INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 18, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare York Pharmacotherapy Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Reports, the facility failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Reports for the 14 facilities contained within the project were reviewed on October 15, 2013. The equivalent of 105.275 full-time counselors are employed within the project. This would require at least 13 full-time clinical supervisors. The project currently employs 7 full-time clinical supervisors.
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Plan of Correction
The Vice President of Clinical Services will ensure that the ratio of Clinical Supervisors for the project is within the defined regulation of 1 fulltime clinical supervisor for every 8 fulltime counselors or counselor assistants. The Project will re-evaluate its current system and restructure the project to include the appropriate number of clinical supervisors. Human Resources coordinators will identify the number of clinical supervisors, counselors, and counselor assistants within the system on a quarterly basis. Vice President of Clinical Services will be responsible to review staffing hours quarterly to ensure that ratio is maintained. Program Directors will notify the Vice President of Clinical Services should any changes in the ratio per site occur during the quarter. Restructuring of the Clinical Supervisor ratio will begin December 1, 2013. Clinical Supervisor ratio will be in 100% compliance by January 1, 2014. |
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 the facility's staffing requirements facility summary report (SRFSR), the facility failed to ensure that staff persons and/or volunteers received 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 as per the regulatory requirements in one of eleven records reviewed.
The findings include:
The facility's SRFSR form completed by the facility was reviewed on October 4, 2013. The form listed one staff member as not having completed the mandatory training within the regulatory time frames
Employee # 11, a support staff person, was hired on November 19, 2007. Employee # 11 was required to obtain 4 hours of TB/STD training by November 19, 2009. The training was not documented as of the date of the inspection.
The findings were confirmed by the (position of the facility representative).
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Plan of Correction
Employee #11 has scheduled necessary training to be held January 15, 2014.
Human resource coordinators will ensure that training evaluations for all trainings are placed in each individual's employee file. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel and training records, the facility failed to document the completion of 12 clock hours of annual training required for project directors in one of one personnel records.
The findings include:
Fourteen personnel records were reviewed on October 8, 2013. One personnel record pertained to the project director and required the documentation of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 has been the project director since July 1, 1999. The facility training year is from July through June. Employee # 1 had documentation of 10.5 hours of training for the July 2012 - June 2013 training year.
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Plan of Correction
Project Manager will complete 12 hours of training annually. Project Manager will ensure needed documentation of completed trainings is presented to Human Resources to be recorded in Personnel File. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant tour, the facility failed to ventilate staff and client restrooms by an exhaust fan or window.
The findings include:
The physical plant tour was conducted on October 17, 2013. The staff restroom, the three client restrooms and one monitoring restroom failed to have an operable window or a working exhaust fan. An interview with the facility director on October 17, 2013 confirmed the findings.
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Plan of Correction
York County maintenance conducted an inspection of ventilation system on October 18, 2013. All ventilation units are operating appropriately.
The facility will conduct monthly checks on all ventilation systems to ensure operational.
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709.91(b)(6) LICENSURE Intake and admission
709.91. 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, the facility failed to provide a psychosocial evaluation to include the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and/or counselor conclusions and impressions in six of eight records reviewed.
The findings include:
Sixteen client records were reviewed October 17, 2013 Psychosocial evaluations were reviewed in eight client records.
The psychosocial evaluations in client records # 2, 3, 4, 5, 6 and 7 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records # 2, 3, 4, 5 and 7 did not include an evaluation of the client's support systems.
The psychosocial evaluations in client records # 2, 3, 4, 5, 6 and 7 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records # 2, 3, 4, 5 and 7 did not include an evaluation of the negative factors of the client.
The psychosocial evaluations in client record # 3 did not include an evaluation of the counselor conclusions/impressions of the client.
Additionally, based on the review of client records, the facility failed to develop a psychosocial evaluation upon completion of the intake process in 2 of eight records reviewed, #1 and 8.
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Plan of Correction
All counselors were provided informative packets on psychosocial evaluations and necessary
information that is required to demonstrate treatment needs and client history.
Program Director will conduct monthly random chart reviews to ensure compliance. Corporate Compliance Officer will conduct quarterly compliance audits.
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