INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 22, 2013 by staff from the Division of Drug and Alcohol 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.
|
Plan of Correction
|
704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Reports, the facility failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Reports for the 14 facilities contained within the project were reviewed on October 15, 2013. The equivalent of 105.275 full-time counselors are employed within the project. This would require at least 13 full-time clinical supervisors. The project currently employs 7 full-time clinical supervisors.
|
Plan of Correction
The Vice President of Clinical Services will ensure that the ratio of Clinical Supervisors for the project is within the defined regulation of 1 fulltime clinical supervisor for every 8 fulltime counselors or counselor assistants. The Project will re-evaluate its current system and restructure the project to include the appropriate number of clinical supervisors. Human resources coordinators will identify the number of clinical supervisors, counselors, and counselor assistants within the system on a quarterly basis. Vice President of Clinical Services will be responsible to review staffing hours quarterly to ensure that ratio is maintained. Program Directors will notify the Vice President of Clinical Services should any changes in the ratio per site occur during the quarter. Restructuing of the Clinical Supervisor ratio will begin December 1, 2013. Clinical Supervisor ratio will be in 100% compliance by January 1, 2014. |
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.
|
Observations
Based on a review of the facility's staffing requirements facility summary report (SRFSR), the facility failed to ensure that staff persons and/or volunteers received 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 as per the regulatory requirements in three of fifteen records reviewed.
The findings include:
The facility's SRFSR form completed by the facility on October 1, 2013 was reviewed on October 4, 2013. The form listed three staff as not having completed the mandatory training within the regulatory time frames
Employee # 5, a counselor, was hired on March 12, 2012. Employee #5 was required to obtain 4 hours of TB/STD training by March 12, 2013. The training was not documented as of the date of the inspection.
Employee #13, a support staff person, was hired on August 22, 2011. Employee #13 was required to obtain 4 hours of TB/STD training by August 22, 2013. The training was not documented until September 27, 2013.
Employee #15, a support staff person, was hired on August 22, 2011. Employee #15 was required to obtain 4 hours of TB/STD training by August 22, 2013. The training was not documented until September 27, 2013
The findings were confirmed by the facility director.
|
Plan of Correction
Administrative Assistance for the facility will track/monitor completion of mandatory communicable disease training compliance for all employees. Program Manager will ensure that all Department Supervisors monitor their assigned staff for compliance of training attendance through bi-weekly individual and monthly group supervision. Human Resource Coordinator to complete quarterly reviews of employee files for facility staff to ensure 100% compliance. Target date for completion is December 1, 2013.
Employee #5 has successfully completed the mandatory TB/STD training effective 10/22/2013. Documented proof of training to be found in employees HR file. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project directors in one of one personnel records.
The findings include:
Fourteen personnel records were reviewed on October 8, 2013. One personnel record pertained to the project director required the documentation of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 has been the project director since July 1, 1999. The facility training year is from July through June. Employee # 1 had documentation of 10.5 hours of training for the July 2012 - June 2013 training year.
|
Plan of Correction
Project Manager will complete 12 hours of training annually. Project Manager will ensure needed documentation of completed trainings is presented to Human Resources to be recorded in Personnel File. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records on October 22, 2013, the facility failed to provide a psychosocial evaluation to include the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and/or counselor conclusions and impressions in eight of twelve records reviewed.
The findings include:
The psychosocial evaluations in client records # 1, 2, 3, 5, 6, 7 and 8 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records # 2, 3, 6, 7 and 8 did not include an evaluation of the client's support systems.
The psychosocial evaluations in client records # 2, 3, 5, 6, 7 and 8 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records # 6 and 8 did not include an evaluation of the negative factors of the client.
|
Plan of Correction
Clinical Staff will provide a psychosocial evaluation to include: assets/strengths, positive support systems, coping mechanisms, negative factors that may inhibit treatment and counselor conclusions and impressions. Clinical Supervisor will review with clinical staff at next scheduled group supervision,all that is to be included in a complete psychosocial evaluation as part of the clinical record. Clinical Supervisor will monitor compliance through bi-weekly documented supervision and through the completion of monthly open and closed chart audits. Target for completion is December 1, 2013. |