INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 31, 2021 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. 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(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of thirteen personnel records, the facility failed to ensure one clinical supervisor meet the educational and clinical requirements for the position.
Employee #3 was hired as a clinical supervisor on June 28, 2021 and was still current in that position at the time of the inspection had a bachelor ' s degree in psychology and no clinical experience.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On September 2, 2021, a meeting was held with Executive Director and higher leadership to discuss current Clinical Supervisors credentials. Current Clinical Supervisor will be promoted to Assistant Executive Director effective Nov 1, 2021. Moving forward, all applicants for Clinical Supervisor will be reviewed with Pyramid's Regional Quality Management Team to ensure said applicant meets DDAP and Pyramid regulations for Clinical Supervisor. Executive Director will have oversight of the promotion to Assistant Director and the hiring of a Clinical Supervisor who will meet DDAP Clinical Supervisor requirements. Executive Director will send potential Clinical Supervisor Candidate's resumes to the Quality Management Team to ensure qualifications are met. Target date 9/2/21. Target date for promotion of current Clinical Supervisor to Assistant Director is 11/1/21. |
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 fourteen personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee 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.
Employee #11 was hired as a counselor on August 10, 2020 and was due to have the communicable disease trainings no later than August 20, 2021. 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.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Employee number 11 will schedule and take the required TB/STD training and HIV/AIDs training within the next 3 months. Clinical Supervisor to have oversight that said trainings are scheduled and completed by Dec 31, 2021. Executive Director to have oversight that this is completed by target date of 12/31/21. Moving forward, Clinical Supervisor will track trainings via smartsheet to ensure all clinicians take their required trainings within the required timeframe of one year. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection the facility failed to ensure that counseling session could not be seen or heard from outside of the counseling room.
The downstairs living room/group room has a window in the one door and no door on the other side of the room allowing the counseling session to be both seen and heard from outside of the room.
The ping pong room which is used for a group room does not have a door which allows for the counseling session to be both seen and heard from outside of the room.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
A door will be installed, without a window, on the ping pong room by October 15, 2021. The downstairs living room/group room is no longer being utilized for group space. Additional areas, with a private door, have been converted into group rooms so the utilization of the downstairs living room/group room is no longer needed. This was effective September 1, 2021. Maintenance Supervisor, NR, to have oversight that door to ping pong room is installed by target date of 10/15/21. Executive Director to have full oversight that plan is completed by target date of 10/15/21. |