INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 12, 2024 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee in the required time frame, appropriate to that employee's skill level in one out of eleven employee records reviewed.
Employee #7 was hired on May 6, 2024 as a counselor and was still in the position as of the date of the inspection. The training plan was due no later than June 6, 2024; however, it was not completed until June 26, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Department managers will be responsible for ensuring that the individual written training plans are completed for all new staff during the first week of hire. Signed individual written training plans will be added to the managers new hire checklist. Executive Director will oversee the managers by making this an agenda item in monthly leadership meetings. |
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 Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that 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 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.
Employee #12 was hired as BHT supervisor on April 4, 2022 and was in that position as of the time of the inspection. Her training was due no later than April 4, 2024; however, it was not completed until April 18, 2024.
This finding was reviewed with the facility staff during the licensing process.
This is repeat citation from the July 31, 2023 licensing inspection.
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Plan of Correction
Department managers will be responsible for updating and tracking training due dates and completion. These are tracked utilizing Relias Training System. Department Mangers will run quarterly reports to ensure compliance. These trainings shall be scheduled and completed prior to the 2 year due date. The Facility director monitor completion of these in leadership meetings x4 yearly. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling rooms.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Since inspection, this has been corrected by paper being taped over the camera. No camera in the building is audio recording. Corporate compliance met with Executive director and Regional Director on 7/22/24 to review 705.4 (3) and due to the dual use of these group spaces, an exception request is being submitted. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to provide either individual paper towels or a mechanical dryer in each client ' s bathroom.
Bedroom #A125 had no paper towels or mechanical dryer.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Correction Completed during inspection. Paper towel dispensers were filled in each client bathroom. Housekeeping is responsible for checking them daily and refilling them as necessary. Housekeeping supervisor will check with staff to ensure this is happening on a daily basis. |