INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 2, 2018 of Pyramid Healthcare Pine Ridge by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Pyramid Healthcare Pine Ridge 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
The facility failed to document an individual training plan for support staff #10 and #11.Staff #10 was hired on February 27, 2017 and was still employed at the time of the inspection.Staff #11 was hired on July 31, 2017 and was still employed at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff training plans for employee #10 and #11 were updated on August 27, 2018. Program Director will ensure training plans are completed annually for all program staff. Pyramid's Human Resource Department will conduct annual checks of employee files and notify Program Director if anything is missing. |
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
The facility failed to provide documentation for adequate staff coverage providing at least one staff person trained in CPR onsite.Employee #6 was hired as a direct support professional June 12, 2018 and did not have CPR training. Staff # 6 was the only staff onsite on June 19, 2018.Employee #7 was hired as a direct support professional October 16, 2015 and did not have CPR training. Staff # 7 was the only staff onsite on June 5,7, and 22, 2018. Employee #8 was hired as a direct support professional May 15, 2017 and did not have CPR training. Staff # 8 was one of two staff onsite without CPR training on June 3, 2018 and the only staff onsite on June 4, and 5 2018.Employee #9 was hired as a maintenance professional January 27, 2017 and did not have CPR training. Staff # 9 was one of two staff onsite without CPR training on June 3, 2018.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and BH Tech Supervisor will ensure that all shifts are covered by at least one employee who is CPR/first aid certified. Program Director and BH Tech Supervisor will monitor compliance via obtaining a copy of all employees CPR/first aid cards and comparing these to the staff schedule on a monthly basis. Any employee who is due for CPR/first aid recertification will be scheduled by BH Tech Supervisor and reminded of the training. BH Tech Supervisor will follow up with Human Resources following each training to ensure that the employee completed the required training.
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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
The facility failed to ensure the safety and well-being of clients, staff, and visitors, based on the physical plant inspection and observation of the following:1. A picnic table located outside Building C was in disrepair.2. There was not adequate lighting in the back emergency exit stairway of B house.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The picnic table was removed by maintenance on August 12, 2018. Maintenance will install new lighting in the B House emergency stairwell by August 28, 2018. The risk committee will check these areas during their monthly physical plant inspections to ensure ongoing compliance. Program Director will review month risk concerns and schedule needed repairs with the maintenance department. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. Doors to the bathrooms of room #1 in B house would stick and did not fit the door jamb adequately for closure. The shower head in upstairs bathroom in B house was broken.The bathroom on the first floor of D house had windows for ventilation, however there were no screens and the windows were difficult to open. When the windows were opened, there were wasp nests in the in the window jambs. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed citations with maintenance department on August 5, 2018. B House bathroom doors will be adjusted to fit door frame appropriately by September 28,2018. The B House bathroom shower head was replaced by maintenance staff on August 3, 2018. With regard to the D house bathroom, maintenance removed the wasps nest on August 3, 2018. New screens will be installed in the D house bathroom by September 28, 2018. Program Director and Risk Committee will continue to monitor these areas and address any ongoing concerns with the maintenance department. |
705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to cover the silverware during non-eating times.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director ordered new plastic storage bins with lids on August 3, 2018 to ensure silverware is covered at all times when not in use. Lifeskills coordinator will ensure lid remains in place following each meal. |
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
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 1, 2, 3, 4, 5, and 7. Client # 1 was admitted on March 14, 2018 and discharged on May 22, 2018. Consent for release of information that included treatment plan update, medical administration, psychological assessment, psychiatric evaluation, history and physical, and treatment progress update was signed by the client on March 13, 2018 to government agencies and a funding source.Client #2 was admitted on April 23, 2018 and was discharged on July 6, 2018. Consent for release of information that included treatment plan update, medical administration, psychological assessment, psychiatric evaluation, history and physical, and treatment progress update was signed by the client on April 23, 2018 to government agencies and a funding source.Client #3 was admitted March 15, 2018 and was discharged on May 29, 2018. Consent for release of information that included treatment plan update, medical administration, psychological assessment, psychiatric evaluation, history and physical, and treatment progress update was signed by the client on March 15, 2018 to government agencies and a funding source.Client #4 was admitted on June 29, 2018 and was still an active client at the time of the inspection. Consent for release of information that included treatment plan update, medical administration, psychological assessment, psychiatric evaluation, history and physical, and treatment progress update was signed by the client on June 29, 2018 to government agencies and a funding source.Client #5 was admitted on May 29, 2018 and was still an active client at the time of the inspection. Consent for release of information that included treatment plan update, medical administration, psychological assessment, psychiatric evaluation, history and physical, and treatment progress update was signed by the client on May 29, 2018 to government agencies and a funding source.Client #7 was admitted on June 18, 2018 and was still an active client at the time of the inspection. Consent for release of information that included treatment plan update, medical administration, psychological assessment, psychiatric evaluation, history and physical, and treatment progress update was signed by the client on June 18, 2018 to government agencies and a funding source.This is a repeat citation for this facility.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager conducted an in-house training with clinical and administrative staff on August 13,2018 pertaining to consents. Reviewed parameters of 255.5.Program Manager and Lead Counselor will review consents during monthly clinical chart audits and monitor accuracy. Lead Counselor and Program Director will individually address any ongoing compliance concerns during monthly supervision. Consents for current clients will be updated as needed by September 28,2018. |
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
The facility failed to document an updated individualized treatment plan for client #3.Client #3 was admitted on March 15, 2018 and was discharged on May 29, 2018. The client was transferred to a lower level of care and the treatment plan documented verbiage from the previous facility without updating goals, type and frequency, and proposed type of services. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Manager conducted an in-house treatment plan training for all clinical staff on August 20,2018. All current clinical staff were present. Reviewed all regulations and timeframes required. Program Director and Lead Counselor will monitor compliance during monthly chart audits. Next chart audit will be conducted by September 28 31,2018. Program Director and Lead Counselor will address any ongoing compliance issues individually during monthly clinical supervision. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
The facility failed to document treatment plan updates in two of seven client records reviewed. Client # 2 was admitted April 23, 2018 and was discharged on July 6, 2018. A comprehensive treatment plan was developed on April 22, 2018, an update on May 25, 2018 and July 2, 2018. There was no update documented for June 2018.Client #5 was admitted on May 29, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed on May 29, 2018, an update on May 30, 2018 and July 13, 2018. There was no update documented for June 2018.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director will reviewed group and individual requirements during clinical staff meeting on September 17, 2018. Clinical will ensure all individual/group session are being completed and documented in required time frame. Treatment plan will be updated to reflect if client is receiving group once per week due to work therapy. Program Director and Lead Counselor will monitor compliance through monthly chart audits. Results will be addressed monthly with clinicians during supervision. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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
The facility failed to document that the clients received counseling services according to their individual comprehensive treatment plan in four out of seven charts reviewed.Client #2 was admitted on April 23, 2018 and discharged on July 6, 2018. A comprehensive treatment plan developed on April 23, 2018, indicated one individual session bi-weekly and two group sessions per week. The chart's record of service and group notes indicated that the week of June 3 to June 9 the client did not receive an individual session. Record of service indicates the client did not receive two groups the weeks of April 25-31, May 6-12, June 3-9, June 10-16, and June 17-23 and received only one group the weeks of May 20-26, May 27-June 2, and June 24-30.Client #5 was admitted on May 29, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan developed on May 30, 2018 indicated one individual session bi-weekly and two group sessions per week. The chart's record of service and group notes indicated that the client did not receive two groups the weeks of June 17-23 and July 22-28.Client # 6 was admitted on June 18, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan developed on June 19, 2018 indicated one individual session bi-weekly and two group sessions per week. The chart's record of service and group notes indicated that the client did not receive two groups the weeks of July 15-21 and July 22-28. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director will reviewed group and individual requirements during clinical staff meeting on September 17, 2018. Clinical will ensure all individual/group session are being completed and documented in required time frame. Treatment plan will be updated to reflect if client is receiving group once per week due to work therapy. Program Director and Lead Counselor will monitor compliance through monthly chart audits. Results will be addressed monthly with clinicians during supervision. |
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
The facility failed to provide a complete client record, which is to include progress notes, aftercare, record of service, and verification that work being done by the client at the project is an integral part of his/her treatment and rehabilitation plan.Client #1 was admitted on March 14, 2018 and was discharged on May 22, 2018. Individual progress notes indicate sessions on March 16, 18, and 22 but does not reflect on the record of service. Work therapy is not documented on the treatment plan and there is no documentation of an aftercare plan.Client # 2 was admitted on April 23, 2018 and was discharged July 6, 2018. Record of service indicates an individual session on July 3 with no documentation of a progress note. Client #4 was admitted on June 29, 2018 and was still an active client at the time of the inspection. Work therapy is not documented on the treatment plan.Client # 5 was admitted on May 29, 2018 and was still an active client at the time of the inspection. Record of service indicates group sessions on May 31, June 5, 12, 14, 26, and July 19 with no documentation of progress notes. There is no documentation of work therapy in the treatment plan.Client #7 was admitted on June 18, 2018 and was still an active client at the time of the inspection. Record of service indicates group sessions on July 10 and July 31 with no documentation of progress notes. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director and Lead Counselor will monitor compliance with completion of daily record of services. Program Director will review importance of documenting work therapy on treatment plans during clinical meeting on September 17, 2018. Program Director will also review requirements for discharge during clinical meeting on September 17, 2018. Program director and Lead Counselor will monitor ongoing compliance with documentation of provided services through monthly chart audits. Any ongoing concerns will be address during monthly supervision. |