INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 1, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pyramid Ridgeview Behavioral Health Center 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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that staff 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.
Staff #9 was hired as a Behavioral Health Tech on March 21, 2022, and was due to have the communicable disease trainings no later than March 21, 2024. There was no documentation in the personnel file of the completion of the HIV/AIDS and the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
On 8-19-24, ED will have a meeting with all staff Supervisors. We will review process for tracking training hours and review all required trainings, along with required staff hours for each position. Supervisors will review training hours for all staff in each staff's individual monthly supervision. Any staff deficient in trainings will have designated training days each month that will allow them time to get their training hours completed during their work day, or allow supervisors to schedule them to be in trainings during those days. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Staff #4 was hired as a counselor on November 10, 2003, and was still in the position as of the date of the onsite inspection. The training year that was reviewed was from January 1, 2023, through December 1, 2023. Staff #8's employee record only documented 23.75 hours of annual training for the 2023 year.
This is a repeat citaiton freom the July 19, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8-19-24, ED will have a meeting with all staff Supervisors. We will review process for tracking training hours and review all required trainings, along with required staff hours for each position. Supervisors will review training hours for all staff in each staff's individual monthly supervision. Any staff deficient in trainings will have designated training days each month that will allow them time to get their training hours completed during their work day, or allow supervisors to schedule them to be in trainings during those days. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to not permit in the facility, heaters that are not permanently mounted or installed. A portable space heater was observed by DDAP staff in the Behavioral Health Manager's office.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Maintenance will review with staff the ability to not have space heaters by 8/20/24. Any area in the facility that does not feel warm enough, maintenance can mount or install permanent heaters in those areas. Maintenance will review the need for permanent heaters in facility areas each month during monthly safety meetings and ED will ensure follow through with installation of the heaters. ED conducts monthly facility walk throughs and can ensure space heaters is added to the check list of what is being checked for during the walk through. Any space heaters found will be removed from offices. ED will re review the expectation of no heaters in the office, unless the are mounted during all staff meeting on 8-28-24. |
709.24 (a) (3) 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:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of residential client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in two of three applicable client records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in DDAP Licensing Alert 02-21.
Client # 4 was admitted to the inpatient non-hospital detoxification activity on January 5, 2024, and was discharged against medical advice on January 10, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client #6 was admitted to the inpatient non-hospital rehabilitation activity on May 19, 2024, and was discharged against medical advice on May 22, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
This is a repeat citaiton freom the July 19, 2023 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 8-19-24, ED will have a meeting with all staff Supervisors. We will review the process for non routine discharges which involves calling the emergency contact and ensuring proper documentation is in the chart. The supervisor on shift during the non routine discharge, will be responsible for calling the referral and emergency contact and documenting it in the chart. An email chain has been created with all supervisors in it, and the supervisor on shift will send out an email noting when there is an unplanned discharge. They will note in the email that everyone is called and its documented. ED and Clinical supervisor will review charts weekly to ensure proper documentation and that this procedure is being followed. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of residential client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in two out of six applicable records reviewed.
Client #2 was admitted on June 18, 2024, and was still active at the time of the inspection. An updated treatment plan dated July 18, 2024, indicated the client was to receive one individual session per week and five group sessions per week. There was no documentation to verify that an individual session had occurred during the week of July 21-July 27, 2024.
Client #3 was admitted on June 12, 2024, and was still active at the time of the inspection. A comprehensive treatment plan dated June 27, 2024, indicated the client was to receive one individual session per week and five group sessions per week. There was no documentation to verify that an individual session occurred during the weeks of July 1-July 6, 2024 and July 7-July 13, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor reviews charts weekly to ensure all individual notes, group notes and treatment plans/treatment plan updates are done. Along with Case Consults and Level of Care Assessments. She documents the results of these reviews and gives a copy to each counselor. If there is an area that is deficient, Clinical supervisor will review with the counselor during supervision and a plan will be implemented. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in five out of five applicable records reviewed. The facility's policy is that case consultations must be completed within seven days of admission.
Client #1 was admitted on July 8, 2024, and was still active at the time of the inspection. A case consultation was due no later than July 15, 2024; however, a case consultation was not documented until July 31, 2024.
Client #2 was admitted on admitted on June 18, 2024, and was still active at the time of the inspection. A case consultation was due no later than June 25, 2024; however, a case consultation was not documented until July 15, 2024.
Client #3 was admitted on June 12, 2024, and was still active at the time of the inspection. A case consultation was due no later than June 19, 2024; however, a case consultation was not documented until July 31, 2024.
Client #5 was admitted on May 16, 2024, and was discharged on June 12, 2024. There was no documentation of a completed case consultation in the client record.
Client #7 was admitted on April 17, 2024, and was discharged on June 3, 2024. There was no documentation of a completed case consultation in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor reviews charts weekly to ensure all individual notes, group notes and treatment plans/treatment plan updates are done. Along with Case Consults and Level of Care Assessments. She documents the results of these reviews and gives a copy to each counselor. If there is an area that is deficient, Clinical supervisor will review with the counselor during supervision and a plan will be implemented. |