INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 13, 2024 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 Lehigh Valley 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide direct observation by a trained counselor or clinical supervisor for the first 3 months of employment or for the next 9 months, under close supervision.
Employee #9 was hired on February 19, 2024 as a counselor assistant and was still employed at the time of the inspection. She had no documentation of direct observation the weeks of March 18th, March 25th, April 1st, April 26th, and May 10th, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Director and Executive Director reviewed the DDAP qualifications and supervisory needs for Counselor Assistants with a high school diploma or GED equivalent on 6/20/24.
CD and ED will meet on a weekly basis, no later than 6/28/24, to review her supervision schedule and ensure that employee #9 is receiving the appropriate observation and supervision. Employee #9 requires an additional 5 weeks of direct observation. Anticipated date that direct observation will be complete is 8/5/2024 (employee #9 has a scheduled vacation on 7/1-7/5). |
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 (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee in the required time frame, appropriate to that employee's skill level in one out of nine employee records reviewed.
Employee #8 was hired on April 2, 2024 as a counselor assistant and was still in the position as of the date of the inspection. The plan is dated June 10, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director will meet with all Department Heads to review this POC on June 20th, 2024.
Administrative Assistant will ensure that all new hires complete their training plans with their respective Department Head within their first 30 days of hire. AA will track completion via Smartsheet, with ED's oversight. ED will monitor this Smartsheet on a quarterly basis, with first audit being completed no later than 10/1/2024.
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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
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed t ensure that 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 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.
Employee #9 was hired as BHT on December 27, 2021 and was promoted to counselor assistant on February 19, 2024. Her training was due no later than December 27, 2023; however, none was completed.
Employee #10 was hired as a BHT Manager on February 8, 2021. His training was due no later than February 8, 2023; however, his HIV/AIDS was not completed until October 5, 2023 and his TB/STD training was not completed as of the time of the inspection.
Employee #11 was hired as a Maintenance Tech on September 8, 2021. His training was due no later than September 8, 2023; however, his HIV/AIDS was not completed until June 6, 2024 and his TB/STD training was not completed as of the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation form the August 4, 2021, August 19, 2022, and June 26, 2023 licensing inspections.
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Plan of Correction
Employee #10 completed TB/STD Training on 7/2/24.
Employee #9 and #11 are registered for TB/STD Training and will complete on 10/22/24.
Employee #9's HIV Training was completed on 6/21/24.
As mentioned in the previous POC, trainings will be strictly monitored by Administrative Assistant and Executive Director.
Administrative Assistant will ensure that all new hires complete their training plans with their respective Department Head within their first 30 days of hire. AA will track completion via Smartsheet, with ED's oversight. ED will monitor this Smartsheet on a quarterly basis, with first audit being completed no later than 10/1/2024.
Current employees' trainings will also be tracked in this smartsheet. |
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
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 30 clock hours of annual training required for counselor assistants.
Employee #7 was hired as a counselor assistant on February 8, 2021 and was still in the position at the time of the inspection. The training year reviewed was January 1, 2023 through December 31, 2023. She had only 16.9 hours documented of annual training.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon further review, Employee #7 has more than 30 hours of training that were not uploaded to Pyramid's tracking system. Executive Director and Clinical Director reviewed with Employee #7 the importance of uploading certificates in real-time. CD will ensure that her team uploads any training certificates in real-time, and complete quarterly audits of their training transcripts, starting no later 10/1/2024. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of inpatient client records, the facility failed to notify the emergency contact of the client leaving the facility against medical advice.
Client #7 was admitted on March 18, 2024 and left the facility AMA on April 16, 2024. No notification was made to the emergency contact.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director met with Clinical Director and BHT Manager to review this POC on June 20th, 2024.
Moving forward, if a client leaves the facility as a non-routine discharge (against facility advice, behaviorally, medically, etc.) Monday through Friday from 7am-4pm, their Primary Counselor or Clinical Director will call the emergency contact and document this attempt in the client's chart.
If a client leaves the facility as a non-routine discharge outside of those timeframes, the BHT Shift Lead or BHT Shift Supervisor will call the emergency contact and document this attempt in the client's chart.
CD will monitor compliance on a weekly basis, every Friday, by reviewing any non-routine discharges from that week and reviewing the client's chart. After 90 days of consistent compliance, CD will monitor compliance on a monthly basis. |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on a physical plant inspection, the facility failed to keep medication carts locked when not in use, as required by the facilities policy and procedure manual. Both carts in the nurse ' s office were observed to be unlocked and not in use.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director met with LPN Supervisor to review this POC on June 20th, 2024. ED communicated, via e-mail, no later than 6/21/24, the expectation that medication carts be kept locked when not in use.
LPN Supervisor and ED to have oversight. LPN Supervisor to complete random cart checks on a weekly basis for the next 90 days to ensure compliance.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of inpatient client records, the facility failed to document a complete psychosocial evaluation according to the facilities policy and procedure to be completed within 24 hours in three out of seven applicable records reviewed.
Client #4 was admitted on April 30, 2024 and was still active at the time of the inspection. There was no psychosocial evaluation completed.
Client #6 was admitted on February 6, 2024 and was discharged on February 15, 2024. The psychosocial evaluation was due no later than February 7, 2024; however, it was not completed until February 8, 2024.
Client #7 was admitted on March 18, 2024 and was discharged on April 16, 2024. There was no psychosocial evaluation completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director met with Clinical Director to review this POC on June 20th, 2024.
Clinical Director to ensure that Psychosocial Evaluations are completed within 24 hours of a client's admission into treatment. CD will monitor compliance on a weekly basis, every Friday, by reviewing all admissions from that week and reviewing the client's chart. After 90 days of consistent compliance, CD will monitor compliance on a monthly basis.
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of inpatient client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed seven days following admission or as needed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director met with Clinical Director to review this POC on June 20th, 2024.
Clinical Director to ensure that Case Consultations are completed within 7 days of a client's admission into treatment. CD will monitor compliance on a weekly basis, every Friday, by reviewing all admissions from that week and reviewing the client's chart. After 90 days of consistent compliance, CD will monitor compliance on a monthly basis.
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of inpatient client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed within seven days following discharge.
Client #7 was admitted on March 18, 2024 and was discharged on April 16, 2024. A follow up was due no later than April 23, 2024; however, none was completed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director met with Clinical Director to review this POC on June 20th, 2024.
Clinical Director to ensure that 7-day follow-up calls are completed by Case Coordinator after a client discharges from treatment. CD will monitor compliance via already existing Smartsheet and Executive Director will have additional oversight. Monitoring will occur on a weekly basis for the first 90 days, then monthly after consistent compliance.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of staff training records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for mandatory communicable disease training were submitted and approved by the Department for the August 4, 2021, August 19, 2022 and June 26, 2023 annual licensing inspections. Mandatory communicable disease training was again found to be a deficiency in the June 13, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director met with all Department Heads to review this POC on June 20th, 2024 and will review monthly thereafter, to review the progress of this POC due to the repeat citations.
Administrative Assistant will ensure that all new hires register for HIV and TB/STD Trainings within their first 30 days of hire, and complete both trainings within their first year of hire (no matter their position). AA will track completion via Smartsheet, with ED's oversight. ED will monitor this Smartsheet on a quarterly basis, with first audit being completed no later than 10/1/2024.
Any staff member who has not yet completed HIV and/or TB/STD will be registered no later than 7/1/2024. |