INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 1 - 2, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records on October 1, 2019, two employees did not meet the educational or experience requirements to be a counselor.Employee #10 was hired as a counselor on July 15, 2019. At the time of the hire, the employee only had ten months of clinical experience in addition to a Bachelor's degree. A counselor is required to have a full year of clinical experience in a health or human service agency. Employee #9 was hired as a counselor on July 1, 2019. At the time of the hire, the employee had a Bachelor's Degree in Social Sciences, which is a non-qualifying degree for the position of counselor. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to hiring any potential employees for the position of counselor the HR recruiter, Clinical Supervisor and Executive Director will ensure they all applicants meet the minimum qualifications for the position as set forth in DDAP regulations to years of clinical experience in a health or human service agency to equal at minimum one year of experience and to ensure that the applicant's degree type is identified as an acceptable degree by DDAP regulations. The HR recruiter, Clinical Supervisor and Executive Director will ensure that the months/years of experience is documented on the employment application as well as on the resume and meets the necessary one year of clinical experience standard prior to employee starting in counseling position. Employee #10 meets the qualifications as of the date of the inspection. The HR recruiter, Clinical Supervisor and Executive Director will ensure that the degree meets the DDAP standards for an acceptable field for the counseling position and is documented on the employment application as well as on the resume. In addition for employee #9 Pyramid Dallas has requested from DDAP that the Social Sciences degree is accepted as a qualifying degree due to the coursework required as part of the degree program. In the event that DDAP does not accept Social Sciences as a qualifying degree employee #9 will be reclassified as a counselor assistant and will receive all necessary supervision as such. This request was made on 10/7/2019. |
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 on October 1, 2019 and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #11 received at least four hours of TB/STD and other health related topics training within the regulatory timeframe.Employee #11 was hired as a case coordinator on March 13, 2016 and was due to the have the communicable disease trainings no later than March 13, 2018. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
All employees shall have necessary training documented within their training file to ensure they meet the DDAP regulations regarding mandatory training. Program supervisors and/or Executive Director will review training plans of employees on a monthly basis to ensure that the necessary training hours have been obtained by staff members within the appropriate time frames. Program Supervisors and/or Executive Director will request copies of training certificates from employees and will directly submit these documents to Human resources for the employee's training file. Employee# 11 attended training on 10/18/2019. This will be reviewed at upcoming leadership meeting scheduled for 11/5/19. Due date for completion 11/5/19. |
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 on October 1, 2019, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. In the group rooms on both the men's and women's floors, the doors to the rooms were open during a Psycho-ed class. From the hallway, conversations could be overheard. During the review of progress notes in client records, it was determined that clients are encouraged to share personal information during these group classes, therefore the facility should provide privacy. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Doors will be closed during any clinical group or psycho-education group in which individuals are encouraged to share personal information. All staff have been educated and reminded that in order to ensure that confidentiality for all individuals is maintained that doors must be closed during clinical and psycho educational groups. This re-education was completed and documented in a clinical/staffing supervision on 11/3/2019. All leadership staff will complete spot checks during group and psycho-education times to ensure that doors are being closed as required. Completion date: 11/3/2019. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical site inspection on October 1, 2019, the facility failed to ensure electronic records were confidential. On two different occasions during the physical site inspection, staff were observed in the first floor medication room leaving their workstations with confidential client information left visible on their computer screens. The facility's Policy and Procedures manual, section PHC 6.9 Information Technology, subsection XIV states "Close confidential documentation or log off of the network or local desktop before leaving workstation." These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing staff will be re-educated in the importance of ensuring that computers are appropriately logged off of or are closed when leaving work stations in order to protect confidentiality. The nursing department had a staffing on 10/31/2019. Clinical staff and administrative were provided a re-education on 10/3/2019 on the need to ensure the safeguarding of electronic records and that it is necessary to log off or close computer screens with client information when leaving their work space or when in their computer screens are in view of other people. All Supervisors and Leadership will monitor that staff are following this procedure during any time that they are walking around the building and will provide feedback to the Executive Director. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
During a Project Wide review of Policy and Procedures, the facilities Client Rights policy was missing - sex, ethnicity and marital status in 709.30 (2), and Reasons for removing sections shall be documented in the record in 709.30 (3). These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy and Procedures are being updated with sex, ethnicity and marital status in 709.30 and reasons for removing sections shall be documented in the record 709.30. These policies shall be reviewed and modified at the corporate level. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of fourteen client records, the facility failed to ensure that the client was made aware of all of their rights in all fourteen records. In the client acknowledged rights, the facility failed to notify the client that they may not be discriminated again based on their color. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The language will be added to the current client acknowledged rights to include that no one shall be discriminated against based on their color. This shall go through the corporate policy and procedure process and electronic medical record sign off will be updated to reflect this addition. All current client sign the revised client's rights forms making them aware of all of their rights. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of fourteen client records, the facility failed to ensure that the client was made aware of all of their rights in all fourteen records. In the client acknowledged rights, the facility failed to notify the client that they have the right to appeal a decision limiting access to their records. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In the client acknowledged rights the language will be added and staff will be re-educated on the change regarding the client right to appeal the decision to limit access to their record. A policy and procedure will be developed to include the process for requesting the information to be accessed and client acknowledgement of this request will be required. All current client sign the revised client's rights forms making them aware of all of their right to appeal the decision to limit access to their record. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven inpatient rehabilitation client records, the facility failed to provide a complete client record, which is to include work therapy in client record #'s 8, 9, 10, 11, 12, 13 and 14.Client #8 was admitted on August 2, 2019 and was still active at the time of the inspection.Client #9 was admitted on September 18, 2019 and was still active at the time of the inspection.Client #10 was admitted on June 27, 2019 and was discharged on July 25, 2019.Client #11 was admitted on August 2, 2019 and was still active at the time of the inspection.Client #12 was admitted on March 19, 2019 and was discharged on May 2, 2019.Client #13 was admitted on August 24, 2019 and discharged on September 17, 2019.Client #14 was admitted on July 28, 2019 and discharged on September 26, 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff received training on 10/3/2019 during clinical staffing on the need to add work therapy as an intervention for those individuals in the inpatient rehabilitation that perform duties such as wiping tables, vacuuming or other activities of daily living outside of their bedrooms. Clinical supervisor and Quality management staff will monitor this on a monthly basis when completing chart reviews and will document this on the chart review form. |