INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc. Pine Ridge 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of the clinical supervisor's completion of a core curriculum in clinical supervision. Employee #3 was hired as a clinical supervisor on June 28, 2020 and was still in the position as of the date of the inspection. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor is scheduled for clinical supervisor training August 23-27. Executive Director will ensure all training requirement are met within required times frames. |
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 a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #8 and #10 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee #8 was hired as a counselor on February 24, 2020 and was due to have the communicable disease training no later than February 24, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.Employee #9 was hired as a support staff on September 11, 2018 and was due to have the communicable disease training no later than September 11, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
BHT Supervior, Clinical Supervisor and Executive Director will ensure all training hours are completed for all employees. Executive Director reviewed training guidelines during staff meeting held on August 3, 2021. All Supervisors will complete a written report monthly, reviewing staff's training needs. All staff who were out of compliance have been scheduled for the next available training in December 2021. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure the safety and well-being of clients, staff, and visitors as evidenced by the following:1.) There was a broken heater cover in the dining hall in Building B.2.) A drainage hose coming from E house that goes across the sidewalk, causing a tripping hazard.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Broken heater cover was fixed by maintenance on August 2, 2021. 2. Hose for sump pump was moved and relocated on August 2, 2021. Risk committee will continue to monitor safety issues each month and report finding to Executive Director to be corrected. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. It was observed that the group counseling room in the Rec Building did not have window coverings.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Maintenance was reviewed on this area, new window blinds will be installed on August 9, 2021. Risk committee will monitor monthly to ensure compliance. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical site inspection, it was observed that the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The shower in the bathroom of room 1 of the B Building and E House second floor bathroom both had mildewed shower curtains. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director will work on hiring housekeeping for daily cleaning. BHT department will check restrooms daily to ensure cleanliness. BHT will notify supervisor if immediate issues arise. Big clean of restrooms was conducted on August 7, 2021. |
705.7 (b) (4) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure that storage areas for foods are free of food particles, dust and dirt. The kitchen freezer in Building B was dirty with spilled food and food particles.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
BHT staff will monitor client refrigerator daily to ensure cleanliness. Staff will notify supervisors immediately if an issue should arise. Big Clean of this area was conducted on August 7, 2021. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure that cold food was at or below 40 degrees and frozen food was being kept cold at or below 0 degrees. B building dining room refrigerator nor freezer had thermometers, the kitchen freezer had no thermometer, and the pantry freezer had no thermometer.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director met with lifeskills specialist on August 3, 2021 to review kitchen regulations. All fridges and freezers have thermometers as of August 6, 2021. Executive Director will do monthly checks to ensure ongoing compliance. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure that interior exits and stairs are lit at all times. The hallway on the second floor of D House did not have a lighted exit.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director met with maintenance on 8/6, 2021 to review lighting needs for back stairwell leading to fire escape. New lighting will be purchased and installed bu August 8, 2021. Risk committee will monitor monthly for complaince. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drills from August 12, 2020 through June 23, 2021 was conducted during the onsite inspection, the facility failed to set off a fire alarm or smoke detector during the fire drill. Fire alarms nor smoke detectors were pulled during fire drills on August 12, 2020, September 11. 2020, October 29, 2020, November 21, 2020, December 15, 2020, January 15, 2021, February 13, 2021, March 24, 2021, April 17, 2021, May 5, 2021, and June 23, 2021.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director reviewed regulations with Maintenance Supervisor on August 5, 2021. Reviewed that pull stations need to be utilized for monthly fire drills. Maintenance will be holding a meeting on August 12 to review process and conduct a fire drill training with maintenance staff. Executive Director will ensure ongoing monthly complaince. |
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
Based on a review of client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not identify that clients may not be discriminated against based on religion and creed in four out of four records. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedures manual was updated on 7/29/2021 by the Policy and procedure committee to include religion, creed instead of the previously stated religious creed. The new policy was made available to staff on that date via the Pyramid Healthcare intranet. The compliance officer, via email, informed all programs of the change on that date and all handbooks and consents for treatment were amended to reflect the change. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not identify that clients have the right to appeal a decision limiting access to their records in four out of four records. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The PHC compliance officer will be responsible for making an amendment to the electronic health record, specifically the consent for treatment, to include the client's right to appeal the decision limiting access to their records. The PHC compliance officer will ensure this change occurs and is shared with all staff by 9/1/2021. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document in the client records work done at the project as part of treatment in four out of four records.Client #1 was admitted on April 8, 2021 and was still active at the time of the inspection.Client #2 was admitted on April 19, 2021 and was discharged on June 2, 2021.Client #3 was admitted on April 27, 2021 and was discharged on June 18, 2021.Client #4 was admitted on May 21, 2021 and was discharged July 7, 2021.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor reviewed utilization of work therapy in individual treatment plans at clinical team meeting on August 2, 2021. Clinical staff will ensure work therapy is added to treatment plans detailing involvmenet in employment, volunteer work, or lifeskills. Clinical supervisor will complete monthly chart audits to review progress. She will address any ongoing concerns during individual supervision. |