INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 12, 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. York Inpatient 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the staffing facility summary report, staffing schedules and CPR certification cards, the facility failed to ensure that a least one person trained in CPR and first-aid was onsite during the projects hours of operations for the following shifts:
June 6, 2021 from 3pm until 11pm
June 7, 2021 from 3pm until 11pm
June 8, 2021 from 3pm until 11pm
June 12, 2021 from 7pm until 7 am.
June 14, 2021 from 3pm until 11pm
June 19, 2021 from 3pm until 11pm
June 20th, 2021 from 3pm until 11pm
June 21, 2021 from 3pm until 11pm
June 28, 2021 from 3pm until 11pm
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Since inspection CPR training was completed on 7/14/21 for 13 staff. As a result of this training, at least one person per each shift per department is trained in CPR. Another CPR training will occur on 8/31/21 for 7 staff, which will result in 90% of staff being CPR certified.
To ensure this does not occur in the future, Executive Director will run reports, effective 7/27/21, at the beginning of each month to ensure at least one person per shift per department is CPR certified. Based on these reports, CPR classes will be assigned to staff who are due to be recertified within the next 90 days, this process will be effective 7/30/21. To ensure new hire CPR certification, effective immediately 7/27/21, CPR classes will be required within 120 days by newly hired employees, offered quarterly, and if needed, offered more frequently to ensure all shifts have at least one staff CPR certified per department.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on review of the Staffing Requirements Facility Summary Report and six personnel records, the facility failed to document the completion of 25 clock hours of annual training in one personnel record reviewed.
Employee #4 was hired a counselor on April 15, 2019 and was still current in that position. The personnel record only had 19 hours of the required 25 hours of training documented
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
By 8/23/21, this staff will be required to complete 6 additional training hours to meet the 25 hours required that were initially failed to complete. To avoid this issue moving forward, the clinical director (effective 7/30/21) will run training reports at the end of each month to ensure 25 training hours are on track to be met for each calendar year. To ensure accurate report data of training hours, clinical director will review in group supervision on 7/28/21 the necessity to upload all training certificates to the organizational training platform (Relias). |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection the facility failed to ensure that all stairways, hallways, and exits were unobstructed as the third floor exit door was blocked by a chair and the bottom of the emergency exit stairs also had a chair in front of the stairs and a chain in front of the first step.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
These barriers were removed during inspection. Maintenance staff will ensure all exits are not obstructed during daily facility walkthrough. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a physical plant inspection the facility failed to ensure that a sleeping hours fire drill was conducted at least every six months as the last sleeping hour fire drill was conducted on July 31, 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Maintenance staff will complete an unannounced fire drill during sleeping hours at minimum of every 6 months effective 7/27/21. Executive director informed maintenance staff of this requirement effective 7/27/21, sleeping drill to be completed by 7/29/21. Moving forward, all fire drills will be logged via online company platform and reviewed monthly by the executive director. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records and policy and procedure manual the facility failed to document written acknowledgement by clients that they have been notified that the project may not discriminate in the provision of services on the basis religion or creed.
These finding were discussed with facility staff during the inspection process.
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Plan of Correction
Since inspection, this has been corrected. Corporate compliance was responsible for the change and sent out the correction on 8/3/2021 to executive directors. Executive director sent the corrected information to clinical director to have this change reflected immediately in the handbook and posted in the facility. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to include within their client rights policy that clients have the right to appeal a decision limiting access to their records to the director.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Since inspection, this has been corrected. Corporate compliance was responsible for the change and sent out the correction on 8/3/2021 to executive directors. Executive director sent the corrected information to clinical director to have this change reflected immediately in the handbook and posted in the facility. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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.
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Observations
Based on a discussion with facility staff and a review of client records, case consultations are to be completed every month. The facility failed to ensure client records contained case consults in five client records.
Client #3 was admitted on May 22, 2021 and was still active at the time of the inspection. No case consultation was documented for the month of June 2021.
Client #4 was admitted on May 23, 2021 and was still active at the time of the inspection. No case consultation was documented for the month of June 2021.
Client #5 was admitted on April 14, 2021 and was discharged on June 21, 2021. No case consultation was documented for the month of May 2021.
Client #6 was admitted on February 12, 2021 and was discharged on April 1, 2021. No case consultation was documented in the client record.
Client #7 was admitted on April 14, 2021 and was discharged on June 22, 2021. No case consultation was documented for the month of June 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
To ensure the compliance, Clinical director will instruct clinical team to ensure all active clients have a case consult in their chart by the end of business day 7/28/21. To ensure the compliance, Clinical director will check each active client chart on 7/29/21 and confirm that a case consultation is present and signed by clinical director. In group supervision on 7/28/21 Clinical director will review/ train clinical staff on case consultations being present in each client's chart within the first 7 days of admission and document in supervision note. To avoid further reoccurrence, Clinical director will complete monthly documented chart audits of at least 2 clients per counselor to ensure compliance of case consults. In addition our Regional Quality Manager team conducts monthly documented audits for active and discharged clients. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. 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.
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Observations
Based on a review of client records, the facility failed to ensure that each client record contained an aftercare plan in one of three applicable client records reviewed.
Client #6 was admitted on February 12, 2021 and was discharged on April 1, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Upon further inspection of chart, clinical director was able to locate the aftercare plan in the client #6 chart. This was unable to be located due to the document not being accessible from the client #6 facesheet. To avoid further reoccurrence, the clinical director will be present for all exit interviews and will review with staff how to access archived forms on and will address the necessity of the aftercare plan on 7/28/21. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure that the client record contained a discharge summary in one of three applicable client records reviewed.
Client #6 was admitted on February 12, 2021 and was discharged on April 1, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Upon further inspection of chart, clinical director was able to locate the discharge summary in the client #6 chart. This was unable to be located due to the document not being accessible from the client #6 facesheet. To avoid further reoccurrence, the clinical director will be present for all exit interviews and will review with staff how to access archived forms on and will address the necessity of the discharge summary on 7/28/21. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 ensure that client records contained follow up information in one of three applicable client records reviewed.
Client #6 was admitted on February 12, 2021 and was discharged on April 1, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
To ensure further reoccurrence, clinical director will train CRS staff on completing follow up documentation for all discharged clients. Clinical director will train CRS staff of this on 7/30/21 and will be effective 7/30/21 moving forward for all discharged clients. CRS will document all follow up documentation in the client chart. |