the treatment plan and objectives. This will be also be monitored for compliance by the Program Director monthly via open and closed chart monitors. |