INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 9, 2021 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of facility fire drills from June 2020 until June 2021, the facility failed to ensure that fire drills from January 2021 to June 2021 included the exit routes used. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
We will have an indicator of the exit that we use on the fire drill form.
All staff will be trained on protocol in weekly staff meeting, once per month and will be able to identify exit in real life as well as where to document it on the drill form.
Director will be responsible for ensuring that all staff understand the protocol.
New protocol and form creation will be reviewed and created to be addressed on in staffing meeting on 9/23/21 and will be implemented for September fire drill for 2021. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment plan that was developed with the client within seven days of admission, per facility policy, in two of four partial hospitalization client records reviewed on August 9, 2021.No individual treatment plans were documented in the following client records:Client # 4 was admitted February 4, 2021 and discharged March 15, 2021.Client # 5 was admitted January 12, 2021 and discharged January 29, 2021.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors will ensure that clinical records include a comprehensive treatment plan which identifies goals and actions steps towards recovery planning within 7 days of a client's admission into the program. This document will show mutual acceptance by the patient and the program through required signatures of the patient, primary counselor, clinical supervisor and physician. Treatment plan updates will be completed and reviewed minimally every 60 days or during a change in the course of treatment.
Compliance will be monitored monthly through open chart reviews completed by the Regional Quality Manager and Clinical Supervisor. Results of the open chart monitors will then be submitted to the Program Director for further review. Any deficiencies noted will be address in clinical supervision. |
709.83(a)(11) LICENSURE Client records
709.83. 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.
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Observations
Based on a review of client records, the facility failed to document follow-up information within seven days of discharge, per facility policy, in three of four partial hospitalization client records reviewed on August 9, 2021.No follow-up information was documented in the following client records:Client # 4 was admitted February 4, 2021 and discharged March 15, 2021.Client # 5 was admitted January 12, 2021 and discharged January 29, 2021.Client # 6 was admitted January 13, 2021 and discharged January 26, 2021.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A follow-up call within 7 days of discharge will be required for discharged patients. This follow-up call will be completed by the primary clinician and then documented with the electronic health record.
Compliance will be monitored monthly through open and closed chart reviews completed by the Regional Quality Manager and Clinical Supervisor. Results of the open and closed chart monitors will then be submitted to the Program Director for further review. Any deficiencies noted will be address in clinical supervision.
Director will ensure that clients who weren't called upon discharge, will be called and followed up on in real time and outcome of needs will be documented.
Director will be sending out discharge listings twice weekly and will require all counselors to ensure discharge call occurs upon official discharge.
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