INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 17, 2012 by staff from the Division of Drug and Alcohol 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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704.11(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
Based on a review of staff records, the facility failed to document a mechanism to collect feedback on completed training, as required by regulation.The findings include:Employee records were reviewed on October 2 -3 and 17, 2012. The facility failed to document the submission of feedback forms after the completion of employee training in employee records # 2, 3, 4 and 5. Although there was documentation that the employees reviewed had attended training in both 2011 and 2012, there was no documentation provided that the employees completed feedback evaluations on the completed training documented in the personnel or training records. The Facility Director was interviewed on October 17, 2012 and confirmed the findings.
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Plan of Correction
Beginning October 22, 2012, Human resource coordinators will ensure that training evaluations for all trainings are placed in each individual's employee file. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance. |
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, the facility failed to provide documentation of at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics for other staff required to complete the training within the first 2 years of employment in one of two records reviewed.The findings include:Six personnel records were reviewed on October 2-3 and 17, 2012. Two personnel records were reviewed for compliance with the completion of the required training. Employee # 6 was hired on June 11, 2009 as a BH technician. The required sexually transmitted diseases and other health related topics was to be completed by June 11, 2011. There was no documentation that the training had been completed. The Facility Director was interviewed on October 17, 2012 and confirmed the findings.
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Plan of Correction
Facility Director will ensure employee #6 will attend the next STD/TB training offered at Pyramid's Corporate Training office on Nov 27,2012. Facility Director will follow-up with Human Resource Coordinators and employee after said training date to ensure attendance. Human Resource Coordinators will monitor all employee files quarterly to ensure all employees attend the mandatory trainings within the required time frame. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project director in one of one personnel record.The findings include:Six personnel records were reviewed on October 2-3, 2012. One personnel record pertained to the project director. The facility's training year is January- December. The facility's 2011 training year was reviewed. One personnel record required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1. Employee # 1 has been the project director since July 1999. There were no training hours documented for the 2011 training year. Human resources personnel were interviewed on October 5, 2012 and confirmed the findings
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Plan of Correction
Employee #1, Project Director, will complete 12 hours of training by November 30, 2012. Human Resource Coordinator will ensure completion. Human Resource Coordinators will complete HR file audits quarterly to ensure training requirements of all staff are up to date. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two personnel records.The findings include:Six personnel records were reviewed on October 2-3 and October 17, 2012. Two personnel records pertained to counselors. The facility's training year is January- December. The facility's 2011 training year was reviewed. Two personnel records required the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 3.Employee # 3 was hired on July 5, 2010. There were only 18 clock hours of annual training documented for the 2011 training year.The Facility Director was interviewed on October 17, 2012 and confirmed the findings.
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Plan of Correction
Facility Director will meet with employee #3 by 11/16/2012 to discuss adherence to the training requirement of 25 clock hours. Employee will be advised to attend 7 more clock hours of training by Nov 30, 2012. Facility Director will follow-up with Human Resource Coordinator and employee on Nov 30, 2012 to ensure compliance. Human Resource Coordinators will conduct quarterly file audits to ensure compliance to training requirements of all staff. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on the physical plant inspection, the facility failed to ensure that each porch that has over an 18-inch drop had a well-secured railing. The finding included:The physical plant inspection was completed on October 17, 2012 at approximately 2:15 P.M. During the inspection of Building E, the handrail on the outside stairs was found to be loose and easily moved from side to side. The rail was not secure. The Facility Director and Maintenance Supervisor were present during the inspection and confirmed the findings.
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Plan of Correction
Facility Director met with Director of Maintenance to discuss handrail being loose on the outside stairs of Building E on 10/19/2012. Director of Maintenance sent a member of the maintenance staff to Pine Ridge to ensure the handrail is secure on 11/1/2012. Facility Director checked upon completion to find it secure. Compliance to this standard will be monitored via monthly walk throughs of the physical plant by facility risk committee members and maintenance staff. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on the review of client records, the facility failed to document that discharge summaries were completed within one week in two of four client records. The findings include:Seven client records were reviewed on October 17, 2012. Four client records were reviewed as discharged clients and required documentation of a discharge summary. Discharge summaries are to be completed within one week of discharge. The facility did not document the completion of the discharge summary within one week of discharge in client records # 1 and 3. Client # 1 was discharged on July 18, 2012. The discharge summary was due to be completed by July 25, 2012. The discharge summary was completed on August 1, 2012.Client # 3 was discharged on August 2, 2012. The discharge summary was due to be completed by August 9, 2012. The discharge summary was completed on August 20, 2012. The Facility Director was interviewed on October 17, 2012 and confirmed the findings.
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Plan of Correction
Facility Director will conduct an in-service with the counselors by 11/16/2012 to review discharge summary completion expectations, to include that they be completed within one week of discharge. Compliance will be measured via closed chart monitors monthly by facility director. |
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 the review of client records, the facility failed to document follow-up information in two of four client records. The findings include:Seven client records were reviewed on October 17, 2012. Four client records were reviewed as discharged clients and required documentation of follow-up information. Per agency policy, follow-up is to be completed within 7 days of discharge. The facility did not document the completion of follow-up information within 7 days of discharge in client records # 3 and 4.Client # 3 was discharged on August 2, 2012. The follow-up information was to be completed by August 9, 2012. There was no documentation of follow-up information. Client # 4 was discharged on August 2, 2012. The follow-up information was to be completed by August 9, 2012. There was no documentation of follow-up information.The Facility Director was interviewed on October 17, 2012 and confirmed the findings.
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Plan of Correction
Facility director will meet with administrative assistant by 11/16/2012 in order to review timeline expectations of follow-up on every dishcarged client within 7 days of discharge. Compliance will be measured by facility director via monthly closed chart monitors. |