INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 4, 2022, 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 personnel records and the facility staffing requirements summary report, the facility was unable to provide documentation for TB/STD and/or HIV/AIDS training for the following employees:
Employee # 7 was hired as a counselor on June 28, 2021. Employee # 7 did not receive at least 4 hours TB/STD training and 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee # 10 was hired as a counselor assistant on June 15, 2020. Employee # 10 did not receive at least 4 hours TB/STD training within the regulatory timeframe.
Employee # 11 was hired as a behavior tech on February 20, 2020. Employee # 11 did not receive at least 4 hours TB/STD training and 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee # 12 was hired as a behavior tech supervisor on December 30, 2019. Employee # 12 did not receive at least 4 hours TB/STD training and 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee # 13 was hired as a dietary coordinator on April 18, 2018. Employee # 13 did not receive at least 4 hours TB/STD training and 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee # 14 was hired as the facilities supervisor on February 24, 2020. Employee # 14 did not receive at least 4 hours TB/STD training and 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee # 15 was hired as housekeeping on March 2, 2020. Employee # 15 did not receive at least 4 hours TB/STD training and 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee # 16 was hired as housekeeping on March 21, 2019. Employee # 16 did not receive at least 4 hours TB/STD train
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Plan of Correction
To ensure continued compliance with trainings, all new staff complete a New Hire Orientation which outlines required trainings and timeframes. Executive Director will meet with each department supervisor on August 29, 2022 and review with them required trainings and timeframes for all staff and walk them through our training platform. This will also be tracked through the yearly Training Plans that each staff complete yearly. Each department supervisor will be responsible for ensuring their departments have required trainings in a timely manner. Each department supervisor will also sign their staff up for any required trainings. Employees who are overdue for trainings have until September 1, 2022 to sign up for past due trainings. This will be monitored by their specific Department supervisors and Executive Director. |
705.10 (c) (2) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
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Observations
Based on a physical plant inspection on August 4, 2022, the facility failed to maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
The facility did not have an ABC fire extinguisher in the kitchen area.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
ABC fire extinguisher was ordered and installed in the kitchen area on August 16, 2022. This specific fire extinguisher will be added into our monthly checks of all fire extinguishers. The Facilities Supervisor and maintenance staff routinely check during the monthly facility risk walk through that all fire extinguishers are present. If a fire extinguisher is not present in an area which is required, Facilities Supervisor will order and install. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of seven client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated signature of the client in two records reviewed.
Client #4 was admitted on July 7, 2022 and was current at the time of the inspection. An informed and voluntary consent dated August 1, 2022, to the emergency contact did not include the client's signature.
Client #7 was admitted on June 12, 2022 and was discharged on June 29, 2022. An informed and voluntary consent dated June 12, 2022, to the funding source did not include the client's signature.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinical Director has reviewed regulation 709.28c4 with the clinical team during group supervision on August 17, 2022. It was also reviewed with medical staff who complete consents to release information, on August 17, 2022. To ensure compliance with this regulation monthly internal chart audits will occur by our compliance team. Quality Specialist Department will pull 10 charts monthly and review findings with Executive Director and Clinical Director. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 14 days per their policy and procedure manual, in four out of seven applicable records reviewed.
Client #1 was admitted on June 30, 2022 and was active at the time of the inspection. A treatment plan update was completed on June 14, 2022 and a treatment plan update was due by June 28, 2022; however, the next update was not completed until June 29, 2022.
Client #3 was admitted on July 5, 2022 and was active at the time of the inspection. A treatment plan update was completed on July 6, 2022 with the next update due by July 20, 2022; however, the next update was not completed until July 21, 2022.
Client #5 was admitted on February 6, 2022 and was discharged on March 21, 2022. A treatment plan update was completed on March 4, 2022 with the next update due by March 18, 2022; however, one was not completed prior to discharge on March 21, 2022.
Client #7 was admitted on June 12, 2022 and was discharged on June 29, 2022. A comprehensive treatment plan was completed on June 14, 2022 and a treatment plan update was due by June 28, 2022; however, one was not completed prior to discharge on June 29, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director has reviewed regulation 709.52b with the clinical team during group supervision on August 17, 2022. To ensure compliance with this regulation monthly internal chart audits will occur by our compliance team. Quality Specialist Department will pull 10 charts monthly and review findings with Executive Director and Clinical Director. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that all clients received counseling services according to the individual treatment plan in three out of seven inpatient client records reviewed.
Client #1 was admitted on June 30, 2022 and was still active at the time of the inspection. The treatment plan specified individual counseling on a weekly basis. Client #1 did not receive individual counseling the weeks of July 4th -July 8th, 2022 and July 18-July 22, 2022.
Client #2 was admitted on June 9, 2022 and was still active at the time of the inspection. The treatment plan specified individual counseling on a weekly basis. Client #2 did not receive individual counseling the weeks of June 13-June 17, 2022, June 27-July 1, 2022, July 11-July 15, 2022 and July 25-29. 2022.
Client #4 was admitted on July 7, 2022 and was still active at the time of the inspection. The treatment plan specified individual counseling on a weekly basis. Client #4 did not receive individual counseling the week of July 11th -July 15th, 2022.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Clinical Director has reviewed regulation 709.52c with the clinical team during group supervision on August 17, 2022. To ensure compliance with this regulation monthly internal chart audits will occur by our compliance team. Quality Specialist Department will pull 10 charts monthly and review findings with Executive Director and Clinical Director monthly. |