INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the October 7, 2009 licensure renewal inspection. The follow-up inspection was conducted on March 30, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 and a plan of correction is due on April 29, 2010.
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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 training records and an interview with the facility director, the facility failed to provide documentation of TB/STD training in seven of ten personnel training records, as required by regulation.
The findings include:
Ten personnel training records were reviewed on March 30, 2010. Ten personnel training records were required to have documentation of TB/STD training. Per regulation, staff persons shall receive a minimum of 4 hours of TB/STD training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training with the first 2 years of employment. The facility did not provide documentation of TB/STD training in personnel training records # 1, 2, 3, 4, 5, 6 and 7.
Employee # 1 is support staff and was hired March 28, 2007. TB/STD training was due to be completed no later than March 28, 2009. The facility failed to provide documentation of TB/STD training.
Employee # 2 is support staff and was hired March 28, 2007. TB/STD training was due to be completed no later than March 28, 2009. The facility failed to provide documentation of TB/STD training.
Employee # 3 is support staff and was hired December 18, 2006. TB/STD training was due to be completed no later than December 18, 2008. The facility failed to provide documentation of TB/STD training.
Employee # 4 is support staff and was hired August 2, 2007. TB/STD training was due to be completed no later than August 2, 2009. The facility failed to provide documentation of TB/STD training.
Employee # 5 is support staff and was hired September 27, 2006. TB/STD training was due to be completed no later than September 27, 2008. The facility failed to provide documentation of TB/STD training.
Employee # 6 is support staff and was hired March 30, 2005. TB/STD training was due to be completed no later than March 30, 2007. The facility failed to provide documentation of TB/STD training.
Employee # 7 is support staff and was hired April 25, 2005. TB/STD training was due to be completed no later than April 25, 2007. The facility failed to provide documentation of TB/STD training.
The facility director was interviewed on March 30, 2010 at approximately 11:00 AM and confirmed that these employees had not completed TB/STD training. The facility director reported these employees are scheduled to complete TB/STD training on April 28, 2010.
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Plan of Correction
Employee #1 is scheduled for TB/STD training on 7/13/10.
Employee #2 attended training on 4/28/10.
Employee #3 is scheduled for TB/STD training on 7/13/10.
Employee #4 is scheduled for TB/STD training on 7/13/10.
Employee #5 attended training on 4/28/10.
Employee #6 is scheduled for STD/TB training on 7/13/10.
Employee #7 is scheduled for TB/STD training on 7/13/10.
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709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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 a review of client records and an interview with the facility director and counselor, the facility failed to document an individual treatment and rehabilitation plan which includes the proposed type of support service in six of six client records, as required by regulation.
The findings include:
Eight client records were reviewed on March 30, 2010. Six client records were required to include documentation of the proposed type of support service on the treatment plans. Two client records included treatment plans that were from a time frame outside of the current licensing inspection. Per regulation, an individual treatment and rehabilitation plan shall be developed with the client to include written documentation of the proposed type of support service. The facility failed to document an individual rehabilitation and treatment plan which included the proposed type of support service in client records # 1, 4, 5, 6, 7 and 8.
Client # 1 was admitted on January 27, 2010 and discharged on March 5, 2010. The individual treatment and rehabilitation plan was completed on February 2, 2010 and did not include the proposed type of support service.
Client # 4 was admitted on February 1, 2010 and discharged on March 10, 2010. The individual treatment and rehabilitation plan was completed on February 5, 2010 and did not include the proposed type of support service.
Client # 5 was admitted on March 15, 2010. The individual treatment and rehabilitation plan was completed on March 19, 2010 and did not include the proposed type of support service.
Client # 6 was admitted on March 22, 2010. The individual treatment and rehabilitation plan was completed on March 22, 2010 and did not include the proposed type of support service.
Client # 7 was admitted on March 24, 2010. The individual treatment and rehabilitation plan was completed on March 24, 2010 and did not include the proposed type of support service.
Client # 8 was admitted on March 11, 2010. The individual treatment and rehabilitation plan was completed on March 17, 2010 and did not include the proposed type of support service.
The facility director and counselor were interviewed on March 30, 2010 at approximately 10:45 AM. Both the facility director and counselor reported there was no documentation of the proposed type of support service on the individual treatment and rehabilitation plans. The facility director discussed support services with the counselor and also options for including these services on the treatment plans.
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Plan of Correction
The Program Director will meet with the counselor who was assigned to Clients #1 through #8. Discussion/training will specifically focus on the importance of including support services on the individual treatment and rehabilitation plan.
The Program Director and identified counselor will meet on a weekly basis for a period of one month to monitor/review all open charts, and on a monthly basis thereafter, with the intent of focusing on identified support services for clients assigned to his caseload. |