INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 10, 2014 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.
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Plan of Correction
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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 records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in one of one personnel record.
The findings include:
Three personnel records were reviewed on September 10, 2014. One personnel record was required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training in personnel record # 2.
Employee # 2 is a clinical supervisor and was hired July 22, 2013 as a counselor and promoted on January 14, 2014 as the clinical supervisor. HIV/AIDS and TB/STD training was due to be completed no later than July 22, 2014. The facility failed to provide documentation of HIV/AIDS and TB/STD training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pyramid's HR Coordinator has recently created a database to track for each facility initial and ongoing training requirements for each employee. The HR Coordinator is sharing this information with the staff member's direct supervisor to ensure training needs are discussed during supervision.
Employee #2 is registered to attend the following trainings:
Basic HIV
Registration #: N/A
Course Date: November 20, 2014
Time: 9-3:00 pm
Location: Pyramid Hillside
6000 Frutchy Drive
East Stroudsburg, Pa 1802
TB/STD
Registration #: N/A
Date: November 4, 2014
Time: 9am-1:00 pm
Location: Pyramid Hillside
6000 Frutchy Drive
East Stroudsburg, Pa. 18302 |
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 a review of personnel records and CPR certification cards, the facility failed to ensure that a sufficient number of staff persons were trained in CPR.
The findings include:
Three personnel records and employee CPR certification cards were reviewed on September 10, 2014. Employee #3, a van driver, doesn't have his first aid/CPR certifications and he currently transports clients. Employee #3 transports clients alone.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pyramid's HR Coordinator had recently created a database to track for each facility intial and ongoing training requirements for each employee. The HR Coordinator is sharing this information with the staff member's direct supervisor to ensure training needs are discussed during supervision.
Employee #3 is registered to attend the following training:
CPR/First Aid/AED
Registration #: N/A
Date: October 9, 2014
Time: 9:00 am-3:00 pm
Location: Pyramid Quakertown
2705 Old Bethlehem Pike
Quakertown, Pa. 18951 |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on an inspection of the physical plant, the facility failed to provide documentation of cold food being stored at or below 40F and frozen food being stored at or below 0F.
The findings include:
The physical plant was inspected on September 10, 2014. Several refrigerators/freezers are present for client food storage. The refrigerator/freezer located in the basement failed to have thermometers or a temperature log. There is no way to determine if the cold food is stored at 40F and the frozen food is stored at 0F.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Dietary Manager to install a thermometer and institute a temperature log on the refrigerator/freezer located in the basement of the facility. Dietary Manager will assign a kitchen staff to monitor temperature log daily. Dietary Manager to monitor temperature log monthly to ensure compliance. Target date for implementation is October 1, 2014. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
Based on the physical plant inspection, the facility exceeded capacity for the inpatient nonhospital residential treatment and rehabilitation activity.
The findings include:
The facility has the capacity of 52 for the inpatient nonhospital residential treatment and rehabilitation activity which exceeds the authorized capacity of 2.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility is authorized for a capacity of fifty residential beds. At time of inspection, facility exceeded capacity by two beds. Maintenance Director to be responsible for the removal of two beds from the residential portion of the program. Program Director and Maintenance Director to monitor bed capacity at weekly Department Head meetings to ensure compliance. Target date for bed removal is October 1, 2014. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment.
Findings include:
Sixteen client records were reviewed on September 10, 2014. Eight of the sixteen client records were reviewed from the inpatient nonhospital activities, short term detoxification, #1 through #8. Of the eight detoxification records, one was required to have documentation of a notice of termination. The facility failed to document a notice of termination in client record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will facilitate a treatment team meeting to train the clinicians on the utilization and implementation of the involuntary discharge form found in the electronic record. The form is to be completed for all clients identified as being discharged from the facility due to behavioral concerns. Clinical Director will facilitate weekly scheduled clinical meetings, schedule bi-weekly documented supervision and complete monthly open and closed chart auditing to ensure compliance. Target date for completion is October 1, 2014. |
709.63(a) LICENSURE Client record
709.63. 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:
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Observations
Based on a review of client records, the facility failed to have a complete record in eight of sixteen records reviewed.
The findings include:
Sixteen client records were reviewed on September 10, 2014. Eight of the sixteen were reviewed from the inpatient nonhospital activities short-term detoxification, 1 through 8. Eight client records failed to have a complete record, #1, 2, 3, 4, 5, 6, 7 and 8.
The facility failed to document a complete drug and alcohol support plan that reflected the project's efforts to support and motivate the client to seek formal treatment after the detoxification process in five records, #1, 2, 3, 4 and 5.
The facility failed to have a record of service that included other services offered other than individual/group sessions in records #1, 2, 3, 4 and 5.
Client #7 was discharged, successfully, on May 10, 2014. The facility failed to have documented client #7's aftercare plan. Additionally, the facility failed to include in client #7's discharge summary the services offered to the client, the client's response to treatment and the client's status at discharge. The discharge summary was documented on May 10, 2014.
Client #8 was discharged, against facility advice, on June 3, 2014. The facility failed to have documented client #8's discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
New Clinical Director was hired for the program on September 29, 2014 to develop and maintain the clinical programming and the establishment of performance standards for the clinical team. Clinical Director will facilitate weekly treatment team meetings, schedule bi-weekly documented supervision and perform monthly open and closed chart audits to ensure compliance. Target date for implementation is October 6, 2014. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
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Observations
Based on a review of client records, the facility failed to show that the individual treatment and rehabilitation plan was developed with the client in four of seven records reviewed.
The findings include:
Sixteen client records were reviewed on September 10, 2014. Eight of the sixteen were reviewed from the inpatient nonhospital activities, residential treatment and rehabilitation, 9 through 16. Seven of the eight required documentation of a individual treatment and rehabilitation plan, 10 through 16.
Client #11 was admitted on August 20, 2014. The individual treatment and rehabilitation plan was developed on August 24, 2014. The facility failed to have documented the counselor and staff signature.
Client #12 was admitted on August 5, 2014. The individual treatment and rehabilitation plan was developed on August 22, 2014. The facility failed to have documented the counselor and staff signature.
Client #13 was admitted on August 25, 2014. The individual treatment and rehabilitation plan was developed on August 25, 2014. The facility failed to have documented the counselor and staff signature.
Additionally, client #15 was admitted on May 6, 2014 and discharged on May 27, 2014. The facility failed to have documented client #15's individual treatment and rehabilitation plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will facilitate weekly treatment team meetings, schedule bi-weekly documented supervision and perform monthly open and closed chart audits to ensure compliance. Target date for implementation is October 6, 2014. |
709.52(a)(3) LICENSURE Support service type
709.52. 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services in the individual treatment and rehabilitation plan in three of six client records.
The findings include:
Sixteen client records were reviewed on September 10, 2014. Eight of the sixteen were reviewed from the inpatient nonhospital activities, residential treatment and rehabilitation, 9 through 16. Support services were required in the individual treatment and rehabilitation plan in six client records. The facility did not document support services in the individual treatment and rehabilitation plan in client records #11, 12 and 13.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will facilitate weekly treatment meetings, schedule bi-weekly documented supervision and perform monthly open and closed chart audits to ensure compliance. Target date for implementation is October 6, 2014. |
709.53(a) LICENSURE Complete Client Record
709.53. 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:
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Observations
Based on a review of client records, the facility failed to have a complete record in eight of eight records reviewed.
The findings include:
Sixteen client records were reviewed on September 10, 2014. Eight of the sixteen were reviewed from the inpatient nonhospital activities, residential treatment and rehabilitation, 9 through 16. Six client records failed to have a complete record, #9, 10, 11, 12, 13 and 15.
Client #9 was admitted on August 24, 2014. The case consultation was documented on August 27, 2014. The case consultation was signed by the counselor on August 27, 2014 and other staff signed August 28, 2014.
Client #10 was admitted on August 27, 2014. The case consultation was documented on August 29, 2014. There was no documentation of who was involved in the case consultation since staff did not sign the case consultation.
Client #11 was admitted on August 20, 2014. The case consultation was documented on August 28, 2014. There was no documentation of who was involved in the case consultation since staff did not sign the case consultation.
Client #12 was admitted on August 5, 2014. The case consultation was documented on September 2, 2014. The case consultation was signed by the counselor on September 16, 2014 and other staff signed September 10, 2014.
Client #13 was admitted on August 25, 2014. The case consultation was documented on September 1, 2014. There was no documentation of who was involved in the case consultation since staff did not sign the case consultation.
Client #15 was discharged, successfully, on June 14, 2014. The facility failed to have documented client #15's aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director and counselors to meet weekly to present case consultations for new admissions within the five day time frame. Consultation form located in the electronic record requires a Clinical Director signature along with the signature of two other members of the clinical team for verification of completion. Clinical Director to monitor the completion and verification of the consultation forms through monthly open and closed chart audits. Target date for implementation is October 21, 2014. |