INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 8-9, 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 to be not 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(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 facility's Staffing Requirements Facility Summary Report, staff records and a conversation with facility staff, the facility failed to ensure that an individual training plan was developed for employees #6 and 9-22.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Administrative Assistant for the facility will work with the regional Human Resources Department to monitor the completion of training plans for all staff members in accordance with state regulations. Program Manager will ensure that department supervisors are monitoring staff compliance with training plan guidelines through monthly documented supervision. Human Resource Coordinators will complete monthly review of employee files to ensure compliance with training plans and completion for all employees. Target date for completion is February 15, 2017.
Employee #6 and #9-#22 will have updated training plans in their HR files by target date of February 15, 2017 |
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 facility's Staffing Requirements Facility Summary Report, staff records and a conversation with facility staff, the facility failed to ensure that staff #7, #9 and #10 received the required trainings.
Employee #7 was hired as a Counselor on 8/3/2015. The HIV/AIDS and TB/STD trainings were due to be completed by 8/3/2016 but were not documented as completed as of the date of the inspection.
Employee #9 was hired as a Behavioral Health Tech on 10/6/2014. The HIV/AIDS trainings were due to be completed by 10/6/2016 but were not documented as completed as of the date of the inspection.
Employee #10 was hired as a maintenance manager on 7/5/2013. The TB/STD training was due to be completed by 7/5/2015 but was not documented as completed as of the date of the inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Administrative Assistance for the facility will work with the Regional Human Resources Department to monitor the completion of HIV/AIDS and TB/STD trainings for all employees in accordance with state regulations. Program Manager will ensure that Department Supervisors are appropriately monitoring staff for compliance with training guidelines through monthly documented supervision.The Human Resources Coordinators will complete monthly reviews of employee files to ensure compliance with training standards. Target date for completion is February 1, 2017.
Employee #7 who did not meet the training requirements of obtaining TB/STD training attended and obtained their certificate on 12/13/2016. They have been scheduled to attend the next HIV/AIDS training on 4/21/17.
Employee #9 has been scheduled to attend the next HIV/AIDS training on 4/21/17.
Employee #10 who did not meet the training requirement of obtaining their TB/STD training has attended and obtained their certificate on 12/13/16. |
704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of the Staffing Requirement Facility Summary Report (SRFSR), submitted on 12/8/2016, the facility failed to ensure that the staff-to-client ratio remained at or below one primary care staff person for every seven clients.
On Monday 10/10/2016 from 9 p.m. to 11 p.m. there were two primary care staff on the detox unit schedule with the client census reported at 15.
Additionally, on Thursday 10/13/2016 from 12 a.m. to 7 a.m. there were two primary care staff on the detox unit schedule with the client census reported at 17.
The information was reviewed with facility staff.
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Plan of Correction
After further review of the posted nursing schedule by both the Program Manager and Nursing Manager, the schedule created for submission was not accurate. Verification through the electronic time card system showed that on both 10/10/2016 and 10/13/2016 had three nurses on schedule ensuring proper ratio per the regulation standards. Moving forward Nurse Manager will ensure posted schedule is updated daily and will include herself on the schedule to accurately reflect number of nursing staff to client ratio. Target date for completion is February 1, 2017. |
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
Based on a review of client records and a conversation with facility staff that was conducted on December 8 -9, 2016, the facility failed to obtain a valid, informed and voluntary consent form from the client in client records # 1, 2, 3, 4, 6, 7, 8, 9 and 10.
Client #1 was admitted on 8/24/16 and was an active client at the time of the licensing inspection. A consent to release form dated 8/23/16 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."
Client #2 was admitted on 11/7/16 and was an active client at the time of the licensing inspection. Three consent to release forms dated 11/3/16, 11/8/16 and 11/11/16 to criminal justice agencies 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."
Client #3 was admitted on 11/14/16 and was an active client at the time of the licensing inspection. Two consent to release forms dated 11/4/16 and 11/15/16 to treatment providers did not contain a provision for the consents to be revoked.
Client #4 was admitted on 11/17/16 and was an active client at the time of the licensing inspection. A consent to release form dated 11/17/16 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."
Client #6 was admitted on 10/28/16 and was discharged 11/25/16. A consent to release form dated 11/2/16 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."
Client #7 was admitted on 10/3/16 and was discharged 11/17/16. A consent to release form dated 9/28/16 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."
Client #8 was admitted on 9/20/16 and was discharged 11/3/16. A consent to release form dated 9/21/16 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."
Client #9 was admitted on 8/9/16 and was discharged 11/28/16. Two consents to release forms dated 8/9/16 to criminal justice agencies did not allow for the consents 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."
Client #10 was admitted on 8/31/16 and was discharged 11/19/16. A consent to release form dated 9/1/16 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."
These findings were discussed 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 acknowledgment that a copy was offered to the client as well as the ability to revoke consents verbally or in writing. Criminal Justice consent was revised to eliminate statement that consent cannot be revoked. All staff members who deal directly with consents will receive additional training on revisions and completion of consents. Training will be conducted by VP of Clinical Services and concluded by February 2017. Completion of training will be verified by post test completion and compliance monitored by Clinical Supervisor for 100% completion of new forms.
Statement regarding the inability to revoke criminal justice consents for court mandated clients had been removed from consent forms in ECR system.
Staff reviewed revision to consent forms and client's right to revoke in staff meeting held on 12/5/16.
Charts #11 -#20 are no longer enrolled in treatment services. A caseload review of all currently admitted clients by each counselor has been initiated on 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 addition 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.
An all staff training is under development for our mylearningpoint training system to launch in 2017 training year to reinforce for current and new hires. |