INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 21, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel files, the facility failed to ensure that one applicable clinical supervisor had completed a core curriculum in clinical supervision in clinical supervision which is a requirement for the position.
Employee #3 was hired as the clinical supervisor on March 8, 2021 and is current in that position. Employee #3 did not complete a core curriculum until April 8, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
While the identified staff currently has the required training for clinical supervision, this POC will address preventing further delays and deficiencies in this area.
Executive Director will work with Regional Director, Human Resources and Compliance to identify necessary trainings prior to hire and / or promotion to a position that involves clinical supervision. ED will work with HR to sign potential staff up for required trainings as part of the orientation process.
ED will modify current training plans and new hire check lists to include signing up for required trainings to ensure they are completed in a timely manner and within the established guidelines.
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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 and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that two applicable employees received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #5 was hired as a counselor on June 3, 2021 and was due to have the communicable disease trainings no later than June 3, 2022. However, there was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #6 was hired as a counselor on July 5, 2021 and was due to have the communicable disease trainings no later than July 5, 2022. However, there was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff identified during the licensing process have been signed up for the required trainings. They are scheduled for:
October 3 ? staff that require TB/STD
Staff that requires all trainings will complete them on 10/10, 10/24 & 10/25, 11/3 & 11/4, 11/17 & 11/18, and 12/8 & 12/9.
In order to prevent future deficiencies, the Clinical Supervisor will work with the Clinical Supervisors across PA to add signing new staff up for required trainings into the clinical training plan designed for new hires. The Clinical Supervisor will teach staff how to sign up on the DDAP website, create a login, and will sign off during orientation the new hire is signed up for the first available training.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from September 2021 through June 2022, the facility failed to ensure that each fire drill log contained the exit route used, as the logs for drills between September 2021 and May 2022 were missing this information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will review the Fire Safety Evacuation Procedures Skills Checklist during staff meeting on 8/29/22. Executive Director will review the form that is used for fire drills and highlight each section that needs to be filled out during the same staff meeting.
All staff will also be re-trained on the electronic form found on the intranet on 9/5/2022 during staff meeting.
Administrative Assistant will be responsible for facilitating all fire drills and ensuring all sections of the forms are completed entirely. Executive Director will sign off on every form to ensure all sections are completed. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that personnel records contained a reviewed and signed annual written staff performance evaluation in three of five applicable records reviewed.
Employee # 3 was hired as a Clinical Supervisor on March 8, 2021 and is current in that position. The annual written staff performance evaluation for the period reviewed was not signed or dated by the employee as of the date of the inspection.
Employee #4 was hired as a counselor on January 22, 2018 and is current in that position. The record contained no annual written staff performance evaluation for the prior review period.
Employee #5 was hired as a counselor on June 3, 2021 and is current in that position. The record contained no annual written staff performance evaluation for prior review period.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director has developed a training tracking grid for all staff members that will allow him to track training hours to ensure staff are meeting their requirements. This grid is updated and checked at the beginning of each month to ensure counselors and all staff are on tack to meet hours. On 8/15/2022, Executive Director will add a column for annual performance evaluations to ensure they are monitored and signed off for each staff member annually. |
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 twelve client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in one record reviewed.
Client #1 was admitted on October 20, 2020 and was discharged on July 7, 2022. There was an informed and voluntary consent form to the funding source, signed and dated by the client on August 30, 2020, which expired on August 30, 2021. There was documentation of billing after the expiration date and there was no updated consent form signed by the client documented in the record prior to the disclosures.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Over the course of the last year, Executive Director and Clinical Supervisor created spreadsheet for each counselors case load. The trackers were established on 9/13/2021. The trackers monitor attendance, treatment plan due dates, case consult due dates, psychosocial evaluation completion, pending discharge dates and when the next appointment is scheduled. Over the last year, counselors were required to monitor and update this tracker daily. Clinical supervisor will add a column on this tracker to include releases of information and the due date for renewal. This column will be added by 8/15/2022 at staff meeting.
Clinical supervisor will review case trackers weekly. During staff meeting, all counselors will be required to bring their case tracker to staff meeting to ensure due dates are met for each of the columns. ED and CS will meet at the beginning of each month to monitor any deficiencies and provide reminder emails for staff for items that are due for the upcoming month. Quality Management team will monitor deficiency areas monthly during quality review. Any noted deficiencies will be reported to Clinical Supervisor.
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of six client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 30 days in one of three applicable records.
Client #8 was admitted on March 30, 2022 and discharged on May 18, 2022. An individual treatment and rehabilitation plan was completed on April 6, 2022 and a treatment plan update was due to be completed by May 6, 2022; however, no update was completed prior to the client ' s discharge.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 30, 2021 annual licensing inspection.
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Plan of Correction
Over the course of the last year, Executive Director and Clinical Supervisor created spreadsheet for each counselors case load. The trackers were established on 9/13/2021. The trackers monitor attendance, treatment plan due dates, case consult due dates, psychosocial evaluation completion, pending discharge dates and when the next appointment is scheduled. Over the last year, counselors were required to monitor and update this tracker daily.
Clinical supervisor will review case trackers weekly. During staff meeting, all counselors will be required to bring their case tracker to staff meeting to ensure due dates are met for each of the columns. ED and CS will meet at the beginning of each month to monitor any deficiencies and provide reminder emails for staff for items that are due for the upcoming month.
After reviewing the deficiency during the licensing inspection, it was identified that the client in question has not been attending individual sessions but has been coming to group. In order to address situations such as this, ED and Clinical Supervisor have identified a staff member and modified her schedule. She will be available to meet with clients that have not updated their treatment plan in individual session and will be able to meet with them prior to group. These cases will be identified during staff meeting when CS is reviewing case trackers. Quality Management team will monitor deficiency areas monthly during quality review. Any noted deficiencies will be reported to Clinical Supervisor.
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of six records, the facility failed to ensure that counseling was provided to clients on a regular and scheduled basis, that included individual counseling, at least twice weekly in three of five applicable records reviewed.
Client #2 was admitted on June 2, 2022 and was discharged on June 21, 2022. There was only one note documenting individual counseling for the week of June 13, 2022 through June 17, 2022.
Client #5 was admitted on September 3, 2021 and was discharged on October 18, 2021. The record contained documentation of only one individual counseling session offered between September 3, 2021 and October 1, 2021. Additionally, there was only one individual counseling session documented for the week of October 4, 2021 through October 8, 2021.
Client #8 was admitted on March 30, 2022 and was discharged on May 18, 2022. The record did not contain documentation of any individual counseling sessions between April 18, 2022 and April 22, 2022.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 30, 2021 and November 9, 2020 annual licensing inspections.
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Plan of Correction
Executive Director will be restructuring the PHP program. Staffing assignments have been changed as well. Staff identified to run the PHP program were retrained on the PHP tracker on 8/8/2022. The PHP tracker will not only monitor client engagement with appointments but will also monitor discharge / step down paperwork requirements for each client in PHP programming. These discharge / transition bundles will be documented on the tracker and expected to be completed by the Counselors. The PHP tracker is reviewed weekly and reviewed each Monday with all staff during staff meeting. The clinical supervisor will schedule all individual sessions for PHP clients at the end of each week for the following week.
The tracker will be monitored weekly by the Clinical Supervisor for completion of discharge paperwork as well as the required 7 day reach out call after discharge and will be reviewed during monthly supervision with Executive Director. . Quality Management team will monitor deficiency areas monthly during quality review. Any noted deficiencies will be reported to Clinical Supervisor.
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709.83(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information in one of three applicable records reviewed.
Client #3 was admitted on March 8, 2022 and discharged on April 5, 2022. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 30, 2021 annual licensing inspection.
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Plan of Correction
For all clinical staff, Executive Director and Clinical Supervisor created a Case tracker for staff to utilize. This tracker was trained and implemented on 9/13/2021 with all counselors holding a caseload. Each tracker monitors attendance, treatment plan due dates, case consult due dates, psychosocial evaluation completion pending discharge dates and when next appointments are scheduled. Counselors are required to update tracker daily as meeting with clients. There is a section on the tracker which identifies when 7 Day follow up calls for all discharged clients. This tracker will be reviewed for each counselor at weekly staff meeting. Prior to every staff meeting, Clinical Supervisor will run a discharge report to identify clients that will need follow up calls and will cross check that with the case load trackers.
During staff meeting, this list of discharged clients will be given to the Administrative Assistant and she will complete all outreach over the course of the week. The completed list will be given to the Executive Director at the end of the week to review.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of five applicable records reviewed.
Client #1 was admitted on October 20, 2020 and discharged on July 7, 2022. A treatment plan update was completed on September 10, 2021 and a treatment plan update was due to be completed by November 10, 2021; however, the next treatment plan update was not completed until May 11, 2022.
Client #7 was admitted on October 18, 2021 and discharged on July 4, 2022. The individual treatment and rehabilitation plan was completed on December 16, 2021 and a treatment plan update was due to be completed by February 16, 2022; however, no treatment plan updates were completed prior to discharge.
Client #9 was admitted to the Outpatient activity from the Partial Hospitalization Program on May 18, 2022 and was active at the time of the inspection. No treatment plan updates were completed prior to the date of the inspection.
Client #12 was admitted on August 17, 2021 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 2, 2021 and a treatment plan update was due to be completed by November 2, 2021; however, no treatment plan updates were completed prior to the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 30, 2021 annual licensing inspection.
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Plan of Correction
Over the course of the last year, Executive Director and Clinical Supervisor created spreadsheet for each counselors case load. The trackers were established on 9/13/2021. The trackers monitor attendance, treatment plan due dates, case consult due dates, psychosocial evaluation completion, pending discharge dates and when the next appointment is scheduled. Over the last year, counselors were required to monitor and update this tracker daily. Clinical supervisor will review case trackers weekly. During staff meeting, all counselors will be required to bring their case tracker to staff meeting to ensure due dates are met for each of the columns. ED and CS will meet at the beginning of each month to monitor any deficiencies and provide reminder emails for staff for items that are due for the upcoming month. After reviewing the deficiency during the licensing inspection, it was identified that the client(s) in question has/have not been attending individual sessions but has/have been coming to group. In order to address situations such as this, ED and Clinical Supervisor have identified a staff member and modified her schedule. She will be available to meet with clients that have not updated their treatment plan in individual session and will be able to meet with them prior to group. These cases will be identified during staff meeting when CS is reviewing case trackers.
The clinical supervisor will facilitate a treatment plan workshop on 8/26/22 with all clinical staff. The two identified clients that were active during the time of inspection will be reviewed and their treatment plans will be completed by 8/29/22. The work shop will be used to ensure all treatment plans are not only in compliance but will also provide a training opportunity to ensure quality.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in three of five applicable records reviewed.
Client #1 was admitted on October 20, 2020 and discharged on July 7, 2022. The treatment plan update completed on September 10, 2021 indicated that the client was to receive one individual session monthly; however, the record contained no documentation of individual sessions between December 17, 2021 and May 4, 2022.
Client #7 was admitted on October 18, 2021 and discharged on July 4, 2022. The individual treatment and rehabilitation plan completed on December 16, 2021, indicated that the client was to receive one individual session biweekly; however, the record contained no documentation of individual sessions between April 6, 2022 and the date of discharge. Additionally, there were no individual sessions documented between January 3, 2022 and March 7, 2022.
Client #12 was admitted on August 17, 2021 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on September 2, 2021, indicated that the client was to receive one per week; however, the record contained no documentation of individual sessions between October 2021 and the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 30, 2021 annual licensing inspection.
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Plan of Correction
For all clinical staff, Executive Director and Clinical Supervisor created a Case tracker for staff to utilize. This tracker was trained and implemented on 9/13/2021 with all counselors holding a caseload. Each tracker monitors attendance, treatment plan due dates, case consult due dates, psychosocial evaluation completion pending discharge dates and when next appointments are scheduled. Counselors are required to update tracker daily as meeting with clients. This is a section on the tracker which identifies the last time a client was seen for an individual session and when the next appointment is scheduled.
ED and CS have identified one staff member and modified her schedule so she is available at the end of morning programming and prior to evening programming. Clients identified in staff meeting that have not attended individual session can meet with this staff member for their individual session prior to group.
During Staff meeting, Clinical Supervisor will place a memo on the client chart. This memo will indicate that the client has not attended their scheduled individual session. Administrative Assistant will inform this client at the time of check in for group that they will need to meet with a counselor prior to or directly after group. Administrative Assistant will put this client on the counselor's schedule. If that counselor is not available, the client will be scheduled with the Clinical Supervisor.
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709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
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Observations
Based on a review of six client records, the facility failed to ensure a complete client record included information relative to the client ' s involvement with the project, to include documentation that the clients received case consultations within the first 90 days and yearly afterwards, in each of the four applicable client records reviewed.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from the August 30, 2021 annual licensing inspection.
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Plan of Correction
For all clinical staff, Executive Director and Clinical Supervisor created a Case tracker for staff to utilize. This tracker was trained and implemented on 9/13/2021 with all counselors holding a caseload. Each tracker monitors attendance, treatment plan due dates, case consult due dates, psychosocial evaluation completion pending discharge dates and when next appointments are scheduled. Counselors are required to update tracker daily as meeting with clients.
Each staff member has been trained on how to use the case tracker. This is a section on the tracker which identifies case consult due dates. Staff are also required to provide a case consult at each change in Level of Care. This is reviewed weekly in staff meeting when each staff member discusses clients that are changing level of care. CS monitors these cases weekly to ensure all transition paperwork is completed.
All counselors will be required to bring at least two case consults to each weekly staff meeting starting 8/22/22 and they will be reviewed with the treatment team. Additionally, any remaining case consults that are due for the month will be brought to monthly group supervision starting 8/25/22 and reviewed with the treatment team. . Quality Management team will monitor deficiency areas monthly during quality review. Any noted deficiencies will be reported to Clinical Supervisor.
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709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
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Observations
Based on a review of six client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project including follow-up information. There was not documentation of follow up information in the four applicable records reviewed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 30, 2021 annual licensing inspection.
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Plan of Correction
For all clinical staff, Executive Director and Clinical Supervisor created a Case tracker for staff to utilize. This tracker was trained and implemented on 9/13/2021 with all counselors holding a caseload. Each tracker monitors attendance, treatment plan due dates, case consult due dates, psychosocial evaluation completion pending discharge dates and when next appointments are scheduled. Counselors are required to update tracker daily as meeting with clients. There is a section on the tracker which identifies when 7 Day follow up calls for all discharged clients. This tracker will be reviewed for each counselor at weekly staff meeting. Prior to every staff meeting, Clinical Supervisor will run a discharge report to identify clients that will need follow up calls and will cross check that with the case load trackers.
During staff meeting, this list of discharged clients will be given to the Administrative Assistant and she will complete all outreach over the course of the week. The completed list will be given to the Executive Director at the end of the week to review.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(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.
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Observations
Based on a review of twelve client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for providing individual counseling services twice weekly was submitted and approved by the Department for the August 30, 2021 and November 9, 2020 annual licensing inspections. Providing individual counseling services twice weekly was again found to be a deficiency in the July 21, 2022 licensing inspection.
A plan of correction for reviewing and updating treatment plans every 30 days for clients in the Partial activity was submitted and approved by the Department for the August 30, 2021 annual licensing inspection. Reviewing and update treatment plans every 30 days was again found to be a deficiency in the July 21, 2022 licensing inspection.
Plans of correction for ensuring a complete client record to include follow-up information in the Outpatient and Partial activities were submitted and approved by the Department for the August 30, 2021 annual licensing inspection. Ensuring documentation of follow-up information for Outpatient and Partial clients was again found to be a deficiency in the July 21, 2022 licensing inspection.
A plan of correction for providing counseling services according to the treatment plan for clients in the Outpatient activity was submitted and approved by the Department for the August 30, 2021 annual licensing inspection. Providing counseling services according to the treatment plans was again found to be a deficiency in the July 21, 2022 licensing inspection.
A plan of correction for ensuring a complete client record to include case consultation notes according to facility policy for client records in the Outpatient activity was submitted and approved by the Department for the August 30, 2021 annual licensing inspection. Ensuring case consultation notes was again found to be a deficiency in the July 21, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to monitor compliance with our plans of correction, the Clinical Supervisor will be responsible for weekly supervision with direct care staff to ensure compliance. Executive Director will supervise the Clinical Supervisor weekly to monitor the POC. Executive Director will provide updates to the Regional Director bi-weekly to ensure compliance with plans of correction. |