INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 1, an abbreviated off-site inspection, conducted on July 24, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.Based on the findings of Part 1, an abbreviated off-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)(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 eight personnel records, the facility failed to provide documentation of three staff persons receiving a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training within the regulatory timeframe.Employee # 6 was hired as a counselor May, 6 2019. There was no documentation that 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases training completed by May 6, 2020.Employee # 7 was hired as a counselor April 15, 2019. 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases training completed by April 15, 2020.Employee # 8 was hired as a counselor April 15, 2019. 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases training completed by April 15, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/1/2020, employees' supervisors are responsible to keep a documented list of required trainings, along with the regulated timeframes for completion of said trainings, in all employees' files. Completion of trainings will be monitored, on a monthly basis, in group clinical or staff supervisor sessions. Executive Director will have oversight to ensure plan of correction is being followed. Target date to begin is 9/1/2020.
In reference to employee number 6: Target date for completion of HIV/AIDS and TB/STD to be completed by September 1, 2020. Clinical Director to have oversight to ensure completion.
In reference to employee number 7: Target date for completion of HIV/AIDS and TB/STD to be completed by September 1, 2020. Clinical Director to have oversight to ensure completion.
In reference to employee number 8: Target date for completion of HIV/AIDS and TB/STD to be completed by September 1, 2020. Clinical Director to have oversight to ensure completion. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of eight personnel records, the facility failed to provide documentation of all staff being trained to perform assigned tasks during emergencies within the first seven days of employment.Employee # 2 was hired as the facility director on June 23, 2020. The emergency training documentation provided was dated to have occurred on July 23, 2020.Employee # 3 was hired as the clinical supervisor on December 29, 2019. The emergency training documentation provided was dated to have occurred on July 23, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Within the first seven days of employment, all staff will be trained to perform assigned tasks for emergencies. The employee's direct supervisor is responsible for providing the training for the newly hired individuals. Staff will sign that they have been trained on a training form and orientation checklist, which will kept in their employee files. Although the newly hired employee's supervisor is responsible for said training, the Executive Director will have oversight to ensure completion by supervisor. Target date of 9/1/2020. |
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 review of the facility fire drill log from September 2019 through June 2020, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/1/2020, the facilitation of fire drills, and documentation of said fire drills, will also include the exact location of where the fire occurred in the building, along with the specific exit route utilized by clients and staff and documentation of the exact shift; this will include conducting a fire drill, during sleeping hours, at least every 6 months. Regional Maintenance Director to facilitate change of documentation and practice, to encompass drills on sleeping hours, effective 9/1/2020, with on site maintenance staff. Responsibility for oversight of this process will be a coordination between Executive Director and onsite maintenance personnel where upon Executive Director and maintenance staff will review fire drill logs monthly to ensure compliance in this area. |