INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 24, 2015 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 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 clinical supervisor's personnel record, the facility failed to document the completion of a core curriculum in clinical supervision required for the clinical supervisor.
The findings include:
Employee # 3 was promoted to the clinical supervisor position on 8/11/14. The clinical supervisor's personnel record was reviewed during the renewal inspection on September 24, 2015 for the requirement of the completion of a core curriculum in clinical supervision. The facility failed to document the completion of a core curriculum in clinical supervision for Employee # 3.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor who did not complete the core curriculum in clinical supervision, will schedule and complete this training the next time that it is offered by DDAP. The Program Manager has been in communication with the DDAP Training Administrator, who has indicated that this training will be offered in December of 2015. Program Manager will continue to monitor the website on a weekly basis to ensure registration as soon as the service becomes available.
The Human Resource Department and Program Manager will ensure 100% compliance to this standard through review of resumes and years of experience and close monitoring of training guidelines during monthly supervision with Clinical Supervisor. Target Date for completion is December 31, 2015.
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of employee personnel records, the facility failed to document that the clinical supervisor participated in required monthly meetings with their supervisor for the first 6 months of the clinical supervisor's employment in that position.
The findings include:
Employee # 3 was promoted to the position of Clinical Supervisor on 8/11/14. The facility documented that the clinical supervisor participated in monthly meetings with their supervisor on the following dates: 7/7/14, 8/12/14, 9/17/14, 11/14/14, and 12/3/14. The facility failed to document a required monthly meeting for the month of October.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Manager will ensure that Clinical Supervisors receive documented monthly supervision during their first 6 months in that position. The Program Manager will ensure 100% compliance to this standard by reviewing all applicable standards and guidelines pertaining to the supervision of Clinical Supervisors, at their time of hire and maintaining accurate documentation of each supervisory session. Target completion date is October 9, 2015. |
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 the review of personnel records, the facility failed to document that staff persons received a minimum of and at least 4 hours of HIV/AIDS training in two of thirty-two personnel records.
The findings include:
Personnel records were reviewed on September 24, 2015. Thirty-two personnel records were reviewed for the completion of at least 4 hours of HIV/AIDS training. This training was not documented in two of thirty-two personnel records.
For one of thirty-two personnel records, the employee was hired on 8/12/13 and is employed in the maintenance department. The HIV/AIDS training was due to be completed by August 12, 2015. There was no documentation that the employee completed the training.
For one of thirty-two personnel records, the employee was hired on 4/22/13 and is in the Dietary Supervisor position. The HIV/AIDS training was due to be completed by April 22, 2015. There was no documentation that the employee completed the training.
This finding was reviewed with facility staff during the licensing process.
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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 HIV/AIDS trainings for all staff members in accordance with state regulations. Program Manager will ensure that Department Supervisors are appropriately monitoring staff for compliance with training guidelines through bi-weekly individual and monthly supervision. The Human Resources Coordinator will complete quarterly reviews of employee files to ensure 100% compliance to training standards. Target date for completion is November 1, 2015.
Employee #1 who did not meet the training requirements of obtaining six hours of HIV/AIDS training by 8/12/15, has been scheduled to take this training on 10/20/15.
Employee #2 who did not meet the training requirements of obtaining six hours of HIV/AIDS training by 4/22/15, completed this training on 9/25/15 and her HR file has been updated accordingly.
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