INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 14 through 15, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc. 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 and a plan of correction is due on November 17, 2008.
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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 five employee records on October 14, 2008, the facility failed to ensure that all employees had mandatory TB/STD training within two years of the date of hire for support staff and within one year of the date of hire for clinical staff in one of five employee records where required.
Finding:
There was no documentation of TB/STD training in employee record # 5.
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Plan of Correction
Program Director was contacted by Human Resources regarding training for behavioral tech that had no received TB/STD training. Tech was regitered and attended specified training on October 15, 2008. Staff meeting was held the following week where the program directector reiterated the importance of staff monitoring their required trainings. Program Director will obtain a training audit on a quarterly basis from Human Resources to ensure trainings are up to date. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of four client records on October 15, 2008, the facility failed to ensure that the information released to the Department of Public Welfare did not exceed the limitations imposed at 4 Pa. Code 255.5(b) in two of two client records where required.
Findings:
The facility released a list of medications to the Department of Public Welfare in client records # 1 and 3.
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Plan of Correction
Program Director met with Financial officer responsible for MA benefits. Protocol for MA benefits was established. Confidentiality regulations were reviewed and list of appropriate information was created. Program Director met with staff psychiatrist and reviewed appropriate information. Should a claim be rejected due to lack of information, client will be taken directly to MA office where information can be delivered by the client in person. Program Director will review all forms before they are submitted. |