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.
Part 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.
Part 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 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
During a review of 48 staff on July 2, 2020, the facility failed to provide documentation of a written individual training plan for employee #47.
Staff #47 was hired on August 12, 2019 as a Medication Administration Technician and had no training plan as of the date of this inspection.
The findings were discussed with facility staff during the licensing process.
This was a repeat citation from the August 14, 2019 licensing inspection.
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Plan of Correction
Moving forward effective August 1, 2020, Quakertown Executive Director will continue to ensure that all Department Managers, including regional managers whose employees work at Quakertown, monitor their assigned yearly staff training plans at each of the following occasions: the first month of the year, upon yearly evaluations, and upon new hire. The executive director will create an electronic Smartsheet file and share with managers associated with Quakertown staff listed on the staffing grid to ensure all training plans are electronically monitored separate from paper files. By the end of December yearly, Executive Director will verify via the electronic Smartsheet that all employees have an updated and signed training plan for the new training year. The Pyramid Healthcare compliance officer will review adherence to this POC with quarterly meetings with the executive director. Target date: August 1, 2020. |
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
During a review of 48 staff on July 2, 2020, the facility failed to provide documentation that employee's #4, # 30, # 39, # 40, # 43 and # 46 received the minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee # 4 was hired as a Counselor on March 18, 2019 and was due to have the communicable disease training no later March 18, 2020. There was no documentation of the completion of the TB/STD training as of the date of the inspection
Employee # 30 was hired as a BHT Supervisor on October 23, 2017 and was due to have the communicable disease trainings no later than October 23, 2019. There was no documentation of the completion of the HIV/AIDS training and TB/STD training as of the date of the inspection.
Employee # 39 was hired as a Dietary Coordinator on April 18, 2018 and was due to have the communicable disease trainings no later than April 18, 2018. There was no documentation of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee # 40 was hired as a Dietary Worker on October 16, 2017 and was due to have the communicable disease training no later than October 16, 2019. There was no documentation of the completion of the HIV/AIDS training as of the date of the inspection.
Employee # 43 was hired as a Transportation Supervisor on October 17, 2017 and was due to have the communicable disease trainings no later than October 17, 2019. There was no documentation of the completion of the HIV/AIDS training and TB/STD training as of the date of the inspection.
Employee # 46 was hired as a Driver on June 29, 2016 and was due to have the communicable disease training no later June 29, 2018. There was no documentation 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.
This is a repeat citation from the August 14, 2019 and the August 8, 2018 licensing inspections.
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Plan of Correction
All department heads, including regional managers whose employees work at Quakertown, and AA for the facility will track/monitor completion of staff Communicable Diseases training for all department employees via an electronic Smartsheet and report in monthly leadership meeting. Executive Director will discuss efforts of Department Managers monitoring their assigned staff for compliance of Communicable Diseases training attendance in quarterly meetings with Pyramid Healthcare Compliance Officer. Target date for completion is August 1, 2020. All outstanding employees to attend next scheduled trainings within the next 6 months, and will upload certificates to facility electronic record. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of eleven fire drill logs on July 2, 2020, the facility failed to set off a fire alarm or smoke detector during each fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Pyramid Risk Performance Improvement Committee will be updating the fire drill log and or fire drill evaluation form to include the missing information that would indicate that either a smoke detector or fire alarm was set off for each facility fire drill. The new form is to be added to the Risk Performance Improvement Facility Leads Smartsheet for all programs by September 1, 2020. Executive Director will ensure all maintenance staff are educated on the new form, and replace all existing forms by September 15, 2020 |