INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on July 17, 2019. Based on the findings of the on-site inspection, Pyramid Healthcare-Lehigh Valley 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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704.8(c) LICENSURE Full Caseload Assignment
704.8. Qualifications for the position of counselor assistant.
(c) In addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level.
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Observations
The facility failed to complete a performance evaluation of the counselor assistant's individual skill level prior to assignment of a full caseload.
During a review of staff records on July 17, 2019, it was found that Staff #7 who was hired on January 7, 2019 as a counselor assistant, had no positive performance evaluation prior to being assigned a full caseload.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will receive a 90 day performance evaluation upon hire and/or change in position. Clinical Supervisor to ensure 90 day performance evaluations are completed on her team members. Executive Director, and Human Resources, to monitor and ensure completion. Target date August 1, 2019. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
The facility failed to demonstrate that performance evaluations were conducted semi-annually for counselor assistants.
During a review of staff records on July 17, 2019, it was found that Staff #7 was hired on January 9, 2019 as a counselor assistant and never received a performance evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will receive a 90 day performance evaluation upon hire and/or change in position. Clinical Supervisor to ensure 90 day performance evaluations are completed on her team members. Executive Director, and Human Resources, to monitor and ensure completion. Target date August 1, 2019.
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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.
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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.
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Plan of Correction
The project will 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.
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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.
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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.
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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. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of the Staffing Requirement Facility Summary Report form, the facility failed to ensure that the staff to client ratio remained at or below one full time equivalent (FTE) counselor for every eight clients as per the regulations for inpatient nonhospital treatment and rehabilitation.
The current client census information and clinical staff hours were reviewed with the Facility Director on July 17, 2019. There is currently one full time counselor for every nine clients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pyramid Lehigh Valley has 1 FT clinician for every 8 clients; however, the staffing grid was completed incorrectly upon initial submission and one time thereafter. For upcoming DDAP site inspections, Executive Director will ensure that the DDAP staffing grid is completed correctly, which outlines one FT clinician for every 8 clients, which is Pyramid's current client to counselor ratio. When the need arises, the Clinical Supervisor will also carry a caseload to ensure compliance to staff/client ratio. Executive Director to monitor. Target date 8/1/2019. |
709.1-709.5 LICENSURE Subchapter A. General Provisions
Chapter 709. Standards for Licensure of Freestanding Treatment Activities
709.1. Scope.
(a) This chapter establishes the procedures for the issuance of a license by activity to freestanding drug and alcohol treatment facilities. The term, facility, applies to the physical location from which drug and alcohol services are provided. A facility may provide more than one service.
(b) This chapter provides standards by activity for the licensure of freestanding drug and alcohol treatment facilities, under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059).
709.2. Policy.
(a) Persons, partnerships and corporations, or other legal entities intending to provide drug and alcohol treatment services, shall first be licensed by the Department.
(b) No drug or alcohol freestanding treatment facilities may receive funds from the Department without a license issued under this chapter.
709.3. Legal base.
The authority of the Department to license drug and alcohol treatment activities is established under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059) as transferred to the Department by Reorganization Plan No. 2 of 1977 (P.L. 372) (71 P. S. subsection 751-25) and No. 4 of 1981 (P. L. 610) (71 P. S. subsection 751-31).
709.4. Exceptions.
(a) The Department may, within its discretion, and for good reasons, grant exceptions or extensions of time to this chapter when the policy objectives of this chapter are met, but no exception may be granted which contravenes the authorizing statute.
(b) The project director shall submit a written request for an exception which shall include the approval of the governing body.
(c) Exceptions will not be granted for a situation in which a provisional license would be appropriate.
709.5. Revocation of exceptions.
(a) An exception granted under this chapter may be revoked by the Department. Notice of revocation will be in writing and include the reason for the action of the Department and a specific date upon which the exception will be terminated.
(b) In revoking an exception, the Department will provide for a reasonable time between the date of written notice of revocation and the date of termination of an exception for the project to come into compliance with this part.
(c) If a project wishes to request a reconsideration of a denial or revocation of an exception, it must do so in writing to the Department within 30 days of receipt of the adverse notification.
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Observations
During a Project Wide review of the Policy and Procedures, the project failed to include sex and marital status in the Client Rights policy.709.30 (2), and also the project failed to include documentation of the reasons for removing sections from the record. 709.30 (3).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedures manual will be updated by the Policy and procedure committee to include sex and marital status in section 709.30. Chief Compliance Officer will ensure completion of policy by Sept 1, 2019. The program director will be responsible to ensure that the new policy is shared with all staff by Sept 15, 2019. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
During a review of client records on July 17, 2019, the facility failed to notify clients of all their civil rights in seven out of seven records.
Client #1 was admitted on June 19, 2019 and was current at the time of the inspection. Client #1 was not notified that the project may not discriminate on the basis of sex.
Client #2 was admitted on June 18, 2019 and was current at the time of the inspection. Client #2 was not notified that the project may not discriminate on the basis of sex.
Client #3 was admitted on May 30, 2019 and was current at the time of the inspection. Client #3 was not notified that the project may not discriminate on the basis of sex.
Client #4 was admitted on August 27, 2018 and was discharged on September 6, 2018. Client #4 was not notified that the project may not discriminate on the basis of sex.
Client #5 was admitted on May 22, 2019 and was discharged on June 17, 2019. Client #5 was not notified that the project may not discriminate on the basis of sex.
Client #6 was admitted on February 14, 2019 and was discharged on March 14, 2019. Client #6 was not notified that the project may not discriminate on the basis of sex.
Client #7 was admitted on April 29, 2019 and was discharged on July 5, 2019. Client #7 was not notified that the project may not discriminate on the basis of sex.
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. |