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 2, 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 Pine Ridge 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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704.9(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 the review of seven personnel records, the facility failed to provide documentation of a written semiannual performance evaluation based upon measurable performance standards in two personnel records.
Employee # 6 was hired as a counselor assistant on December 23, 2019 and was still in this position at the time of the inspection. A semi-annual performance evaluation was due no later than June 23, 2020.
Employee # 7 was hired as a counselor assistant on July 14, 2019 and was still in this position at the time of the inspection. A semi-annual performance evaluation was due no later than January 14, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ED reviewed regulations for semi-annual evaluations with lead counselor on 7/17/2020. Lead Counselor will ensure semi-annual evaluations are completed for all Counselor Assistance, displaying if standards were met/not met. ED will monitor that these are being completed. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of the facility staff schedule, the facility failed to provide a sufficient number of staff persons with CPR certification and first aid training, so that at least one person trained in these skills is onsite during the project's hours of operation. The facility did not provide coverage during the third shift hours on the dates of May 10-11, 2020, May 16-17, 2020, May 23-24, 2020, May 30, 31, 2020, June 1, 2020, and June 6-7, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee will attend required CPR training at Pyramid's Corporate Training room on July 27,2020. Executive Director will follow up with Human Resource Coordinator to ensure attendance. Human Resource Coordinator will monitor employee files quarterly to ensure compliance with mandated trainings.
Executive Director will coordinate with HR to review monthly any employees who CPR Trainings are set to expire, then designated employees with be scheduled for the next CPR trainings which are held monthly. Lead Counselor and BHT Supervisor will monitor their perspective employees to ensure ongoing compliance. BHT Supervisor schedules at least two BHT who are CPR certified for each shift (one for on grounds, one for any driving needs). The BHT Supervisor would be the backup to this.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of the facility fire drill log for the months of February 2019 through May 2020, the facility failed to document an unannounced fire drills at least once a month. There was not a fire drill documented for the month of November 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed fire safety regulations with risk team on 7/16/2020.BHT staff will conduct an unannounced fire drill monthly. Executive Director and Risk leader will review the fire safety binder on the last day of each month to ensure that the monthly drill was conducted and protocol met. BHT Supervisor will provide back up to the Executive Director, is she is unavailable or out of the facility. The Executive Director will utilize the schedule in the Electronic medical record system to provide as a reminder that a fire drill is due. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on the review of the facility's fire drill log for the months of February 2019 through May 2020, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. there was only one overnight fire drill documented on October 30, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed fire safety regulations with risk team on 7/16/2020. The BHT Supervisor will designate a 3rd shift BHT to conduct the fire drill quarterly on this particular shift, during sleep hours. Executive Director and Risk Manager will monitor fire safety binder at the end of each month to ensure fire drills are being conducted as designated. Executive Director and Risk Manager will ensure monthly, unannounced drills are being completed on various shifts. |