INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 6-7, 2016 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 to be not 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(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report, a review of staff records and a conversation with the project director, the facility failed to ensure that a counselor assistant received the required supervision.
Employee #9 was hired as a counselor assistant with a high school diploma on 1/31/16. The facility failed to document that Employee #9 received direct supervision for the first three months of employment.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 01/05/17,All clinical applicants will be screened by Human Resources Coordinator to ensure they have met all requirements for the proposed position. Monthly reviews will be conducted by Human Resources to ensure screening is completed on all applicants. Effective immediately, Employee #9 will begin to receive Direct Observation of all individual, family and group therapy sessions for a total of 3 months. Direct Observation will be provided by various qualified clinical staff and documented supervision will be completed on a weekly basis by the supervising clinician. Program Director will ensure supervision is completed appropriately. |
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 the facility's Staffing Requirements Facility Summary Report, staff records and a conversation with facility staff, the facility failed to ensure that staff #11 received the required trainings.
Employee #11, a Behavioral Health Tech, was hired on 10/21/2014. The HIV/AIDS training was due to be completed by 10/21/2016 but was not documented as of the date of the inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Administrative Assistant for the facility will work with the Eastern Region Human Resources representative to monitor the completion of HIV?AIDS trainings for all staff members in accordance with state regulations. Program Manager will ensure that Department Supervisors are appropriately monitoring staff for compliance with training guidelines through bi-weekly individual and monthly supervision. The Human Resources Coordinator will send weekly emails to facility leadership, notifying of employee training status. The Human Resources Coordinator will complete quarterly reviews of employee files to ensure 100% compliance to training standards. Target date for completion is January 19, 2017.
Employee #11 who did not meet the training requirements of obtaining six hours of HIV/AIDS training by 10/21/16, has been scheduled to take the training on 04/21/2017. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on December 6-7, 2016, the facility failed to keep the grounds of the facilty free of hazards.
The outside Bilco doors, leading to the basement, on the side of the building near the main entrance, were rusted and structurally unsound.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 12/7/2016, maintenance staff evaluated and replaced the rusted Bilco doors.It will be the responsibility of the Maintenance Supervisor to document regularly scheduled physical plant audits.Findings will be reviewed by facility Risk Committee on a monthly basis. Target date for completion is January 16, 2017. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records and a conversation with facility staff that was conducted on December 6 -7, 2016, the facility failed to obtain a valid, informed and voluntary consent form from the client in client records # 1, 2, 3, 5, 6, 7, 8, 9 and 10.
Additionally, the facility failed to restrict the release of information to what is permitted by 4 Pa. Code 255.5 by disclosing the probation/parole status of four clients involved in an altercation to law enforcement personnel responding to the incident at the facility on October 10, 2016.
Client #1 was admitted on 11/22/16 and was an active client at the time of the licensing inspection. A consent to release form dated 11/22/16 to a criminal justice agency did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #2 was admitted on 11/3/16 and was an active client at the time of the licensing inspection. A consent to release form dated 11/3/16 to a criminal justice agency did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #3 was admitted on 11/7/16 and was an active client at the time of the licensing inspection. A consent to release form dated 11/7/16 to a treatment provider did not contain a provision for the consent to be revoked.
Client #5 was admitted on 12/17/15 and was discharged 2/12/16. A consent to release form dated 12/14/16 to a criminal justice agency did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #6 was admitted on 12/17/15 and was discharged 2/12/16. A consent to release form dated 2/19/16 to a treatment provider did not contain a provision for the consent to be revoked.
Client #7 was admitted on 5/10/16 and was discharged 7/29/16. A consent to release form dated 5/10/16 to a criminal justice agency did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #8 was admitted on 5/31/16 and was discharged 8/1/16. A consent to release form dated 5/31/16 to a criminal justice agency did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #9 was admitted on 8/10/16 and was discharged 9/12/16. A consent to release form dated 8/10/16 to a criminal justice agency did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #10 was admitted on 9/6/16 and was discharged 10/17/16. A consent to release form dated 9/6/16 to a criminal justice agency did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
VP of Clinical Services revised consents on November 28, 2016 to ensure that all consents contain appropriate elements of a valid consent, including acknowledgment that a copy was offered to the client as well as the ability to revoke consents verbally or in writing. Criminal Justice consent was revised to eliminate statement that consent cannot be revoked. Charts numbered 1,2,3,5,6,7,8,9, and 10 are either no longer enrolled, or were not enrolled in treatment services at the time of the licensing visit. A caseload review of all currently admitted clients by each counselor has been initiated as of 12/21/16 to sign updated consents for all currently enrolled clients, not reviewed in this licensing visit that corrections may apply to during their individual sessions. No additional actions are needed to support new admits into the program, as the form currently in the chart is corrected as of 11/30/2016 and only administrators have the ability to revise to avoid user error at the facility level. An all staff training is under development for our mylearningpointe training system to launch in 2017 training year to reinforce for current and new hires. All staff members who deal directly with consents will receive additional training on revisions and completion of consents. Training will be conducted by February 28, 2017. Completion of training will be verified by post-test completion and monitored by Human Resources Coordinators.
Effective 01/23/2017, all facility employees will receive education on the importance of restricting the release of information to the State Police, to that which is permitted by 4 Pa.Code 255.5. Education to be provided by Department Supervisors during bi-weekly and monthly supervision with oversight by the Program Director. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records and a conversation with the facility staff that was conducted on 12/6-7/16, the facility failed to document whether the client was offered a copy of the consent form in client records, # 1, 3, and 6.
Client #1 was admitted on 11/22/16 and was an active client at the time of the licensing inspection. A consent to release form, dated 11/22/16 to a criminal justice agency, did not indicate whether the client was offered a copy.
Client #3 was admitted on 11/7/16 and was an active client at the time of the licensing inspection. A consent to form, dated 11/7/16 to a treatment provider, did not indicate whether the client was offered a copy.
Client #6 was admitted on 12/17/15 and was discharged 2/12/16. A consent to form, dated 2/19/16 to a treatment provider, did not indicate whether the client was offered a copy.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
VP of Clinical Services revised consents on November 28, 2016 to ensure that all consents contain appropriate elements of a valid consent, including acknowledgment that a copy was offered to the client as well as the ability to revoke consents verbally or in writing. Criminal Justice consent was revised to eliminate statement that consent cannot be revoked.Charts numbered 1,3, and 6 are either no longer enrolled, or were not enrolled in treatment services at the time of the licensing visit. A caseload review of all currently admitted clients by each counselor has been initiated as of 12/21/16 to sign updated consents for all currently enrolled clients, not reviewed in this licensing visit that corrections may apply to during their individual sessions. No additional actions are needed to support new admits into the program, as the form currently in the chart is corrected as of 11/30/2016 and only administrators have the ability to revise to avoid user error at the facility level. An all staff training is under development for our mylearningpointe training system to launch in 2017 training year to reinforce for current and new hires. All staff members who deal directly with consents will receive additional training on revisions and completion of consents. Training will be concluded by February 28, 2017. Completion will be verified by post-test completion and monitored by Human Resources Coordinators. |
709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection conducted on 12/7/16 and a conversation with the project director, the facility failed to conspicuously display the hours of operation for the partial hospitalization activity.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 01/02/2017, signage reflecting the hours of project operation for Residential, Partial Hospitalization, and Intensive Outpatient services, as well as the emergency contact number will be posted within plain site at the main entrance to the program.Effective 1/23/17, it will be the responsibility of the Administrative Assistant to conduct weekly signage audits to ensure that signage is present, and has current information displayed. Results of audits and any necessary corrections will be reported to Program Director on a weekly basis to ensure compliance to the standard |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection conducted on 12/7/16 and a conversation with the project director, the facility failed to conspicuously display the emergency telephone number.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 01/02/2017 signage reflecting the hours of project operation for Residential, Partial Hospitalization, and Intensive Outpatient services, as well as the emergency contact number will be posted within plain site at the main entrance to the program.Effective 1/23/17, it will be the responsibility of the Administrative Assistant to conduct weekly signage audits to ensure that signage is present, and has current information displayed. Results of audits and any necessary corrections will be reported to Program Director on a weekly basis to ensure compliance to the standard |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection conducted on 12/7/16 and a conversation with the project director, the facility failed to conspicuously display the hours of operation for the outpatient activity.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 01/02/2017 signage reflecting the hours of project operation for Residential, Partial Hospitalization, and Intensive Outpatient services, as well as the emergency contact number, will be posted within plain site at the main entrance to the program.Effective 1/23/17, it will be the responsibility of the Administrative Assistant to conduct weekly signage audits to ensure that signage is present, and has current information displayed. Results of audits and any necessary corrections will be reported to Program Director on a weekly basis to ensure compliance to the standard |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection conducted on 12/7/16 and a conversation with the project director, the facility failed to conspicuously display the emergency telephone number.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 01/02/2017 signage reflecting the hours of project operation for Residential, Partial Hospitalization, and Intensive Outpatient services, as well as the emergency contact number, will be posted within plain site at the main entrance to the program.Effective 1/23/17, it will be the responsibility of the Administrative Assistant to conduct weekly signage audits to ensure that signage is present, and has current information displayed. Results of audits and any necessary corrections will be reported to Program Director on a weekly basis to ensure compliance to the standard |