INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 1-2, 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of personnel records, the facility failed to ensure clinical supervisor completed a core curriculum in clinical supervision within a timely fashion.
Staff #3 was promoted to a clinical supervisor position on October 1, 2023, and was still in that position at the time of the inspection. The facility was unable to provide documentation that Staff #3 completed this training at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility Clinical Supervisor has started a Department approved Clinical Supervision core curriculum and will be completed with the Department approved Clinical Supervision core curriculum prior to August 1, 2024.
Moving forward, said approved Clinical Supervision core curriculum will be assigned to any future Clinical Supervisors or applicable staff during onboarding to ensure completion within a timely fashion. It is the responsibility of the Clinical Supervisors direct supervisor, the Executive Director, to ensure follow-through and completion as well as scheduling for any future Clinical Supervisors onboarded. Follow-through is tracked in the same way Communicable Disease Trainings will be tracked moving forward, as detailed in the Mandatory Communicable Disease Training section below.
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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to supervise a counselor assistant by a full-time clinical supervisor or counselor who meets the qualifications.
Employee #8 was hired January 15, 2024, as a counselor assistant and was still employed in this position at the time of the onsite. A review of supervision notes revealed that only one supervisory session was documented for the month of February 2024. Additionally, during the month of May 2024 only three supervisory sessions were documented. There were no additional documents available for review.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Each Counselor Assistant will receive weekly individual supervision for at least the duration of the time the CA is required to, per DDAP regulations. This supervision will begin immediately upon hire. The Clinical Supervisor writes supervision notes on Pyramid's CARF-approved note and uploads them in a timely fashion to the facility's Supervision Tracking Smartsheet. This Smartsheet is monitored on a monthly basis by Pyramid's Compliance Department.
In cases where supervision cannot be completed for a week (i.e. vacations, absences from work, etc.), a supervision note will be completed and filed that details the rationale for why supervision was not completed for that week for review by the Department during inspections. The Clinical Supervisor is responsible for ensuring these notes are entered when supervision is not completed for a week due to extenuating circumstance.
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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's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that staff 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.
Staff #10 was hired as a behavioral health technician on November 15, 20/21 and was due to have the communicable disease trainings no later than November 15, 2023. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Staff #11 was hired as a behavioral health tech supervisor on March 7, 2022 and was due to have the communicable disease trainings no later than March 7, 20/24. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Staff #12 was hired as the Facility Supervisor on February, 24, 2020 and was due to have the communicable disease trainings no later than February 24, 2022. This staff completed the HIV/AIDS training on 6/9/24 and there was no documentation of the TB/STD training in the personnel record as of the date of the inspection.
Staff #13 was hired as Housekeeping on March 2, 2020 and was due to have the communicable disease trainings no later than March 2, 2022. This staff completed the HIV/AIDS training on 6/8/24 and there was no documentation of the TB/STD training in the personnel record as of the date of the inspection.
Staff #14 was hired as the Housekeeping Lead on March 21, 2019 and was due to have the communicable disease trainings no later than March 21, 2021. This staff completed the HIV/AIDS training onJune 8, 2024 and there was no documentation of the TB/STD training in the personnel record as of the date of the inspection.
Staff #15 was hired as Dining Services on March 21, 2022 and was due to have the communicable disease trainings no later than March 21, 2024. This staff completed the HIV/AIDS training on June 13, 2024 and there was no documentation of the TB/STD training in the personnel record as of the date of the inspection.
Staff #16 was hired as a Maintenance Tech on April 27, 2021 and was due to have the communicable disease trainings no later than April 27, 2023. This staff completed the HIV/AIDS training on June 9, 2024 and there was no documentation of the TB/STD training in the personnel record as of the date of the inspection.
Staff #17 was hired as a Maintenance Tech on April 1, 2019 and was due to have the communicable disease trainings no later than April 1, 2021. This staff completed the HIV/AIDS training on June 12, 2024 and there was no documentation of the TB/STD training in the personnel record as of the date of the inspection.
This is a repeat citation from June 27, 2023 and July 28, 2022 licensing inspection renewals.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The facility is implementing a new system in which all staff (clinical and non-clinical) will be scheduled within their first week of employment to meet with a new training committee comprised of the Executive Director who has overall oversight, the BHT Trainer who aids in organizing/tracking, and the Facility Secretary who will aid in helping set up training space weekly to complete the trainings. The goal is to have DDAP HIV/AIDS completed within 1 week of employment, and to have DDAP TB/STD/Hep C scheduled during the first week of employment.
The Executive Director is also responsible for running weekly reports (every Monday) in our training system, Relias, to indicate which trainings are outstanding. This report is shared with the Training Committee.
The training committee meets monthly to review reports, ensure tracking system is up to date and accurate, and identify barriers, what's working, and make improvements as needed to the system.
Trainings are tracked in Smart Sheet, with all active staff listed, their hire date listed, and their completion date for DDAP HIV and DDAP TB/STD/Hep C listed (if completed). It is set up similarly to the annual licensing staffing grid.
As of the time of this submission; 1 staff remains that requires HIV/AIDS training which will be complete by August 1, 2024 (in the 2025 licensing audit this will still be counted as late) and all 8 staff have TB/STD/Hep C training scheduled to be completed by August 3, 2024 (in the 2025 licensing audit these will still be counted as late).
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ventilate toilet and washrooms by exhaust fan or window. The ventilation fans in both bathrooms on the second-floor admin hallway were inoperable.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A vendor has been contracted to diagnose and repair the cause of the ventilation malfunction. Repairs are expected to be completed by August 1, 2024. It is the responsibility of the Facilities Supervisor to schedule the maintenance work with the vendor, follow-up internally for any approvals needed for work done, and ensure timely completion of the project. It is the Executive Directors responsibility to have overall oversight to ensure the repair is made in full with a target date of August 1, 2024. Following full repairs, this will be monitored by the Facilities Supervisor during monthly walk-throughs moving forward. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to not permit in the facility heaters that are not permanently mounted or installed.
A portable space heater was observed in a counselor's office Room 151 on the 1st floor and in the Facility Directors office on the 2nd floor.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All staff notification will be sent out regarding the inability to utilize heathers that are not permanently mounted or installed (i.e. space heaters); and staff who utilize either individual or shared office space will be informed in department meetings. This notification will be sent out no later than July 16th, 2024. The next monthly facility safety walk-through scheduled for July 26, 2024, will include ensuring the absence of any space heaters; and all future monthly facility safety walk-throughs will include the same. It is the responsibility of the Facilities Supervisor to inform the Executive Director of any space heaters found during facility walk-throughs moving forward. It is then the responsibility of the Executive Director to ensure they are removed from the facility if reported by the Facilities Supervisor. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on a review of detoxification client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of three discharged records reviewed. The facility's policy is to follow-up with discharged clients within seven days of discharge.
Client #4 was admitted on April 20, 2024 and was discharged on April 24, 2024. There was no documentation of a follow-up contact in the client record.
Client #7 was admitted on June 18, 2024 and was discharged on June 23, 2024. There was no documentation of a follow-up contact in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Retraining of applicable staff (Clinical & Case Management) regarding these policies and requirements for follow-up with discharged clients within 7 days of discharge will take place prior to August 1, 2024. It is the Executive Directors responsibility to ensure this retraining is completed.
Moving forward, auditing follow-up with discharged clients within 7 days of discharge will take place Monday-Friday to ensure 7-day discharge follow-up is taking place with all clients regardless of discharge type, and is being accurately documented in that clients electronic chart record. This task has been added to the case management board and cases will not be considered closed until after follow-up within 7 days of discharge has taken place. It is the responsibility of the Intake/Case Management Supervisor to ensure follow-through and timely completion for each client. Additionally, it is the responsibility of the Executive Director to have overall oversight on this process to ensure it is occurring for all clients who discharge from the program. This will also be monitored through internal KPI monitoring each month, and those results are shared with both the Intake/Case Management Supervisor and the Executive Director each month.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on the review of patient records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction was submitted to the Department for inspections occurring on July 28, 2022, and June 27, 2023, and again on July 2, 2024 addressing the requirement 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 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.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Current Executive Director arrived to Pyramid Dallas IP on January 26, 2024, and has since reviewed the July 28, 2022 & June 7, 2023 plans of correction related to communicable disease staff training requirements. Prior to the 2024 annual licensing audit, there was considerable progress made to realign this area with regulation as seen by many trainings being categorized as late instead of incomplete.
Some elements of those plans from 2022 and 2023 were carried over to 2024's plan however there is now a Training Committee implemented along with weekly reporting, monthly meetings, and a designated "training day" each day of the week (currently Thursday; may change over time based on success of the day that's scheduled ? the goal is to make it as easy on staff to complete the trainings in a timely manner while maintaining day to day operations with appropriate staffing levels). The above plan of corrections related to communicable disease training will be reinforced throughout 2024-2025 and moving forward beyond that. At present, with this new implemented plan and efforts made prior to the 2024 licensing audit, we expect full compliance with this regulation by August 3, 2024.
In cases where staff have scheduled mandatory TB/STD/Hep C training, but miss the training date; a supervision note will be included in that employees personnel record to document the missed training and rationale why; and the training will be rescheduled the day of the missed training to ensure it is completed in a timely fashion. The Smart Sheet tracker will be updated with the new training date and the employee will be notified of the new training date.
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