INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 5, 2016 through December 8, 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.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of three records reviewed.
Thirty-two personnel records were reviewed on December 5, 2016, three of which were identified as counselors. Employee #4 was hired as a counselor on June 21, 2016. A review of the employee's resume indicated that she did not have the required one year of clinical experience needed for the counselor position.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Office Manager for the facility will track/monitor all new hire documentation for all employees. Program Manager in collaboration with HR will ensure that all new hired counselors meet the DDAP qualification. Human Resource Coordinator to complete quarterly reviews of employee files for facility staff to ensure 100% compliance. Target date for completion is 01/30/17 |
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
Based on a review of the Staffing Requirements Facility Summary Report and an interview with Human Resources staff, twenty-six out of thirty-two personnel records reviewed lacked individual training plans.
The Staffing Requirements Facility Summary Report listed that twenty-six support staff did not have individual training plans. The Human Resources staff were asked if these individuals had training plans, and they indicated that these staff members did not have individual training plans and that the form was an accurate reflection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Office Manager for the facility will track/monitor completion of staff Individual Training Plan compliance for all employees. Program Director will ensure that all Department Supervisors monitor their assigned staff for compliance of Individual Training Plan through supervision. Human Resource Coordinator to complete quarterly reviews of employee files for facility staff to ensure 100% compliance. Target date for completion is 01/30/17 |
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, personnel records #5, #6 and #7 did not contain documentation of tuberculosis, sexually transmitted disease (TB/STD) training within the required time frame.
Employee #5 was hired on March 23, 2015 as a counselor and was still in that position as of the date of the inspection.
Employee #6 was hired on April 17, 2006 as support staff and was still in that position as of the date of the inspection.
Employee #7 was hired on July 2, 2014 as support staff and was still in that position as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Office Manager for the facility will track/monitor completion of staff Communicable Diseases training for all employees. Program Director will ensure that all Department Supervisors monitor their assigned staff for compliance of Communicable Diseases 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 01/30/17
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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 a review of staff schedules and the First Aid and CPR certification cards, the facility failed to provide a sufficient number of staff persons trained in CPR and First Aid during the project's hours of operation.
The CPR certification cards and First Aid certification cards were reviewed on December 5, 2016. The staff schedules reviewed were from the period of October 10, 2016 through November 6, 2016.
There was a lack of sufficient CPR coverage for the following days and shifts: October 14, 2016 from 4:00pm-12:00am, October 16, 2016 from 12:00am-8:00am, October 21, 2016 from 4:00pm-12:00pm, October 23, 2016 from 12:00am-8:00am, October 28, 2016 from 4:00pm-12:00am, October 30, 2016 from 12:00am-8:00am and 4pm-12am, November 6, 2016 from 12:00am-8:00am and 4:00pm-12:00am.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of January 1, 2017, Department Supervisors has ensured to assign CPR and First Aid certificated staff to all areas on each shift. Program Director monitor the compliance to scheduling through supervision in order to ensure that at least one person trained in these skills is onsite during %100 hours of operation. CPR training has been scheduled during the month of February for staff and the target date for completion is 2/25//17 |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The fire drill record log was reviewed on December 5, 2016. The log was reviewed for the period of June 2016 through October 2016.
There was no documentation that a fire drill was conducted in in June 2016 and September 2016 at the Lake House.
Additionally, there was no documentation that a fire drill was conducted in in August 2016 at the Main House.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 01/04/17, The policy for fire drill was reviewed with Leadership staff, Risk Management Committee, and Administrative Coordinator. As of 01/04/17, fire drills are to be performed for all sites on Monthly basis.
All the fire drills are documented by staff. Program Director will review the fire drills in supervision with Program Supervisors on monthly basis. Target date for completion is 02/15/17
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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
Twenty client records were reviewed on December 5, 2016 through December 8, 2016. The facility failed to obtain an informed and voluntary consent in seven of twenty client records reviewed.
Client #3 was admitted on September 23, 2016 and discharged on September 28, 2016. A consent to release information form, dated September 26, 2016 to a criminal justice agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment." Additionally, the release form did not identify the specific information that could be disclosed, did not identify a purpose of the disclosure and did not identify the date, condition or event that the consent would expire. The client record contained documentation indicating that the facility released patient identifying information to the criminal justice agency on October 14, 2016.
Client #6 was admitted on September 4, 2016 and discharged on September 9, 2016. The client record did not contain documentation of a consent to release information form for the funding source. An interview with facility staff confirmed that there was no consent to release information form for the funding source, whom they were billing.
Client #9 was admitted on October 23, 2016 and discharged on October 28, 2016. A consent to release information form, dated October 23, 2016 to a criminal justice agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment." The client record contained documentation indicating that the facility released patient identifying information to the criminal justice agency on October 25, 2016.
Client #12 was admitted on September 23, 2016 and was still an active client at the time of the inspection. A consent to release information form, dated September 26, 2016 to a criminal justice agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment." The client record contained documentation indicating that the facility released patient identifying information to the criminal justice agency on September 26, 2016 and November 15, 2016.
Client #16 was admitted on July 6, 2016 and discharged on August 7, 2016. Two consent to release information forms, one dated July 12, 2016 to a criminal justice agency and one dated July 14, 2016 to a government agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment." The client record contained documentation indicating that the facility released patient identifying information to the criminal justice agency and the government agency and on August 5, 2016.
Client #17 was admitted on August 25, 2016 and discharged on November 1, 2016. A consent to release information form, dated September 14, 2016 to a criminal justice agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment." The client record contained documentation indicating that the facility released patient identifying information to the criminal justice agency on October 6, 2016.
Client #19 was admitted on September 20, 2016 and discharged on November 21, 2016. A consent to release information form, dated September 20, 2016 to a criminal justice agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment." The client record contained documentation indicating that the facility released patient identifying information to the criminal justice agency on November 15, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Statement regarding the inability to revoke criminal justice consents for court mandated clients has been removed from consent forms in ECR system as of 11/30/16. Clinical staff reviewed the need for an informed and voluntary consent from the client for the disclosure of information contained in the client record including consent to release of information for the funding sources, as well as revision to consent forms and client's right to revoke in clinical staff meeting on 12/21/16. Clinical Supervisor will monitor compliance in this area through bi-weekly documented supervision and completion of monthly open and closed chart audits. A caseload review of all currently admitted clients by each counselor has been initiated as of 12/21 to sign updated consents for all currently enrolled clients not reviewed in this licensing visit that corrections may apply to during their individual sessions. No additional actions are needed to support new admits into the program, as the form currently in the chart is corrected as of 11/30/2016 and only administrators have the ability to revise to avoid user error at the facility level. All-staff training is under development for our mylearningpointe training system to launch in 2017 training year to reinforce for current and new hires.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Seventeen out of twenty client records were missing verification that a copy of the consent was offered to the client.
Client #3- Consents to a hospital and a primary care physician, both dated September 23, 2016 and a consent to a criminal justice agency dated September 26, 2016 did not have documentation that the client was offered a copy of the consents.
Client #4-Consent to a hospital, dated July 3, 2016 did not have documentation that the client was offered a copy of the consent.
Client #5-Consent to a hospital, dated September 9, 2016 did not have documentation that the client was offered a copy of the consent.
Client #6- Consents to a hospital and a primary care physician, both dated September 4, 2016 and a consent to a treatment provider dated September 9, 2016 did not have documentation that the client was offered a copy of the consents.
Client #7- Consent to a hospital, dated September 13, 2016 and a consent to a treatment provider, dated September 18, 2016 did not have documentation that the client was offered a copy of the consents.
Client #9- Consent to a hospital, dated October 23, 2016 did not have documentation that the client was offered a copy of the consent.
Client #10-Consent to a hospital, dated October 21, 2016 did not have documentation that the client was offered a copy of the consent.
Client #11-Consents to a hospital and a government agency, both dated November 23, 2016 did not have documentation that the client was offered a copy of the consents.
Client #12- Consents to a hospital and a primary care physician, both dated September 23, 2016, a consent to a treatment provider dated September 30, 2016, six additional consents to treatment providers, dated October 11, 2016, and a consent to a funding source, dated November 30, 2016 did not have documentation that the client was offered a copy of the consents.
Client #13- Consent to a hospital, dated October 4, 2016, a consent to a treatment provider, dated November 9, 2016 and an additional consent to a treatment provider, dated November 16, 2016 did not have documentation that the client was offered a copy of the consents.
Client #14- Consent to a hospital, dated October 21, 2016 did not have documentation that the client was offered a copy of the consent.
Client #15- Consent to a hospital, dated November 15, 2016 and consent to a treatment provider, dated November 28, 2016 did not have documentation that the client was offered a copy of the consents.
Client #16- Consent to a treatment provider, dated July 6, 2016 and three additional consents to treatment providers, dated August 1, 2016 did not have documentation that the client was offered a copy of the consents.
Client #17- Consent to a hospital, dated August 25, 2016, consent to a criminal justice agency, dated September 14, 2016, consent to a funding source, dated October 11, 2016, consent to a treatment provider dated October 20, 2016, three consents to treatment providers, dated October 24, 2016 and two consents to primary care physicians, dated October 25, 2016 did not have documentation that the client was offered a copy of the consents.
Client #18- Consents to a hospital and treatment provider, both dated August 3, 2016 and consent to a primary care physician, dated September 14, 2016, did not have documentation that the client was offered a copy of the consents.
Client #19- Consents to a hospital and a primary care physician, both dated September 20, 2016, consent to a lawyer, dated October 21, 2016, consent to a treatment provider dated November 16, 2016, an additional consent to a treatment provider dated November 17, 2016 did not have documentation that the client was offered a copy of the consents.
Client #20- Consent to a hospital, dated August 22, 2016 and consent to a criminal justice agency, dated September 15, 2016 did not have documentation that the client was offered a copy of the consents.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
VP of Clinical Services revised consents on November 28, 2016 to ensure that all consents contain appropriate elements of a valid consent; including acknowledgement that a copy was offered to the client as well as the ability to revoke consents verbally or in writing. All staff members who deal directly with consents will receive additional training on revisions and completion of consents. Training will be concluded by February 2017. Completion of training will be verified by posttest completion and monitored by Human resources Coordinators. Clinical Supervisor will review with clinical staff the need for documented acknowledgement that a copy of consent to a hospital and primary physician was offered to the clients. 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 2/28/17
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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
Twenty client records were reviewed for client rights on December 5, 2016 through December 8, 2016. The facility failed to include on the facility's Consent to Treatment Client Rights form and the Adult Units Handbook the following verbiage: color and sex.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor revised the Client Handbook on 12-15-16 to ensure that it contains appropriate verbiage of Sex and Color. Copies were offered to the client as well as the staff. All staff members will receive additional training on these revisions in the Client Handbook. Training will be concluded by February 2017. |
709.63(a) LICENSURE Client record
709.63. 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record in seven of ten records reviewed.
Ten client records were reviewed on December 5, 2016, seven of which required documentation of follow up information and a discharge summary.
Client records #4, #5, #6, #7, #8, #9 and #10 failed to include documentation of a follow up.
Client #4 was admitted on July 3, 2016 and was discharged on July 8, 2016. There was no documented follow up. Additionally, the client record contained no documentation of a discharge summary.
Client #5 was admitted on September 9, 2016 and was discharged on September 13, 2016. There was no documented follow up.
Client #6 was admitted on September 4, 2016 and was discharged on September 9, 2016. There was no documented follow up.
Client #7 was admitted on September 13, 2016 and was discharged on September 18, 2016. There was no documented follow up.
Client #8 was admitted on November 6, 2016 and was discharged on November 8, 2016. There was no documented follow up.
Client #9 was admitted on October 23, 2016 and was discharged on October 28, 2016. There was no documented follow up.
Client #10 was admitted on October 20, 2016 and was discharged on October 25, 2016. There was no documented follow up.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #4 record has been updated with the Discharge Summary dated 1/16/17. Clinical supervisor will review with clinical staff the need for completion of the discharge summary in the client record. Clinical Supervisor will monitor compliance in this area through bi-weekly documented supervision and completion of monthly open and closed chart audits. Office Manage for the facility will track/monitor completion of mandatory follow up information after client discharge. Program Director will ensure for 100% compliance of Client follow up through monthly supervision Target date for completion is 01/30/17 |