INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 30, 2019 through July 31, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Ridgeview Adolescent Behavioral Health Center at Pittsburgh 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure that counselor assistants received close supervision by a trained counselor or clinical supervisor for at least the first 6 months of employment.Employee # 5 was hired July 26, 2018 and was a current employee at the time of the licensing inspection. There is no documentation that Employee #5 received weekly supervision during the weeks of 8/27/18, 10/1/18, 11/19/18, 12/24/18 and 1/21/19.Employee #6 was hired August 13, 2018 and was a current employee at the time of the licensing inspection. There is no documentation that Employee # 6 received weekly supervision during the weeks of 8/27/18, 11/19/18 and 2/25/19.Employee #7 was hired August 21, 2017 and was a current employee at the time of the licensing inspection. Employee #7 was promoted to a counselor assistant on April 16, 2018. There is no documentation that Employee #7 received weekly supervision during the weeks of 8/27/18, 10/8/18 and 10/15/18.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 9/1/2019, any counselor assistant who is hired on will be put on a training plan which will include a form to be completed weekly and signed off by the clinical supervisor or the clinical director and the executive director. That form will include the date of weekly supervision, the topics covered during the supervision, the client number of the case discussed or evaluated, and the supervision note (which will be attached) documenting the discussion with the CA. The form will be turned in to the executive director no later than Friday morning before noon in order to ensure supervision occurs that day if it had not happened already. This document will the be kept with the supervision notes held by the clinical director or clinical supervisor and will be available for review for up to 1 year. |
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
The project director failed to have a comprehensive staff development program for agency personnel including policies and procedures for the program on an overall basis. There was no overall comprehensive staff development program documented for agency personnel at the program.This was reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resources Coordinator will develop a Comprehensive policy for Staff Development by September 1, 2019. Director of Human Resources will publish the policy by September 1, 2019. The policy will be shared with all staff by Human Resources with a receipt acknowledgement attached that staff will sign off on. Full implementation of the policy will occur by September 15, 2019. Program Director will develop a comprehensive training plan for each staff annually by December that is based on identified needs from the individual training plans completed by staff by October 1, 2019. Program Director will submit training plan to Human Resources by December 15th each year. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
The project director failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and time frames for completion of assessment of staff training needs overall. There was no facility staff development program for agency personnel including policies and procedures for the program indicating who is responsible and time frames for completion of staff training needs overall documented at the program.This was reviewed with facility staff during the licensing process.
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Plan of Correction
The project with develop and approve a Comprehensive policy for Staff Development that will included who is responsible and time frames for completion of assessment of staff training needs overall by September 1, 2019. Director of Human Resources will publish the policy by September 1, 2019. The policy will be shared with all staff with a receipt acknowledgement attached. Program Director will develop a comprehensive training plan for staff annually in December that is based on identified needs from the individual training plans completed by staff by October 1, 2019. Program Director will submit training plan to Human Resources by December 15th each year. HR coordinator will be responsible to ensure the Assessment of staff training needs is completed on time and available. HR coordinator will review staff records annually to ensure compliance. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
The project director failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of an overall plan addressing these staff needs. There was no comprehensive staff development program for agency personnel including policies and procedures documented for the program indicating who is responsible and the time frames for completion of an overall plan addressing staff needs.This was reviewed with facility staff during the licensing process.
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Plan of Correction
The project will develop and approve a Comprehensive policy for Staff Development including who is responsible and the time frames for completion of an overall plan addressing staff needs by September 1, 2019. Director of Human Resources will publish the policy by September 1, 2019. The policy will be shared with all staff with a receipt acknowledgement attached. The Executive Director will be responsible for ensuring a plan to address staff needs is developed for each staff member annually in accordance to the timeframes identified in the policy. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
The project director failed to develop a comprehensive staff development program for agency personnel as a whole to include policies and procedures for the program indicating who is responsible and the time frames for completion and a mechanism to collect feedback on this this completed training. There was no comprehensive staff development program for agency personnel as a whole to include policies and procedures for the program indicating who is responsible and the time frames for completion and a mechanism to collect feedback on this this completed training documented at the program. This was reviewed with facility staff during the licensing process.
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Plan of Correction
The project's current policy addresses who is responsible and the time frames for completion. The Director of Human Resources will develop and approve a Comprehensive policy for Staff Development including identification of where the staff feedback will be stored and how it will be utilized to assess overall training completed by September 1, 2019. Director of Human Resources will publish the policy by September 1, 2019. The policy will be shared with all staff with a receipt acknowledgement attached. Human Resources Coordinator will ensure feedback for all training completed becomes part of the employee record. These records will be reviewed for compliance annually by the Human Resource Coordinator. Director of Human Resources will review completed training and feedback and develop a comprehensive evaluation annually by March 1 of each year. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
The project director failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of an annual evaluation of the overall training plan. There was no comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of an annual evaluation of the overall training plan documented at the program. This was reviewed with facility staff during the licensing process.
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Plan of Correction
The project will develop and approve a Comprehensive policy for Staff Development including the time frames for completion of an overall evaluation of the staff development programs, including negative and positive conclusions by September 1, 2019. Director of Human Resources will publish the policy by September 1, 2019. The policy will be shared with all staff with a receipt acknowledgement attached. The Director of Human Resources will be responsible for the completion of the evaluation and will ensure it is completed by March of every year. Overall compliance of completion will be monitored by the VP of Human Resources. |
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 the review of personnel records, the facility failed to ensure that staff persons and volunteers receive at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum for one out of eight records.Employee #5 was hired on July 26, 2018 and was a current employee at the time of the licensing inspection. There was no documentation in this employees ' personnel records verifying that this employee received the mandatory 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training.This was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 9/1/19 all new hire direct staff will have mandatory trainings listed on their initial training plan for the upcoming year. A copy his training plan will be given to the employee, one in their employee file and one send to their employment location. The progress of completing their required trainings will be monitored quarterly of the course of their initial year of employment.
Pyramid healthcare will be willing to send out the employee to another location in the state if a specific training is not available locally in order for compliance to be met. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of CPR/First Aid certifications, it was determined that the facility failed to ensure that at least one person certified in CPR/First Aid was onsite during the project's hours of operation. The facility did not have a CPR/First Aid trained staff member on the 11pm-7am shift for the following dates:6/5/19 into 6/6/196/7/19 into 6/8/196/12/19 into 6/13/19,6/15/19 into 6/16/196/21/19 into 6/22/196/22/19 into 6/23/196/28/19 into 6/29/196/29/19 into 6/30/197/6/19 into 7/7/197/7/19 into 7/8/19 7/16/19 into 7/17/197/20/19 into 7/21/197/22/19 into 7/23/197/27/19 into 7/28/197/28/19 into 7/29/19.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A CPR Training is scheduled for 9/3/19 and 9/5/19.
Beginning 9/6/19, BHT Supervisor will provide a written weekly schedule of 24 hour staff coverage that reflects staff qualified to administer CPR and First Aid. All schedules will be maintained in a file by the BHT supervisor for one year to allow access to this information. All new hire employees will complete CPR/First Aid training within 60 days of their date of employment. Any staff who does not have the training within 60 days of employment will be taken off the schedule until the training has been completed.
Effective 9/6/19 all shifts will have at least (1) CPR/First Aid trained staff member.
All Ridgeview staff are instructed to call 911 in the event of an emergency.
Ridgeview has been working diligently to ensure at all staff are CPR/First aid trained and now have an in-house first aid CPR trainer who will work with Human Resources to ensure there the code is followed.
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on July 30, 2019, the facility failed to have an operable mechanical dryer or individual paper towels in the male shower-room bathroom. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This issue was corrected on 7/31/19. Beginning 9/1/19, maintenance will conduct weekly checks to ensure all hand dryers in the facility are operable. If the hand dryer is inoperable, paper towels will be provided until the proper repairs have been made to the equipment. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection conducted on July 30, 2019, the facility failed to ensure that hot water temperatures did not exceed 120F as evidenced by the following:1) The water temperature in the female's shower-room/bathroom sink was 143F.2) The water temperature in the hallway staff bathroom sink was 132F.3) The water temperature in the male bathroom sink was 142F.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This issue was resolved 7/31/19 by Pyramid maintenance.
Beginning 9/1/19, maintenance will conduct weekly checks to ensure water temperature is consistent and meet requirements of the regulation. By 9//30/19, A security device will be installed around the temperature control dial of the water heater to ensrure consistent hot water temperature. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of eight personnel records, the facility failed to have Employee # 3 review and sign the annual written individual staff performance evaluation dated, March 1, 2018 through August 31, 2018.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/1/19, all employee reviews will be submitted to the ED for final review to ensure all employees have seen, reviewed and signed their annual evaluations with their supervisors.
In the event that an employee is not available during the review period to evaluate and sign their review, a written document will be submitted to human resources explaining the reason the employee was not available to sign their evaluation. If the employee is out for medical or personal reasons, they will be required to meet with their supervisor to review and sign their evaluation, which will then be submitted to human resources to place in their personnel file or whichever location is designated by Pyramid Healthcare human resources for safe keeping of the employee reviews. |
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.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent for the disclosure of information contained in client records. Client #4 was admitted on December 25, 2018 and discharged on January 2, 2019. There were letter communications between the facility and a potential funding source. Staff failed to obtain an informed and voluntary consent for the disclosure permitting the release of any information to the potential funding source.Client #7 was admitted on January 26, 2019 and discharged on April 2, 2019. Email correspondence was sent to "Michael" on 1/28/19, 2/8/19, 2/16/19, 2/22/19, 2/28/19, 3/9/19, 3/15/19, 3/22/19 and 3/30/19, disclosing client identifying information, behavioral concerns while in treatment, progress in treatment and school performance. It is unknown who "Michael" is as staff failed to obtain an informed and voluntary consent for the disclosure of information to identify this individual.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/1/19, all consents for primary and secondary funding sources will be completed upon client arrival to facility. Clinical Supervisor will ensure that clients complete a new consent in the event of a change for funding sources.
Effective 9/1/19 consents will be reviewed prior to any form of communication outside of the treatment facility. Consents will be obtained from the client in the event communication is required to a new outside source. This will be monitored by the clinical supervisor within 24 hours of intake and during weekly chart monitors. Consents will also be addressed during weekly treatment team to ensure any communication being sent to outside persons or organizations have consents completed. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
During a Project wide review of Policy and Procedures, the facility ' s Client Rights policy was missing - sex and marital status in 709.30 (2), and Reasons for removing sections shall be documented in the record in 709.30 (3). These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Forms Committee will be updating the form in Carelogic to include the missing information. The new form to be added to Carelogic for all programs by September 1, 2019. Program Director will ensure all staff are educated on the new form by September 15, 2019.
All counselors will be educated on the new process by 9/15/19.
All current clients will have the new form completed in Carelogic by 9/16/19 |