INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 20, 2016, through June 23, 2016, 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to ensure that an annual training plan was developed for each employee.
Staff person #7 was hired as a counselor on 10/01/2014, but the staff person did not have a documented annual training plan.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
Administrative Assistant for the facility will track/monitor completion of staff individual training plan compliance for all employees. Program Manager will ensure that all Department Supervisors monitor their assigned staff for compliance of training attendance through supervision. Human Resource Coordinator to complete quarterly reviews of employee files for facility staff to ensure 100% compliance. Target date for completion is 10/1/16 |
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
The facility failed to ensure that all of the staff of the facility received the required HIV/AIDS training within the required time frames.
Staff person #8 was hired as a counselor on 10/01/2014, but the staff person did not have 6 hours of documented HIV/AIDS training.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Administrative Assistant for the facility will track/monitor completion of mandatory communicable disease training compliance for all employees. Program Manager will ensure that all Department Supervisors monitor their assigned staff for compliance of training attendance through bi-weekly individual and monthly group supervision. Human Resource Coordinator to complete quarterly reviews of employee files for facility staff to ensure 100% compliance. Target date for completion is 10/1/16
Staff #8 will receive 6 hours of HIV/AIDS training in the upcoming training on 9-22-16. |
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
The facility failed to ensure that the hot water temperature in the facility bathrooms did not exceed 120 degrees Fahrenheit.
The hot water temperature in the women's bathroom located on the downstairs floor of the women's inpatient building was tested at 125 degrees Fahrenheit.
The hot water temperature in the bathroom located in the detox unit was tested at 130 degrees Fahrenheit.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
On 6/23/16, all the water temperatures were adjusted to 120 degree Fahrenheit and were tested by the maintenance. The temperatures were review by the director.
As of 7/1/16, the water temperatures are being tested once a week and documented. Program Director reviews the log on monthly basis to ensure that the water temperature is 120 Fahrenheit or below.
Program Director will review the logs for compliance on a monthly basis. Target date for completion is 9/1/16
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct monthly fire drills.
The administration building and the Eastburn building both only conducted one fire drill within the past 12 months.
The only fire drill performed in the Administration building within the past 12 months was conducted on 05/16/2016.
The only fire drill performed in the Eastburn building within the past 12 months was conducted on 05/16/2016.
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Plan of Correction
On 6/23/16, The policy for fire drill was reviewed with Leadership staff, Risk Management Committee, and Administrative Coordinator. As of 7/1/16, fire drills are to be performed for both the administration building as well as Eastburn building on monthly basis.
All the fire drill are documented by the Administrative assistant and Program Director will review the fire drills in supervision with Administrative Assistant on monthly basis. Target date for completion is 7/1/16
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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
The facility failed to ensure that the annual employee evaluations were signed by the employees.
The annual performance evaluations for staff persons #6, #7 and #8, were not signed by the staff persons being evaluated.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
The Procedure of Staff evaluation has been change from electronic to paper version to capture staff signature. Administrative Assistant for the facility will track/monitor completion of all staff performance evaluation for all employees.
Program Manager will ensure that all Department Supervisors ensure compliance of all performance evaluation through supervision meetings. Human Resource Coordinator will complete reviews of employee files for staff to ensure 100% compliance. Target date for completion is 10/1/16
-staff #6, #7 and #8 who currently work with the facility will sign the evaluations by 9/9/2016.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to provide clients with the required documentation for the involuntary discharge of the clients upon the termination of treatment for the clients.
Client #8 was admitted for treatment on 5/18/2016, and was involuntarily discharged on 6/1/2016, but the facility failed to give the client written documentation of the termination of treatment with the reason for the termination.
Client #9 was admitted for treatment on 3/07//2016, and was involuntarily discharged on 8/08/2016, but the facility failed to give the client written documentation of the termination of treatment with the reason for the termination.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
Clinical Supervisor will review with clinical staff the need to notify a client in writing of the decision to involuntarily terminate the client from treatment at the facility. The written notice will include the reasons for the termination. Clinical Supervisor will monitor compliance in this area through bi-weekly documented supervision and completion of monthly open and closed chart audits. Target date for completion is 9/30/16 |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
The facility failed to report to the Department an unusual incident that involved a physical assault against a staff person by a client at the facility.
On May 18, 2016, a male client punched a staff person in the face twice, but the facility never reported the incident to the Department.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
On 9/9/16, the departmental leadership will review the policy on Incident reporting and the importance of reporting the Unusual Incident to the Dept.
The following Procedural steps will be discussed:
1-Residential Supervisor will review the incidents within 24 hours
2-Residential Supervisor will report any unusual incident reports to the Department of Drug and Alcohol within 24 hours
3- Program Director will be provided report and updates on Unusual incidents reported to the department by the residential supervisor during Leadership Meetings every other week to ensure %100 compliance.
Target date for Completion is 9/9/16
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to report to the Department an incident that required the presence of the police at the facility.
On May 18, 2016, after a physical altercation between a client and a staff person, the police were called to the facility, and the police took the client into custody, but the facility did not report the incident to the Department.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
On 9/9/16, the departmental leadership will review the policy on Incident reporting and the importance of reporting the Unusual Incident to the Dept.
The following Procedural steps will be discussed:
1- Review of the Incident report within 24 hours by the Residential Supervisor
2- Residential Supervisor will report any unusual incident to the Department of Drug and Alcohol within 24 hours
3- Program Director will be provided report and updates on Unusual incidents reported to the department by the residential supervisor during Leadership Meetings every other week to ensure %100 compliance.
Target date for Completion is 9/9/16
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to properly screen patients prior to the administration of a narcotic agent.
Patient #12 was admitted for detoxification treatment with a narcotic agent on 06/05/2016, but the facility failed to acquire documentation verifying the patient's age and identity.
Patient #14 was admitted for detoxification treatment with a narcotic agent on 06/02/2016, but the facility failed to acquire documentation verifying the patient's age and identity.
Patient #15 was admitted for detoxification treatment with a narcotic agent on 05/22/2016, but the facility failed to acquire documentation verifying the patient's age and identity.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
On 9/9/16, the departmental leadership will review the policy on admission. The Intake supervisor will document the lack of any Identification documents in the ECR at the time of admission. Clinicians will support and assist clients in obtaining their documentation when applicable.
The Nurse Manager will audit and Program Director will monitor for compliance through bi-weekly supervision. Target date for completion is 9/9/16
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility failed to properly screen patients prior to the administration of a narcotic agent.
Patient #12 was admitted for treatment with a narcotic agent on 06/05/2016, but the patient's opiate addiction was not documented by a physician.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
On 9/8/16, the nursing department will review the policy on admission. The nurse assist the physician with assessing and screening each client upon admission. The Nurse Manager will ensure that the physician documents all the required forms including the diagnosis of opiate addiction and all the completed required documents are scanned in the ECR within 24 hours of admission. Target date for completion is 9/8/16 |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
The facility failed to document an updated treatment plan every 30 days in 3 client records reviewed.
Client # 3 was admitted for treatment on 04/18/2016, and was an active client at the time of the onsite inspection. The client's individualized treatment plan was completed on 04/20/2016, but the client's treatment plan update was not completed until 05/25/2016.
Client # 5 was admitted for treatment on 04/19/2016, and was an active client at the time of the onsite inspection. The client's individualized treatment plan was completed on 04/22/2016, but the client's treatment plan update was not completed until 06/14/2016.
Client # 9 was admitted for treatment on 03/07/2016, and was discharged from treatment on 05/08/2016. The client's individualized treatment plan was completed on 03/08/2016, but the client's treatment plan update was not completed until 04/18/2016.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
The clinical staff will ensure that treatment plans will be reviewed and updated at least every 30 days. If length of treatment stay is less than 30 days, the treatment plan, review and update will occur at least every 15 days and be documented accordingly in each of the clients' records. The Clinical Supervisor will review these documentation parameters with the clinical staff and monitor for compliance through bi-weekly documented supervision and by completing monthly open and closed chart audits. Target for completion date is 9/8/16 |