INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc, was found to not 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
The facility failed to ensure that all non-counseling staff 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 within the first two years of employment for seven staff members reviewed.
Staff #14 was hired on January 18, 2016 as an administrative assistant and did not have HIV/AIDS training documented in their training record.
Staff #15 was hired on January 1, 2015 as a BHT and did not have HIV/AIDS or TB/STD trainings documented in their training file.
Staff #16 as hired on September 4 2015 as a BHT and did not have HIV/AIDS or TB/STD trainings documented in their training file.
Staff #17 was hired on July 21, 2015 as a BHT Supervisor and did not HIV/AIDS or TB/STD trainings documented in their training record.
Staff # 18 was hired on October 17, 2016 as a Driver and did not have HIV/AIDS or TB/STD trainings documented in their training record.
Staff #19 was hired on August 4, 2015 as a Needs Assessment Personnel and did not have HIV/AIDS or TB/TD trainings documented in their training record.
Staff #20 was hired on August 3, 2015 as a UR Coordinator and did not have their HIV/AIDS training documented in their training record.
These findings wer reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/17/18 Leadership will meet with their respective employees #14 through #20 to facilitate each employee being signed up for the next scheduled training they are required to complete to be in compliance.
Staff #14 to attend the agencies next scheduled HIV/AIDS training on 9/25/18 and provide documentation to HR for their records.
Staff #15 to attend the agencies next HIV/AIDS training on 9/25/18 and the next TB/STD training on 11/8/18 and provide documentation to HR for their records.
Staff #16 to attend the agencies next HIV/AIDS training on 9/25/18 and the next TB/STD training on 11/8/18 and provide documentation to HR for their records.
Staff #17 to attend the agencies next HIV/AIDS training on 9/25/18 and the next TB/STD training on 11/8/18 and provide documentation to HR for their records.
Staff #18 to attend the agencies next HIV/AIDS training on 9/25/18 and the next TB/STD training on 11/8/18 and provide documentation to HR for their records.
Staff #19 to attend the agencies next HIV/AIDS training on 9/25/18 and the next TB/STD training on 11/8/18 and provide documentation to HR for their records.
Staff #20 to attend the next HIV/AIDS training on 9/25/18 and provide documentation to HR for their records. Leadership/Supervisors to facilitate monthly individual documented supervision where training needs/requirements will be discussed and documented accordingly to ensure compliance. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
The facility failed to ensure that each counselor assistant completed at least 40 clock hours of training during the first year of employment and 30 clock hours of training annually thereafter.
Staff #13 was hired on March 2, 2016 as a counselor assistant and should have had 30 training hours during the January 1, 2017 through December 31, 2017 training year. There was only 19 hours documented in the staff training file.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #13 requires 11 more hours of documented training to ensure compliance with meeting the total requirement of 30 total hours. Effective 9/17/18 Clinical Director will facilitate a supervisory conference with employee # 13 to arrange/schedule upcoming trainings to meet the 30 day requirement. Clinical Supervisor to establish a 60 day timeframe for employee #13 to successfully obtain 11 documented hours of training. Clinical Supervisor to meet with employee #13 weekly to provide ongoing documented supervision and to ensure compliance with the regulation. Training documents to be forwarded to Human Resource department to be placed in employee file/record for proof of completion.
Effective 9/24/18 Clinical Supervisor will coordinate with Human Resources to receive monthly training grids outlining the members of their clinical staff long with current training requirements. Clinical Supervisor to meet with individual counseling staff on a monthly basis for documented supervision where during that time, they will review with their staff member what trainings are required and facilitate the scheduling of said trainings to ensure compliance. Clinical Supervisor to report during monthly clinical group meetings/supervision current status of all clinical team members with respect to the status of each of their training grids. Clinical Supervisor to report to the Program Director on monthly basis during Department Head meetings to ensure compliance. |
705.10 (c) (2) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
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Observations
The facility failed to maintain at least one portable fire extinguisher with a minimum of an ABC rating in the kitchen.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/24/18 a portable fire extinguisher with a minimum of an ABC rating will be placed/located in the kitchen. Program Director to work with Maintenance Supervisor regarding purchase and placement of said extinguisher. Program Director and Maintenance Supervisor to facilitate monthly, documented walk throughs of the facility to ensure compliance. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document the amount of time it took for the evacuation, the exit routes used, the number of persons in the facility at the time of the drill and whether the fire alarm or smoke detector were operative on each of their fire drill logs conducted from June 2017 through June 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/17/18 Program Director to work with Maintenance Supervisor and agencies RISK Lead Manager to review and re-structure the current fire drill log to reflect the amount of time for the evacuation, the exit routes used, the number of persons in the facility at the time of the drill and whether the fire alarm or smoke detector were operative. Program Director and Maintenance Supervisor to review fire drill logs on a monthly basis as part of their monthly facility walk throughs to ensure compliance. Maintenance Supervisor to report findings during the monthly RISK meetings. |
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
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in ten of fourteen client records.
Client #4 was admitted on July 11, 2018 and was discharged on July 16, 2018. A consent to release information form to the funding source was signed by the client that allowed for the additional release of general progress updates, medical history, and physical and treatment progress updates.
Client #5 was admitted on April 9, 2018 and was discharged on April 14, 2018. A consent to release information form to the funding source was signed on April 9, 2018 by the client that allowed for the additional release of general progress updates and medication administration records.
Client #6 was admitted on February 11, 2018 and discharged on February 16, 2018. A consent to release information form to the funding source was signed by the client on February 11, 2018 that allowed for the additional release of general progress updates and medication administration records.
Client #7 was admitted on January 27, 2018 and discharged on February 1, 2018. A consent to release information form to two separate funding sources were signed by the client on January 1, 2018 that allowed for the additional release of general progress updates and medication administration records.
Client #8 was admitted on May 17, 2018 and was still active at the time of the inspection. A consent to release information form to two separate funding sources were signed by the client on May 17, 2018 that allowed for the additional release of general progress updates, psychological assessment, psychiatric evaluation, medication administration records and treatment progress updates.
Client #9 was admitted on May 11, 2018 and was still active at the time of inspection. A consent to release information form to the funding source was signed by the client on May 11, 2018 that allowed for the additional release of general progress updates and medication administration records.
Client #10 was admitted on March 27, 2018 and discharged on May 28, 2018. A consent to release information form was signed by the client on March 27, 2018 to the funding source that allowed for the additional release of general progress updates.
Client #12 was admitted on December 21, 2017 and discharged on February 10, 2018. A consent to release information form to three separate funding sources were signed by the client on December 21, 2017 that allowed for the additional release of general progress updates, medication administration records, psychological assessment, psychiatric evaluation and treatment progress updates.
Client #13 was admitted on February 1, 2018 and was discharged on March 1, 2018. A consent to release information form to the funding source was signed on February 1, 2018 that allowed for the additional release of general progress updates.
Client #14 was admitted on February 12, 2018 and was discharged on April 20, 2018. A consent to release information form to the funding source was signed by the client on February 12, 2018 that allowed for the additional release of general progress updates, medication administration records, psychological assessments, medical history and physical, psychiatric evaluation and treatment progress updates.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/17/18 all consents specific to funder/payor sources will reflect the release of only information outlined under regulatory guidelines #255.5. Effective 9/17/18 Clinical Supervisor will facilitate a training with all intake staff specific to the completion of said consent forms. Clinical Supervisor will monitor the consents by monthly chart audits to ensure compliance with this regulation. |
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 update treatment plans in three out of seven treatment plans reviewed.
Client #8 was admitted on May 17, 2018 and was still active at the time of the inspection. There was a treatment plan update dated June 19, 2018 with the next being due by July 19, 2018, however the update was not completed until July 24, 2018.
Client #10 was admitted on March 27, 2018 and was discharged on May 28, 2018. The comprehensive treatment plan was dated March 29, 2018 with the next update being due by April 29, 2018, however the update was not completed until April 30, 2018.
Client #14 was admitted on February 12, 2018 and was discharged on April 20, 2018. The comprehensive treatment plan was dated February 14, 2018 with the next update being due no later than March 14, 2018, however the update was not completed until March 15, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/17/18 Clinical Supervisor to facilitate a refresher training for all clinical staff, on the required timeframes, for both short term (14) and long term (30) LOC, for treatment planning guidelines. Clinical Supervisor to monitor charts through monthly chart audits to ensure compliance to established treatment plan update time frames. Clinical Supervisor to report audit outcomes to Program Director at monthly department head meetings to ensure compliance. |
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
The facility failed to provide counseling services according to the individual treatment plan in six out of seven records.
Client #8 was admitted on May 17, 2018 and was still active at the time of the inspection. The treatment plan indicated group therapy five times per week. The client did not have five group therapy sessions documented for the weeks of: May 27, 2018, June 3, 2018 and June 6, 2018.
Client #9 was admitted on May 11, 2018 and was still active at the time of the inspection. The treatment plan indicated group therapy five times per week. The client did not have five group therapy sessions documented for the week of May 27, 2018.
Client #11 was admitted on May 30, 2018 and was still active at the time of the inspection. The treatment plan indicated group therapy five times per week and individual therapy weekly. The client did not have group therapy sessions documented for the weeks of: June 10, 2018, June 17, 2018, June 24, 2018, June 29, 2018 and July 5, 2018. Additionally, the client did not have an individual therapy session during the week of June 24, 2018.
Client #12 was admitted on December 21, 2017 and was discharged on February 10, 2018. The treatment plan indicated group therapy five times per week. The client did not have five group therapy sessions documented for the weeks of December 24, 2018, December 31, 2017, January 28, 2018 and February 4, 2018.
Client #13 was admitted on February 1, 2018 and discharged on Mary 1, 2018. The treatment plan indicated group therapy five times per week. The client did not have group therapy documented five times per week for the weeks of: February 4, 2018 and February 25, 2018.
Client #14 was admitted on February 12, 2018 and was discharged April 20, 2018. The treatment plan indicated group therapy five times per week. The client did not have group therapy documented five times per week for the weeks of: February 11, 2018, February 18, 2018, February 25, 2018, March 4, 2018, March 11, 2018, March 18, 2018 and March 25, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/17/18 Clinical Supervisor to facilitate a refresher training with the clinical team specific to counseling services and requirements of the program. Clinical Supervisor will review with the team that each client must receive X5 documented group therapies per week according to the individual and rehab plan. Clinical Supervisor to generate weekly reports out of the electronic medical record to identify any potential missing/non documented services to ensure compliance. Clinical Supervisor to also facilitate monthly chart audits for compliance and report on findings to Program Director during monthly department head meetings. |