INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Chambersburg 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's staffing requirements facility summary report (SRFSR) and a review of employee records, the facility failed to ensure that all staff persons and/or volunteers received 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 as per the regulatory requirements in one of seven records reviewed.
The findings include:
The facility's SRFSR form completed by the facility on June 18, 2014 was reviewed on July 18, 2014. The form listed one staff member, employee # 6, as not having completed the mandatory communicable disease training within the regulatory time frames
Employee # 6, an administrative assistant, was hired on January 9, 2012. Employee # 6 was required to obtain 6 hours of HIV/Aids training by January 9, 2014. The training was not documented as of the date of the inspection. Additionally, Employee # 6 was required to obtain 4 hours of TB/STD training by January 9, 2014. The training was not documented as of the date of the inspection.
The facility director confirmed the findings.
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Plan of Correction
Employee #6 is registered to attend the following trainings:
Basic HIV
Registration Number: 135377
Course Date: Sep 17, 2014
Course Time: 9:00 AM to 4:00 PM
Course Location: Best Western Premier
800 East Park Drive
Harrisburg, PA 17111
(717) 561-2800
TB/STD
Registration Number: N/A
Course Date: August 5, 2014
Course Time: 9:00 AM to 1:00 PM
Course Location: Pyramid Healthcare - Hillside
6000 Frutchy Drive
East Stroudsburg, PA 18302
(215) 529-1119 ext. 1
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709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of three client records reviewed.
The findings include:
Three discharged outpatient client records were reviewed on July 8, 2014. Two of the three discharged clients have been discharged for the amount of time required for follow-up contact. The facility failed to document follow-up information in client records # 8 and 9.
Client #8 was admitted to outpatient treatment on November 12, 2013 and discharged on December 3, 2013. The facility failed to document follow-up information in client record # 8 as of July 8, 2014.
Client #9 was admitted to outpatient treatment on January 14, 2014 and discharged on March 8, 2014. The facility failed to document follow-up information in client record # 9 as of July 8, 2014.
The facility director confirmed the findings.
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Plan of Correction
The clinical team will conduct chart monitors to determine if there are any existing discharge charts that are out of compliance and follow-up will be conducted. Effective 7/22/14, an alert will be added to the electronic health record that will alert the primary counselor and supervisor when follow-up is required. |