INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 4-5, 2012 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. 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 the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in two of six personnel records.
The findings include:
Fifteen personnel records were reviewed on October 4-5, 2012. Six personnel records were required to include documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel records # 7 and 10.
Employee # 7 was hired as a counselor January 8, 2012. The employee met the education requirement with a master's degree in criminal justice. The employee's resume did not document that the employee had completed a practicum, therefore, the employee did not meet the required 1 year of clinical experience.
Employee # 10 was hired as a counselor November 20, 2011. The employee met the education requirement with a bachelor's degree in criminal justice. The employee's resume did not document that the employee had the required 1 year of clinical experience.
The Facility Director was interviewed on October 5, 2012 and confirmed the findings.
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Plan of Correction
Beginning October 22, 2012, The Vice President of Human Resources and Program Managers will ensure that all persons hired for or promoted to the position of counselor meet the qualifications for the position of counselor. Specifically, employees #7 & #10 were transferred to the position of Counselor Assistant and will remain there until they have completed the appropriate requirements to be returned to the position of counselor. Program Managers will monitor compliance with the supervision needs of employees #7 & #10 through weekly supervision. The Vice President of Human Resources and Program Managers will monitor compliance with hiring or promoting people who meet the appropriate criteria for their position by reviewing the staffing regulations prior to making offers to or promoting chosen candidates for the position of counselor. The Human Resources Department will also review all counselor files quarterly to ensure compliance.
Compliance will be by November 1.
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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 personnel and training records, the facility failed to provide documentation of a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in eight of eleven personnel records.
The findings include:
Fifteen personnel records were reviewed on October 4-5, 2012. Eleven personnel records required documentation of HIV/AIDS and/or tuberculosis, sexually transmitted diseases and other health related topics training. Employees records # 5, 6, 7, 8, 11, 12, 13 and 14 did not include documentation of the completion of the required training.
Employee # 5 was hired as a counselor on April 10. 2011. Tuberculosis and sexually transmitted diseases and other health related topics training was due to be completed by April 10, 2012. There was no documentation that the employee had completed the training as of October 5, 2012.
Employee # 6 was hired as a counselor on April 12, 2010. Tuberculosis and sexually transmitted diseases and other health related topics training was due to be completed by April 12, 2011. There was no documentation that the employee had completed the training as of October 5, 2012.
Employee # 7 was hired as a counselor assistant on August 5, 2011. HIV/AIDS and tuberculosis and sexually transmitted diseases and other health related topics training was due to be completed by April 12, 2011. There was no documentation that the employee had completed the training as of October 5, 2012.
Employee # 8 was hired as a counselor on July 9, 2010. HIV/AIDS and tuberculosis and sexually transmitted diseases and other health related topics training was due to be completed by July 9, 2011. There was no documentation that the employee had completed the training as of October 5, 2012.
Employee # 11 was hired on February 12, 2009 and promoted to a counselor on August 16, 2010. Tuberculosis and sexually transmitted diseases and other health related topics training was due to be completed by February 12, 2010. There was no documentation that the employee had completed the training as of October 5, 2012.
Employee # 12 was hired as a counselor assistant on June 18, 2010. HIV/AIDS and tuberculosis and sexually transmitted diseases and other health related topics training was due to be completed by June 18, 2011. There was no documentation that the employee had completed the training as of October 5, 2012.
Employee # 13 was hired as a counselor on August 2, 2010. Tuberculosis and sexually transmitted diseases and other health related topics training was due to be completed by August 2, 2011. There was no documentation that the employee had completed the training as of October 5, 2012.
Employee # 14 was hired as a counselor on May 17, 2010. HIV/AIDS and tuberculosis and sexually transmitted diseases and other health related topics training was due to be completed by May 17, 2011. There was no documentation that the employee had completed the training as of October 5, 2012.
The Facility Director was interviewed on October 5, 2012 and confirmed the findings.
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Plan of Correction
Beginning October 22, 2012, The Vice President of Human Resources and Program Managers will ensure that all employees receive training in HIV/AIDS and Tuberculosis, Sexually Transmitted Diseases, and Other Health Related Topics in the appropriate time frame. Employees that are currently deficient in receiving the Tuberculosis, Sexually Transmitted Diseases, and Other Health Related Topics training (7,8,11,12,13,14) will be trained by December 1, 2012.Employees that are currently deficient in receiving the HIV/AIDS training (7,8,12,14) will be trained by December 1, 2012. Please note that employee #5 has already received the STD/TB training on 1/27/10 but the certificate was not in the personnel file. Also, employees # 8,11,12,13,14 had STD/TB training but the certificates were not in the employee files. This certificate will be placed into the HR file by November 1, 2012. Please note that employee #6 has already received the STD/TB training on 4/28/10 and this certificate was in the employees personnel file at the time of the audit. Also, employees 8,12,14 had HIV/ Aids training but the certificates were not in the employee files. This certificate will be placed into the HR file by November 1, 2012. The Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance with STD/TB and HIV/AIDS training requirements.
Compliance will be by January 1, 2013
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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.
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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 director and the facility director in two of two personnel records.
The findings include:
Fifteen personnel records were reviewed on October 4-5, 2012. One personnel record pertained to the project director and one personnel record pertained to the facility director. The facility's training year is January- December. The facility's 2011 training year was reviewed. Two personnel records required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1 and 2.
Employee # 1 has been the project director since July, 1999. There were no training hours documented for the 2011 training year.
Employee # 2 has been the facility director since November 2008. There were 9 training hours documented for the 2011 training year.
Human resources personnel were interviewed on October 5, 2012 and confirmed the findings.
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Plan of Correction
Project Manager will complete 12 hours of training by November 30, 2012. Beginning October 22, 2012, Human Resources along with the Program Manager's/Supervisors will ensure that employees receive the appropriate training hours. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in six of six personnel records.
The findings include:
Fifteen personnel records were reviewed on October 4-5, 2012. Thirteen personnel records pertained to counselors. Six personnel records were required to include documentation of the completion of 25 clock hours of annual training. The facility's training year is from January through December. The facility's 2011 training year was reviewed. The facility failed to document 25 clock hours of annual training in personnel records # 6, 8, 9, 11, 13 and 14.
Employee # 6 was hired on April 12, 2010. Employee # 6 had only 21 clock hours of training documented for the 2011 training year.
Employee # 8 was hired on July 9, 2010. Employee # 8 had only 3 clock hours of training documented for the 2011 training year.
Employee # 9 was hired on October 25, 2010. Employee # 9 had only 21 clock hours of training documented for the 2011 training year.
Employee # 11 was hired on August 16, 2010. Employee # 11 had only 3 clock hours of training documented for the 2011 training year.
Employee # 13 was hired on August 2, 2010. Employee # 13 had only 6 clock hours of training documented for the 2011 training year.
Employee # 14 was hired on November 15, 2010. Employee # 14 had 0 clock hours of training documented for the 2011 training year.
The Facility Director was interviewed on October 5, 2012 and confirmed the findings.
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Plan of Correction
Beginning October 22, 2012, The Vice President of Human Resources and Program Manager will ensure that employees receive the appropriate training hours for 2012 and every subsequent training year. Training Certificates and Training Evaluations will be placed into employee personnel files as opposed to a separate folder. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance.
Compliance will be by December 31, 2012
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709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document complete psychosocial evaluations in five of five client records.
The findings include:
Twenty client records were reviewed on October 4-5, 2012. Five client records were reviewed as partial hospitalization records. The psychosocial evaluations in client records #2, 3, 4, 5 and 6 did not include an evaluation of the client's assets/strengths, coping mechanisms, support systems, negative factors towards treatment and the counselor's conclusions and impressions of the client.
The Facility Director was interviewed on October 5, 2012 and confirmed the findings.
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Plan of Correction
The Clinical Supervisor for the counselor who was assigned to clients # 2, 3, 4, 5 and 6 will meet with the counselor to review the appropriate way to complete an evaluative psychosocial evaluation. This will include an evaluation of clients' assets/strengths, coping mechanisms, support systems, negative factors towards treatment, and the counselor conclusions /impressions of the client. This will begin by 12/3/12 and be monitored during monthly Chart Monitors by counselors' supervisors. |
709.82(a)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of client records, the facility failed to develop an individual treatment and rehabilitation that included short- and long-term goals for treatment as formulated by both staff and client in five of five client records.
The findings include:
Twenty patient records were reviewed on October 4-5, 2012. Six patient records were reviewed as partial hospitalization clients. Five partial hospitalization client records were required to include documentation of an individual treatment and rehabilitation plan. The individual treatment and rehabilitation plan in client records # 2, 3, 5 and 6 were not individualized as the plans had identical short and long term goals.
The Facility Director was interviewed on October 5, 2012 and confirmed the findings.
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Plan of Correction
The Clinical Supervisor for the counselor who was assigned to clients # 2, 3, 4, 5 and 6 will meet with the counselor regarding short- and long-term goals for treatment. Discussions/training will specifically focus on the importance of individualizing short- and long-term treatment goals. Compliance will be ensured through monthly reviews of treatment plans during clinical supervision. This will begin by 12/3/12 and be monitored during monthly Chart Monitors by counselors' supervisors. |
709.83(a)(6) LICENSURE Client records
709.83. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on the review of client records, the facility failed to document an aftercare plan that in included goals with time frames in three of three client records.
The findings include:
Twenty patient records were reviewed on October 4-5, 2012. Six patient records were reviewed as partial hospitalization clients. Three of the partial hospitalization client records were closed client records. All three of the closed client records were required to include documentation of an aftercare plan.
The aftercare plans in client records # 4, 5, and 6 did not include documentation of the time frames for the completion of the aftercare goals.
The Facility Director was interviewed on October 5, 2012 and confirmed the findings.
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Plan of Correction
The Clinical Supervisor for the counselor who was assigned to clients # 4, 5 and 6 will meet with the counselor to discuss completion of documentation of the time frames for aftercare goals. Compliance will be ensured through monthly reviews of aftercare plans during clinical supervision. This will begin by 12/3/12 and be monitored during monthly Chart Monitors by counselor's supervisor.
Compliance will be by 12.3.12
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observation and the physical plant inspection, the facility failed to secure client records within locked storage containers.
The findings include:
The physical plant inspection was conducted on October 5, 2012. The first floor "A" wing storage closet contained closed client charts that were stored in unsecured boxes. Staff other than those permitted access to the client records had complete access to the closed client charts.
The Facility Director was present when the charts were observed and confirmed the findings.
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Plan of Correction
The Program Director will speak with the facility Medical Records Coordinator who placed the box of client charts in the storage closet. At that time she will be told she will no longer be able to store any client charts in this closet. This conversation will occur by 11/5/2012. Compliance will be ensured by changing the lock on the closet so only Maintenance Supervisor has a key and closet will be locked at all times. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation that was evaluative in seven of eight client records.
The findings include:
Twenty client records were reviewed on October 4-5, 2012. Eight client records were reviewed as inpatient records. # 7, 8, 9, 10,11,12 and 14.
Twenty client records were reviewed on October 4-5, 2012. The psychosocial evaluations in client records # 7, 8, 9, 10, 11, 12 and 14 did not include an evaluation of the client's assets/strengths, coping mechanisms, support systems, negative factors towards treatment and the counselor conclusions/impressions of the client.
The Facility Director was interviewed on October 5, 2012 and confirmed the findings.
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Plan of Correction
The Clinical Supervisors in both the Men's and Women's Inpatient Units will meet with their respective counselors on their units no later than 12/3/12 to review the appropriate way to complete an evaluative psychosocial evaluation. This will include an evaluation of clients' assets/strengths, coping mechanisms, support systems, negative factors towards treatment, and the counselor conclusions /impressions of the client. This will be monitored during monthly Chart Monitors by counselors' supervisors. |