INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 27, 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 to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. No deficiencies were identified during this inspection and no plan of correction is required.
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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 thirteen personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that seven 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 #10 was hired as a BH Tech on April 12, 2021 and was due to have the communicable disease trainings no later than April 12, 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.Employee #11 was hired as a case manager on May 17, 2021 and was due to have the communicable disease trainings no later than May 17, 2023 . There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.Employee #12 was hired as housekeeping on July 27, 2020 and was due to have the communicable disease trainings no later than July 27, 2022. 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.Employee #13 was hired as housekeeping on March 2, 2020 and was due to have the communicable disease trainings no later than March 2, 2022. 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.Employee #14 was hired as housekeeping on March 21, 2019 and was due to have the communicable disease trainings no later than March 21, 2021. 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.Employee #15 was hired as a maintenance on April 27, 2021 and was due to have the communicable disease trainings no later than April 27, 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.Employee #16 was hired as a maintenance on April 1, 2019 and was due to have the communicable disease trainings no later than April 1, 2021. 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.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the July 28, 2022 annual licensing inspection
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Plan of Correction
Executive Director and all department supervisors will review training needs of staff on a monthly basis and report on outstanding needs during weekly leadership meetings. A training Smartsheet has been developed for all new and existing employees with their date of hire and mandatory trainings listed. During the employees first week of hire new employees will request the HIV/AIDS and TB/STD training though the link in Relias (Pyramid training management system) with the assistance of the BHT trainer and or their supervisor. Once scheduled the supervisor will document the date and will ensure the staff member completes the necessary training. Employee or Supervisor will upload the certificate of completion after training has been completed into Relias for tracking purposes. All current employees in need of the HIV/AIDS and TB/STD trainings will be scheduled by August 31, 2023. Executive Director will have training needs as a standing agenda item on Leadership Agenda on a weekly basis. |
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 fourteen client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable records reviewed.Client #12 was admitted on August 23, 2022 and discharged Against Medical Advice (AMA) on September 1, 2022. 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.This is a repeat citation from the July 28, 2022 annual licensing inspection
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Plan of Correction
All agency staff will be re- trained in policy and procedure regarding the necessity to contact the emergency contact listed in the client record that is obtained upon admission to the program during an all staff meeting scheduled for 8/17/2023. Additionally all departmental meetings in August will provide a re-training to staff for BHT, nursing, clinical and case coordination regarding the policy of contacting the emergency contact for anyone who leaves the facility AFA, AMA or is a behavioral discharge. Staff will be re-trained by August 31, 2023 and this will be documented via meeting minutes for each department. BHT or nursing staff will complete a memo to chart documenting the contact or the attempted contact with the emergency contact, if the emergency contact was reached, the name of the emergency contact, information shared and the staff completing the contact. If the contact is unable to be reached staff will document the attempt and send an email report the attempt to the Office Manager, Executive Director, Clinical Director and BHT Manager so that another attempt could be made and documented within the chart within 12 hours of the client leaving treatment AMA/AFA. Charts of those who left AFA/AMA will be audited on a weekly basis to demonstrate evidence of the phone call by the case coordination supervisor by 8/1/23 and on going. |
709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of seven detox client records, the facility failed to document personal history in two out of four applicable records reviewed.Client #2 was admitted on June 22, 2023 and was discharge June 27, 2023 . Client #2had no personal history documented in their client record. Client #5 was admitted on June 22, 2023 and was discharged June 27, 2023. Client #5 had no personal history documented in their client record. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the July 28, 2022 annual licensing inspection
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Plan of Correction
Plan of Correction:
Intake/Case Coordinator Supervisor will send out a daily email of the Level of Care Assessments and biopsychosocial complete these will be tracked on a Smartsheet and will be marked off when the LOCA/biopsychosocial has been completed. To ensure that LOCA's that includes personal history are being completed as required the Clinical Director (for residential) and the Intake Supervisor (for detox) will complete 100% review of cases on a monthly basis and in addition to random chart audits being completed on monthly basis by Quality specialist in order to track the completion of LOCA's in adherence with the regulations. Executive Director will review Smartsheet for LOCA completion on a weekly basis and will provide support and supervision regarding the completion of these documents.
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on the review of seven detox client records, the facility failed to document psychosocial evaluation in two out of four applicable records reviewed.Client #2 was admitted on June 22, 2023 and was discharge June 27, 2023.Client #5 was admitted on June 22, 2023 and was discharged June 27, 2023. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the July 28, 2022 annual licensing inspection
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Plan of Correction
Intake/Case Coordinator Supervisor will send out a daily email of the Level of Care Assessments and biopsychosocial complete these will be tracked on a Smartsheet and will be marked off when the LOCA/biopsychosocial has been completed. To ensure that LOCA's that includes personal history are being completed as required the Clinical Director (for residential) and the Intake Supervisor (for detox) will complete 100% review of cases on a monthly basis and in addition to random chart audits being completed on monthly basis by Quality Specialist in order to track the completion of LOCA's in adherence with the regulations. Executive Director will review Smartsheet for LOCA completion on a weekly basis and will provide support and supervision regarding the completion of these documents. |
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 seven inpatient client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in five charts reviewed.Client #8 was admitted on April 8, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, dated April 14, 2023, indicated 1 individual session weekly and group daily. The chart's record of service and progress notes indicated that the client only received individual sessions on April 22, 2023, May 1, 2023, May 25, 2023, June 5, 2023 and June 21, 2023. Client #9 was admitted on May 19, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, dated May 23, 2023 , indicated 1 individual session weekly and group daily. The chart's record of service and progress notes indicated that the client only received individual sessions on May 23, 2023, June 1, 2023 and June 22, 2023. Client #10 was admitted on June 1, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, dated June 5, 2023, indicated 1 individual session weekly and group daily. The chart's record of service and progress notes indicated that the client did not receive any group sessions June 12-16, 2023 and only two group session June 19-23, 2023. Client #11 was admitted on May 31, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, dated May 31, 2023 , indicated 1 individual weekly and group daily. The chart's record of service and progress notes indicated that the client received one individual session on June 14, 2023. Client #13 was admitted on September 21, 2022 and was discharged on October 31, 2022. The comprehensive treatment plan, dated September 22, 2022, indicated 1 individual session per week. The chart's record of service and progress notes indicated that the client only received individual session on September 27, 2022, October 13, 2022 and October 28, 2022. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the July 28, 2022 annual licensing inspection
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Plan of Correction
: All clients are offered and expected to attend group counseling sessions provided by clinical staff Monday through Friday. These sessions are documented in group progress notes. Clinical Director and lead counselor will audit all progress notes on a weekly basis for the months of July, August and September to ensure that notes are present in the chart and meet documentation standards and will provide feedback to clinicians each week and as part of ongoing supervision. CD and lead counselor will complete 100% audit of 2 charts per clinician each week moving forward after October. On-going supervision and training will be provided each month to support clinicians and re-enforce appropriate documentation.
If client refuses to attend groups or individual sessions or misses a session due to illness or another appointment this will be documented as a DNS for the session. If client had a bed pass this will be documented by medical staff as to the length of time of the bed pass and the reason for the bed pass.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to follow their written client follow-up policy in three of three applicable inpatient client records reviewed. Client #12 was admitted on August 23, 2022 and was discharged on September 1, 2022. The client record did not contain documentation of follow up information with the client within 7 days of discharge.Client #13 was admitted on September 21, 2022 and was discharged on October 31, 2022. The client record did not contain documentation of follow up information with the client within 7 days of discharge. Client#14 was admitted on March 18, 2023 and was discharged on April 17, 2023. The client record did not contain documentation of follow up information with the client within 7 days of discharge. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the July 28, 2022 annual licensing inspection
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Plan of Correction
Case coordination staff will document follow up phone calls to clients within 7 days of discharge. Case Coordinator staff will be assigned a day of the week to complete these follow up calls for all discharges that occurred any time within the 7 days prior. A tracking smartsheet for follow up calls has been created and Case Coordinator supervisor will review data on a weekly basis to ensure calls are being completed. Follow up calls will be a standing agenda items for monthly group supervision beginning on 7/27/23. Random chart audits by quality specialist will review charts for ongoing compliance to policy and procedure related to 7 day follow up phone calls. All attempts to complete follow up will be documented in client's chart with the outcome of the phone call. Executive Director will review follow up smartsheet on a weekly basis for additional oversight for compliance to policy and procedure and will send out follow up communications for any outstanding follow up calls |