INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensure renewal inspection that was conducted on October 25-26, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, Pyramid Healthcare, Inc. - Pyramid 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:
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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
Fifteen client records were reviewed for the licensing renewal inspection that was conducted on October 25-26, 2017. The facility failed to provide documentation of HIV/AIDS and/or TB/STD training for employee records # 14 and 15.
Employee # 14, a detox technician, was hired by the facility on 1/28/15. The employee was required to complete HIV/AIDS training by no later than 1/28/17. Provision of this training was not documented in the employee's record.
Employee # 15, a life skills specialist, was hired by the facility on 9/14/15. The employee was required to complete both HIV/AIDS and STD/TB training by no later than 9/14/17. Provision of this training was not documented in the employee's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately HR will continue to send out training reminders monthly when training classes are being offered so supervisors can regularly schedule staff trainings. Supervisors will monitor staff monthly to ensure they are turning in any training certificates that are available, and training requirements are being met. Pyramid Pittsburgh will be willing to send staff out of area to complete trainings if they are not offered locally or trainings are cancelled. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Administrative documentation was reviewed for the licensing renewal inspection conducted on October 25-26, 2017. The facility failed to provide physician timesheets and a complete physician schedule. Therefore, the facility failed to provide documentation verifying the provision of narcotic treatment services at least 1 hour per week onsite for every ten patients.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Starting January 1, 2018, Physician time sheets will be requested monthly from accounts payable and will be kept on record by Program Director so they are easily accessible. |