INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28, 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 ten personnel records and the facility staffing requirements summary report, the facility failed to provide documentation for TB/STD and/or HIV/AIDS training for ten personnel reviewed: 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 training and 6 hours of HIV/AIDS training within the regulatory timeframe.Employee # 17 was hired as maintenance on April 1, 2019. Employee # 17 did not receive at least 4 hours TB/STD training and 6 hours of HIV/AIDS training within the regulatory timeframe.Employee # 18 was hired as medical assistant on February 10, 2019. Employee # 18 did not receive at least 4 hours TB/STD training and 6 hours of HIV/AIDS 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 all department supervisors will review training needs of staff on a monthly basis and report on outstanding needs during monthly leadership meetings. During the employees first month of hire new employees will request the HIV/AIDS and TB/STD training though the link in Relias (Pyramid training management system) and will provide the date of training to their supervisor. Employee 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 September 15, 2022. Executive Director will have training needs as a standing agenda item on Leadership Agenda on a monthly basis. |
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 on July 28, 2022, the facility failed to provide individual paper towels or a mechanical dryer in each bathroom. The facility used cloth hand towels for all client bathrooms. These findings were discussed with facility staff during the licensing process.
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Plan of Correction
All bathrooms in patient rooms will be equipped with individual paper towel dispensers for use. New paper towel dispensers have been order and will be installed upon arrival in all patient rooms. Maintenance director will be responsible for installation and housekeeping staff will be responsible for filling the dispensers when the rooms are cleaned daily. Estimated date of installation is October 1, 2022. |
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 two of two applicable records reviewed.Client #6 was admitted on May 31, 2022 and discharged Against Medical Advice (AMA) on June 3, 2022. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours. Client #14 was admitted on May 7, 2022 and discharged Against Medical Advice (AMA) on May 23, 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.
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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. Staff will be re-trained by September 15, 2022 during staff meetings held by each department. BHT, clinical and 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, 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. |
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 client records, the facility failed to document personal history in five out of seven applicable records reviewed.Client #3 was admitted on July 22, 2022 and was still current in detox. Client #3 had no personal history documented in their client record. Client #4 was admitted on July 24, 2022 and was still current in detox. Client #4 had no personal history documented in their client record. Client #5 was admitted on October 18, 2021 and was discharged on October 26, 2021.Client #5 had no personal history documented in their client record. Client #6 was admitted on May 31, 2022 and was discharged on June 3, 2022.Client #6 had no personal history documented in their client record. Client #7 was admitted on December 9, 2021 and was discharged on December 13, 2021. Client #7 had no personal history documented in their client record. These findings were reviewed with facility staff during the licensing process. This was a repeat citation from the August 19, 2021 inspection.
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Plan of Correction
Clinical Director and Intake/Case Coordinator Supervisor will assign new clients to have Level of Care Assessment and biopsychosocial completed within 72 hours of admission to the facility for 3.7 WM and within 24 hours for 3.5 level of care. Clinical Director and Intake/Case Coordinator Supervisor will utilize the LOCA completion Smartsheet to track LOCA completions and will review and update on a daily basis and will report to Executive Director on a weekly basis regarding any LOCA that is outstanding. The Clinical Director and Intake/Case Coordination Supervisor will schedule LOCA's to be completed via telehealth with another qualified Pyramid employee if the LOCA has not been completed within 48 hours of arrival at the facility. 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 Regional Quality Management team 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. |
709.62(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 client records, the facility failed to document a psychosocial evaluation in five out of seven applicable records reviewed.Client #3 was admitted on July 22, 2022 and was still current in detox. Client #3 had no psychosocial evaluation documented in their client record. Client #4 was admitted on July 24, 2022 and was still current in detox. Client #4 had no psychosocial evaluation documented in their client record. Client #5 was admitted on October 18, 2021 and was discharged on October 26, 2021.Client #5 had no psychosocial evaluation documented in their client record. Client #6 was admitted on May 31, 2022 and was discharged on June 3, 2022.Client #6 had no psychosocial evaluation documented in their client record. Client #7 was admitted on December 9, 2021 and was discharged on December 13, 2021. Client #7 had no psychosocial evaluation documented in their client record. These findings were reviewed with facility staff during the licensing process. This was a repeat citation from the August 19, 2021 inspection.
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Plan of Correction
Clinical Director and Intake/Case Coordinator Supervisor will assign new clients to have Level of Care Assessment and biopsychosocial completed within 72 hours of admission to the facility for 3.7 WM and within 24 hours for 3.5 level of care. Clinical Director and Intake/Case Coordinator Supervisor will utilize the LOCA/Biopsychosocial completion Smartsheet to track LOCA/biopsychsocial completions and will review and update on a daily basis and will report to Executive Director on a weekly basis regarding any LOCA/biopsychosocial that is outstanding. The Clinical Director and Intake/Case Coordination Supervisor will schedule LOCA's to be completed via telehealth with another qualified Pyramid employee if the LOCA has not been completed within 48 hours of arrival at the facility. 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 Regional Quality Management team in order to track the completion of LOCA's in adherence with the regulations. Executive Director will review Smartsheet for LOCA/biopsychosocial completion on a weekly basis and will provide support and supervision regarding the completion of these documents. |
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 three applicable client records, the facility failed to provide a complete client record in two out of three individuals relative to the client's involvement with the project that included follow up information in accordance with the facility's policy and procedure manual. The facility's policy and procedure manual indicated the facility is to follow-up on the client within seven days of discharge.Client # 5 was admitted on October 18, 2021 and was discharged on October 26, 2021. There was no documented follow-up information in the client record at the time of the inspection.Client # 6 was admitted on May 31, 2022 and was discharged on June 3, 2022. There was no documented follow-up information in the client record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.This was a repeat citation from a licensing inspection dated August 19, 2021.
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Plan of Correction
Case coordination staff will document follow up phone calls to clients within 7 days of discharge. Case coordinators will be assigned phone calls on a daily basis by Intake/Case Coordinator supervisor that need to be completed as per the policy and procedure. If the follow up call is unable to be completed by assigned staff Office Manager and Administrative assistant will be trained to complete 7 day follow up phone calls. Office Manager and Administrative assistant will be trained to assist in completion of calls by September 15, 2022. Tracking smartsheet for follow up calls will be created by September 7, 2022 and Intake/Case Coordinator Supervisor will review on a weekly basis and will be a standing agenda items for monthly group supervision. Random chart audits by regional quality management also 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. |
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 five out of seven applicable records reviewed.Client #8 was admitted on June 2, 2022 and was active at the time of the inspection. A comprehensive treatment plan was completed on June 8, 2022 and a treatment plan update was due by June 22, 2022; however, the next update was not completed until July 15, 2022. Client #9 was admitted on May 31, 2022 and was active at the time of the inspection. A treatment plan update was completed on June 14, 2022 with the next update due by July 28, 2022; however, the next update was not completed until July 5, 2022. The next treatment plan update was due on July 19, 2022 but was not documented at the time of inspection. Client #10 was admitted on June 16, 2022 and was active at the time of the inspection. A treatment plan update was completed on June 30, 2022 with the next update due by July 14, 2022; however, the next update was not completed until July 25, 2022. Client #11 was admitted on May 8, 2022 and was active at the time of the inspection. A treatment plan update was completed on May 26, 2022 and a treatment plan update was due by June 9, 2022; however, the next update was not completed until July 1, 2022. The next treatment plan update was due by July 15, 2022; however, was not completed until July 28, 2022.Client #12 was admitted on October 25, 2021 and was discharged on January 18, 2022. A treatment plan update was completed on December 27, 2021 and a treatment plan update was due by January 10, 2022; however, there were no more updates documented at the time of the inspection. These findings were reviewed with facility staff during the licensing process.This was a repeat citation from a licensing inspection dated August 19, 2021.
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Plan of Correction
Treatment plan updates will occur according to regulatory standards. Clinicians will be expected to have treatment plans completed as per the regulations 14 days for short term treatment or 30 days for long term treatment. Clinical Director will complete 100% review of all treatment plans on a weekly basis as of September 1, 2022 to ensure all treatment plans are completed within the required timeframes and will provide feedback and supervision to clinician. Clinical supervisor will have treatment plan completion as a standing agenda item on both individual and group supervision for all clinical staff members. Regional quality management staff will complete random chart audits on a monthly basis and will report results to Clinical Director and Executive 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 all seven inpatient client records reviewed. These findings were discussed with facility staff during the inspection process. This was a repeat citation from a licensing inspection dated August 19, 2021.
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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 re-trained clinical team on documentation standards and best practices for progress note writing to include strengths based language, incorporating treatment plan goals and specific interventions used during session during group supervision on 8/25/22 and will continue to review on a monthly basis during individual and group supervisions. Clinical Director and lead counselor will audit all progress notes on a weekly basis for the months of September and October to ensure that notes are present in the chart and meet documentation standards and will provide feedback to clinicians as part of ongoing supervision. If improvements are noted then CD or lead counselor will complete 100% audit of 2 charts per clinician each month (25% of residential population) at random each month moving forward. 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. |
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 three applicable client records, the facility failed to provide a complete client record in one out of three individuals relative to the client's involvement with the project that included follow up information in accordance with the facility's policy and procedure manual. The facility's policy and procedure manual indicated the facility is to follow-up on the client within seven days of discharge.Client # 7 was admitted on May 7, 2022 and was discharged on May 23, 2022. There was no documented follow-up information in the client record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.This was a repeat citation from a licensing inspection dated August 19, 2021.
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Plan of Correction
Case coordination staff will document follow up phone calls to clients within 7 days of discharge. Case coordinators will be assigned phone calls on a daily basis by Intake/Case Coordinator supervisor that need to be completed as per the policy and procedure. If the follow up call is unable to be completed by assigned staff Office Manager and Administrative assistant will be trained to complete 7 day follow up phone calls. Office Manager and Administrative assistant will be trained to assist in completion of calls by September 15, 2022. Tracking smartsheet for follow up calls will be created by September 7, 2022 and Intake/Case Coordinator Supervisor will review on a weekly basis and will be a standing agenda items for monthly group supervision. Random chart audits by regional quality management also 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. |