INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 31, 2023 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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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 nine personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that two applicable employees received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #8 was hired as a BH Tech on January 11, 2021 and was due to have the communicable disease trainings no later than January 11, 2023. There was no documentation in the personnel file of the completion of the HIV/AIDS training until June 10, 2023 and the TB/STD training until June 13, 2023.
Employee #9 was hired as housekeeping on February 15, 2021 and was due to have the communicable disease trainings no later than February 15, 2023 . There was no documentation in the personnel file of the completion of the HIV/AIDS training until March 17, 2023 and the TB/STD training until May 2, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Tracking system will be created and reviewed with leadership by 9/1/23 via Smartsheet application. This Smartsheet will track all new employees per department. It will also track hire dates and due dates for required trainings. Department managers will be responsible for updating and tracking this Smartsheet. These trainings shall be scheduled and completed prior to the 2 year due date. The Facility director will have oversight of this Smartsheet. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for Project and Facility Directors in employee #2's employee record.
Employee #2 was hired as the Facility Director on November 29, 2021 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2022 through December 31, 2022. Employee #2's employee record only documented 2.5 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will ensure all 12 training hours are completed within the set timeframe of one calendar year. The Regional Director will have oversight of training hours on a quarterly basis. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the June 2022 through July 2023 fire drill logs, the facility failed to conduct an unannounced fire drill during January 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/31/23, Facility Director reviewed with maintenance supervisor that if an actual event and evacuation does occur, an unannounced fire drill must also still occur in the same month. This unannounced drill must be documented as all other drills are, utilizing the Smartsheet submission form. This will be monitored during the monthly RISK and leadership meetings and documented on RISK meeting minutes. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable record reviewed.
Client #5 was admitted on June 30, 2023 and discharged Against Medical Advice (AMA) on July 19, 2023. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Staff meeting scheduled for 8/30/23, during this time Facility director will review policy related to staff contacting a clients Emergency contact should a client leave treatment AFA/AMA. During this time, it will be reviewed where and how to document this contact. Lead counselor will have oversight to ensure all calls are being made and documented when appropriate. Lead counselor will complete chart checks on a case-by-case basis after discharge for any client who has left AMA/AFA to ensure this documentation is completed. |