INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 30-31, 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, 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 during this inspection:
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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
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that staff 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.Staff #11 was hired as an Administrative Assistant on November 2, 2020, and was due to have the communicable disease trainings no later than November 2, 2022. There was no documentation in the personnel file of the completion of the HIV/AIDS and the TB/STD training as of the date of the inspection.Staff #12 was hired as a Behavioral Health Lead Tech on May 16, 2022, and was due to have the communicable disease trainings no later than May 16, 2024. 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. Staff #13 was hired as a Medical Assistant on March 17, 2021, and was due to have the communicable disease trainings no later than March 17, 2023. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.Staff #14 was hired as a Behavioral Health Tech on May 3, 2021, and was due to have the communicable disease trainings no later than May 3, 2023. 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.Staff #15 was hired as a Behavioral Health Tech on April 5, 2016, and was due to have the communicable disease trainings no later than April 5, 2018. There was no documentation in the personnel file of the completion of TB/STD training as of the date of the inspection. Staff #16 was hired as a Housekeeper on May 23, 2022, and was due to have the communicable disease trainings no later than May 23, 2024. 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. Staff #17 was hired the Maintenance Manager on January 25, 2013, and was due to have the communicable disease trainings no later than January 25, 2015. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection. Staff #18 was hired in Medical Records on June 26, 2017, and was due to have the communicable disease trainings no later than June 26, 2019. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.Staff #19 was hired as a Maintenance Tech on August 22, 2017, and was due to have the communicable disease trainings no later than August 22, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.This is a repeat citation from the July 19, 2023 licensing inspection. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Leadership will meet 8/28/2024 to discuss the importance of enrolling new staff in required trainings. Moving forward all new employees will be registered on the DDAP training site within the first two weeks of employment for both the 6 hour HIV/AIDS training and the 4 hour TB/STD training. Trainings will be assigned based on availability. Anyone currently not in compliance will be assigned the next available training. All current staff will be enrolled in future training by 10/1/2024. Compliance will be reviewed monthly during a weekly leadership meeting. Each member of leadership will be responsible for reviewing and reporting on their team's training enrollment/completion at that time. |
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 detox and residential client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in three of five applicable client records reviewed.The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in DDAP Licensing Alert 02-21.Client # 7 was admitted to the inpatient non-hospital detoxification activity on April 10, 2024, and was discharged against medical advice on April 10, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.Client #12 was admitted to the inpatient non-hospital rehabilitation activity on October 2, 2023, and was discharged against medical advice on October 7, 2023. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.Client #14 was admitted to the inpatient non-hospital rehabilitation activity on November 9, 2023, and was discharged against medical advice on November 10, 2023. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In response to emergency contact notification for non-routine discharges the clinical department will be trained on 8/28/2024 regarding the importance of notifying emergency contacts. The department will be held to the expectation that the emergency contact will be notified and placed as a memo in the chart prior to completing the bed management request for which discharges the electronic medical record. For non-routine discharges that occur Monday through Friday 4:00 PM to 8:00 AM and weekends the emergency contact will be notified by the nurse completing the medical discharge summary and will be noted in their nursing discharge note. The nursing department will be educated on this process during their next monthly meeting on 8/28/2024. This process for nursing will go live on 9/2/2024. Completion of calls will be monitored through monthly KPI chart reviews and weekly clinical chart audits completed by Clinical Supervisor and Clinical Director. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on a review of detox client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of four applicable discharged records reviewed. The facility ' s policy is to follow-up with discharged clients within seven days of discharge. Client #6 was admitted on June 23, 2024, and was discharged on June 24, 2024. A follow-up contact was to be completed no later than July 1, 2024; however there was no documented follow-up contact in the client record. Client #7 was admitted on April 10, 2024, and was discharged on April 10, 2024. A follow-up contact was to be completed no later than April 17, 2024; however, it was not documented until April 26, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Office Manager and their staff will receive a re-training on 8/28/2024 regarding the necessity of placing a 7 day follow up phone call for all discharges regardless of discharge status. Documentation of the 7 day follow up phone call will be placed in a memo to chart. The Office Manager will monitor the completion of the calls by utilizing the electronic bed board to ensure that all discharged clients from 7 days prior have a follow up phone call documented in the chart. This will occur daily and documented in a smartsheet created for tracking purposes. Monthly KPI chart reviews will also verify 7 day follow up calls are being completed. |