INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on July 22, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-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(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of twelve personnel records, the facility failed to provide documentation for one clinical supervisor having monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position.
Employee # 3 was hired as a clinical supervisor on June 1, 2020 and was still in this position at the time of the inspection. There were no supervision notes documented for the month June 1, 2020 through July 1, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Clinical Supervisor and Regional Quality Management staff will ensure that all staff are receiving the necessary supervision as per DDAP regulations. Executive Director and Clinical supervisor will create a supervision Smartsheet to track supervision due dates for each staff member and will upload supervision documentation and direct observation documentation to the supervision smartsheet as well as the Clinical excellence smartsheet within 24 hours of the supervision being completed. Executive Director and Clinical supervisor will review the smartsheet at the end of each week to ensure that all supervisions are occurring as per regulations. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of twelve personnel records, the facility failed to provide documentation of a semi-annual review for one counselor assistant.
Employee # 11 was hired as a counselor assistant on September 11, 2019 and was still in this position at the time of the inspection. A semi-annual performance evaluation was due no later than March 11, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor will ensure that all staff are receiving the necessary semi annual and annual performance reviews as per DDAP regulations. Executive Director and Clinical supervisor will utilize a tracking form with the hire date and semi annual/annual performance evaluation due dates for each clinical staff member. The performance evaluation will be completed by the appropriate supervising staff member at least 1 week prior to due date in order to have to to review with clinical staff member. Executive Director and Clinical supervisor will review all employee dates on a monthly basis to ensure compliance with regulations. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of twelve personnel records, the facility failed to provide documentation of the required counselor assistant supervision for employee's # 11 and # 12.
Employee # 11 was hired as a counselor assistant on September 11, 2019 and was still in this position at the time of the inspection. The counselor assistant ' s supervision was not documented weekly and did not include at least one hour of direct observation.
Employee # 12 was hired as a counselor assistant on June 15, 2020 and was still in this position at the time of the inspection. The counselor assistant ' s supervision was not documented weekly and did not include at least one hour of direct observation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Clinical Supervisor and Regional Quality Management staff will ensure that all staff are receiving the necessary supervision as per DDAP regulations. Executive Director and Clinical supervisor will create a supervision Smartsheet to track supervision due dates for each staff member and will upload supervision documentation and direct observation documentation to the supervision smartsheet as well as the Clinical excellence smartsheet within 24 hours of the supervision being completed. Executive Director and Clinical supervisor will review the smartsheet at the end of each week to ensure that all supervisions are occurring as per regulations. |
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 twelve personnel records and the facility staffing requirements facility summary report, the facility was unable to provide documentation on TB/STD training for employee # 2.
Employee # 2 was hired with the project on August 2, 2018 and promoted to their current position on June 1, 2020. Employee # 2 did not receive at least 4 hours of tuberculosis, sexually transmitted diseases training within the regulatory timeframe.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Facility Leadership team will review all staff training needs as a standing agenda item of bi-weekly Leadership meetings starting on 8/18/2020. Each department head will be responsible for reviewing training plan and due dates for each employee that reports to them and ensuring that the staff attend the necessary training. Any barriers to staff being able to register or attend training will be documented in a supervision form.
In addition employee #2 has since completed the TB/STI training on 7/31/2020. |