INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 22, 2011 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. The following deficiencies were identified during this inspection:
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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 the facility summary report, and a conversation with the facility director, the facility failed to provide documentation of HIV/AIDS and TB/STD training for two personnel.
The findings include:
Personnel records for this facility were reviewed on October 4-5, 2011. At the time of the on-site inspection, two staff members were required to have the general training requirements completed. The facility did not provide documentation of the required HIV/AIDS and TB/STD training for employees # 7 and 8.
Employee # 7 is a counselor and was hired November 1, 2010. HIV/AIDS and TB/STD training was to be completed within one year of hire, by November 1, 2011. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of November 22, 2011.
Employee # 8 is a counselor and was hired October 5, 2010. HIV/AIDS and TB/STD training was to be completed within one year of hire, by October 5, 2011. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of November 22, 2011.
The facility director confirmed on 11-22-2011 that the general training requirements were not completed for these employees.
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Plan of Correction
Clinical Supervisor will schedule employees 7 & 8 to attend the required trainings by 3/31/12. Clinical Supervisor and Program Director will schedule all employees to have all required trainings in the appropriate time frame on an ongoing basis. This will be monitored monthly by Program Director in Supervision with the Clinical Supervisor. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel and training records, the facility failed to document the completion of 25 clock hours of annual training for counselors in one of two personnel training records reviewed.
The findings include:
Ten personnel records were reviewed on October 4 - 5, 2011. Two of the ten personnel training records were counselors that were required to include documentation of the completion of 25 clock hours of annual training for the January to December 2010 training year. The facility failed to document 25 clock hours of annual training in personnel record # 10.
Employee # 10 was hired on January 28, 2004. The facility training year is from January through December. The training year for January 2010 to December 2010 was reviewed. Employee # 10 completed 20 clock hours of annual training in 2010.
The Human Resource Director confirmed on October 5, 2011 that the counselor did not have the 25 clock hours of training for the 2010 training year. The Facility Director confirmed on November 22, 2011 that the counselor did not have the 25 clock hours of training for the 2010 training year.
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Plan of Correction
Clinical Supervisor and Program Director will schedule all employees for the required amount of training hours every year. This will be monitored in Supervision with the Clinical Supervisor on a monthly basis. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of the client records, the facility failed to document progress notes which contained the individual assessment in four of five outpatient records.
The findings include:
Nine client records were reviewed on November 22, 2011. Five of the nine client records were reviewed as part of the outpatient activity. Five client records were required to include documentation of the progress notes that include an assessment. Four of the five records, records # 5, 7, 8, and 9, included the same, exact assessment for each client, and did not include an individualized assessment.
Client #5 was admitted on 6-6-11, and was discharged on 8-12-11. The group progress notes that did not include an individualized assessment were dated 7-11-11, 7-18-11, 8-1-11, and 8-8-11.
Client #7 was admitted on 6-6-11, and was discharged on 7-5-11. The group progress notes that did not include an individualized assessment were dated 6-6-11, 6-7-11, 6-9-11, and 6-21-11.
Client #8 was admitted on 8-24-11. The group progress notes that did not include an individualized assessment were dated 8-24-11, 8-31-11, 9-7-11, 9-21-11, 9-28-11, 10-5-11, and 10-12-11.
Client #9 was admitted on 7-14-11. The group progress notes that did not include an individualized assessment were dated 8-24-11, 8-31-11, 9-7-11, 9-14-11,10-5-11, and 10-19-11.
This was discussed with and confirmed by the facility director on 11-22-11.
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Plan of Correction
Clinical Supervisor will train all clinical employees on individualized progress note documentation requirements. This will be monitored through monthly chart monitors. |