INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 3, 2023 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of 27 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that 11 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 #17 was hired as a BH Tech Supervisor on October 18, 2018 and was due to have the communicable disease trainings no later than October 18, 2020. 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 #18 was hired as BH Trainer on September 9, 2019 and was due to have the communicable disease trainings no later than September 9, 2021 . 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 #19 was hired as BHT on June 23, 2021 and was due to have the communicable disease trainings no later than June 23, 2023 . 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 #20 was hired as Nutritionist on April 22, 2013 and was due to have the communicable disease trainings no later than April 22, 2015 . 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 #21 was hired as Housing Keeping on November 4, 2019 and was due to have the communicable disease trainings no later than November 4, 2021 . 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 #22 was hired as Kitchen Staff on March 22, 2021 and was due to have the communicable disease trainings no later than March 22, 2023 . 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 #23 was hired as Medical Assistant on January 7, 2020 and was due to have the communicable disease trainings no later than January 7, 2022 . 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 #24 was hired as Medical Assistant on November 9, 2020 and was due to have the communicable disease trainings no later than November 9, 2022 . 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 #25 was hired as Medical Assistant on December 28, 2020 and was due to have the communicable disease trainings no later than December 28, 2022 . 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 #26 was hired as Medical Assistant on March 9, 2020 and was due to have the communicable disease trainings no later than March 9, 2022 . 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 #27 was hired as Housekeeping on February 13, 2019 and was due to have the communicable disease trainings no later than February 13, 2021 . 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.
This is a repeat citation from the September 6, 2022 and August 31, 2021 licensing inspection.
|
Plan of Correction
Upon further review of the employees identified here there is a clear pattern that they are all within support departments. Approx. 3 years ago a tracking system was developed for clinical/nursing staff based on POC completed at that time to improve in this same area for those departments. That system has proven successful evident through a lack of citation relating to mandatory trainings for clinical and nursing personnel. ED is going to incorporate all support departments and their staff into this same existing system. The system categorizes employees by job title, and then provides a template based on that job title that includes all mandatory DDAP trainings as well as any other trainings made mandatory by other agencies/organizations, or by the facility ED. The template ensures consistency of training for all employees of the same job type, as well as making it simple for managers, particularly new ones, to identify which trainings to schedule for newly hired employees. The template includes the training name, type (i.e. TrainPA, DDAP TMS, Relias, etc.), training date(s) and training time(s) with a check-box to indicate that the training certificate has been uploaded to Relias so that it is easily accessible during audits. The framework for this exists already, next steps are for the ED to use the facility staff roster to update the tracker with Medical Assistant, House Keeping, Maintenance, BHT, Dietary, and Miscellaneous Supports (i.e. dietitian). Then, each individual employee has to be entered under their applicable job title, and the training is then scheduled through DDAP TMS, or self-paced instructions are provided to the employee with a date scheduled for them to be off the "floor" and able to focus on completing the training with their supervisor present on that date for technical support if need-be. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that counseling could not be seen or heard from outside of the counseling room as Acceptance Group Room had a window not covered on the door. In addition, employee #16's office could be heard outside of the room during a counseling session.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
1. The Acceptance Room (the room with the door that has a window) is being moved acrossed the hall-way to where our gym currently is, and the gym is moving into the Acceptance Room. The time-frame for this is dictated by the moving company that is assisting in movement of the gym equipment which is still unscheduled. In the interim, facility ED will have the window of the Acceptance Room door covered. The room that the Acceptance Room is moving to has a door with no window on it so once the move occurs, groups will continue to take place in the Acceptance Rooms new location (currently the gym) and the door will have no window.
2. There are noise machines throughout the building and clinical offices spaces however upon further inspection following the exit interview, many were broken and not reported. The expectation up until now has been that counselors will report when their noise machines stop working so we can order replacements however with staff turn-over this does not appear to be an effective approach. Instead, moving forward, the clinical leads (there are 2) will be tasked with rotating bi-weekly checks during which time they will go around and ensure they're all in working order, batteries are replaced if applicable, and a form that was developed is filled out and archived on a smart sheet specifically for the purpose of showing ongoing compliance with POC. At present, we have replaced 4 of the sound machines with those we had on hand for ongoing replacement, and ordered an additional 6. By 9/1/2023 all sound machines will be replaced and in working condition. |
709.24 (a) (4) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
|
Observations
Based on a review of fourteen client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in five of five applicable records reviewed.
Client #3 was admitted on July 29, 2023 and discharged Against Medical Advice (AMA) on August 2, 2023. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours.
Client #5 was admitted on June 13, 2023 and discharged Against Medical Advice (AMA) on June 15, 2023 . The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours.
Client #7 was admitted on June 13, 2023 and discharged Against Medical Advice (AMA) on June 13, 2023 . The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours.
Client #11 was admitted on May 23, 2023 and discharged Against Medical Advice (AMA) on May 25, 2023 . The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours
Client #13 was admitted on April 18, 2023 and discharged Against Medical Advice (AMA) on June 22, 2023 . The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours
These findings were reviewed with the project staff during the licensing process.
This is a repeat citation from the September 6, 2022 annual licensing inspection
|
Plan of Correction
Calling emergency contacts on AMA or AFA discharges is a task handled by two departments in the facility; nursing and clinical. Clinical is instructed to do these calls for AMA or AFA that occur during normal business hours of 8am-4pm Monday-Friday. Outside these hours, nursing is instructed to do these calls when clinical is not present as nursing is present in the facility 24/7. Instructions are to call the emergency contact within 12 hours of of the discharge and document that in the appropriate documentation applicable to that department (DMP for clinical, discharge memo for nursing). In the event that the client did not designate an emergency contact, the note is still to be done and to indicate that an emergency contact could not be notified of the AMA/AFA discharge due to a lack of emergency contact releases in the chart.
Retraining in this area is necessary for both departments, and will occur in group format (individually for each department). This retraining will occur before 9/15/2023. In addition, for the purpose of monitoring, department heads are being assigned responsibility to update a tracking system (newly developed), in which AMA/AFA discharges are added after they occur and auditing is done to confirm the notes are complete for emergency contact calls. Oversight will be ED responsibility, through monitoring the tracking system to ensure it's utilized ongoing and reflecting compliance. |
709.63(a)(8) LICENSURE Follow-up Information
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:
(8) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to follow their written client follow-up policy in one of three applicable inpatient client records reviewed.
Client #7 was admitted on June 13, 2023 and was discharged on June 13, 2023 . The client record did not contain documentation of follow up information with the client within 7 days of discharge.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 6, 2022 annual licensing inspection
|
Plan of Correction
Follow-Up calls are being moved as a whole to the case coordination department because they assist in organizing and scheduling all aftercare for all clients in both levels of care offered at Hillside. This department has a case board that tracks the work they are doing on each case. A column has been added to this board to indicate when a follow-up call has been made post-discharge; and cases are not to be removed from the board until after 7 days following discharge. This centralizes the task into a department that already has a strong presence in terms of aftercare and client follow-up, and incorporates tracking/monitoring into an existing successful system.
Oversight will be responsibility of Intake/Case Coordination supervisor with ED ensuring there is continued follow through, utilization of the tracking system, and ongoing compliance with the regulation. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to follow their written client follow-up policy in one of three applicable inpatient client records reviewed.
Client #12 was admitted on June 6, 2023 and was discharged on July 4, 2023 . The client record did not contain documentation of follow up information with the client within 7 days of discharge.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 6, 2022 annual licensing inspection
|
Plan of Correction
Follow-Up calls are being moved as a whole to the case coordination department because they assist in organizing and scheduling all aftercare for all clients in both levels of care offered at Hillside. This department has a case board that tracks the work they are doing on each case. A column has been added to this board to indicate when a follow-up call has been made post-discharge; and cases are not to be removed from the board until after 7 days following discharge. This centralizes the task into a department that already has a strong presence in terms of aftercare and client follow-up, and incorporates tracking/monitoring into an existing successful system.
Oversight will be responsibility of Intake/Case Coordination supervisor with ED ensuring there is continued follow through, utilization of the tracking system, and ongoing compliance with the regulation.
This citation is the same as the previous one, for a different case, and the same solution is being applied to both. |
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.
|
Observations
Based on a review of staff training records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for mandatory communicable disease training were submitted and approved by the Department for the September 6, 2022 and August 31, 2021 annual licensing inspection. Mandatory communicable disease training was again found to be a deficiency in the August 3, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Mandatory communicable disease training, along with all other clinically related mandatory DDAP trainings, are currently being stored and housed on a smart sheet for tracking purposes for all clinical staff. This helps us to keep track of what is scheduled for when, and ensure we're scheudeling all required trainings at the start of employment. This system has worked very well and is the reason we have no citations for clinical staff reltaing to this area. As a fix to the issue we're seeing this year, which is all support staff, we're going to be adding all support staff to the same system that's working so well for clinical. This will mean the entire employee roster for the site will be housed on this smart sheet, with their DDAP trainings and other mandatory trainings listed out as they pertain to their job title/role, and the dates those were scheduled for and when they were completed. It also includes a section to confirm the training certificate was uploaded to Relias so that during audit we are prepared ahead of time and have a complete transcript to present. We've started porting over all the support staff in the building (house keeping, BHT, dietary, maintenance, admin, and medical assistants). Presently, all of those departments are tracked independently by those department managers but this is clearly not working and very difficult to monitor. By centralizing it all into one system that already works for several departments, and the ED has ongoing oversight of, I expect to see this problem completely go away. In addition, a leadership meeting will be held on 9/11/2023 to review the system with all managers to explain how it works. ED is going to take lead on having all of the staff confirmed as scheduled for these trainings and cataloging them in the smart sheet. Department heads will be responsible for ensuring their staff have the day on their scheduled date to dedicate to the training, and to get self-paced ones done by the end of October 2023. ED will have full oversight of compliance, and ensuring the smart sheet that keeps it all operational is up to date and being utilized routinely with new hires so they get communicable disease training done in the first year. |