INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 4, 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 Lehigh Valley 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 on August 4, 2021, the facility failed to ensure that counselors and counselor assistants received 6 hours of HIV/AIDS and at least 4 hours of TB/STD training within one year of hire. Furthermore, they failed to ensure that all other staff completed the training within the first two years of employment.
Staff #5 was hired as a counselor on February 24, 2020 and did not have the HIV/AIDS training documented in their staff training record.
Staff #8 was hired as a counselor assistant on October 16, 2017 and did not have the TB/STD training documented in their staff training record.
Staff #9 was hired as a counselor assistant on May 20, 2019 and did not have the HIV/AIDS or TB/STD training documented in their staff training record.
Staff #10 was hired as an administrative assistant on March 24, 2018 and did not have the HIV/AIDS training documented in their staff training record.
Staff #11 was hired as a BHT on November 4, 2017 and did not have the HIV/AIDS or TB/STD training documented in their staff training record.
Staff #12 was hired as a Med Administration Tech on November 8, 2017 and did not have the HIV/AIDS training documented in their staff training record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Goal is to have all staff complete HIV/AIDS and TB/STD within three months. Clinical supervisor and Behavioral Tech Manager will over see staff to ensure that it is completed. Executive Director will oversee Administrative staff.
Staff #10: Administrative assistant (1344717) will complete HIV/AID training in January 2022.
Staff#11: Manager will complete supervision with staff and have completed in three months.
Staff #12: DON will work with Medical Assistant to complete training within 3 months.
TO ensure all supervisors are monitoring trainings for staff, they will be required to give a list of outstanding staff and their trainings every three months.
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704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records on August 4, 2021, the facility failed to ensure that two out of two counselor assistants completed 30 clock hours of training.
Staff #8 was hired as a counselor assistant on October 16, 2017. Staff #8 had 17 hours of training documented.
Staff #9 was hired as a counselor assistant on May 20, 2019. Staff #9 had 21.25 hours of training documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will monitor CA hours every 3 months but providing an update on required hours for each year. The executive director will over see Manager.
Clinical supervisor will provide a check list of first year trainings for Counselor Assistants and a check list for Counselors for their mandatory training hours. During supervision Clinical supervisor will review trainings scheduled or taken every three months. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records on August 4, 2021, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven client records reviewed.
Client #1 was admitted on June 11, 2021 and was still active at the time of the inspection. A treatment plan update was completed on June 28, 2021 and the next update was due no later than July 28, 2021; however, there was not one documented in the client record.
Client #3 was admitted on June 11, 2021 and was still active at the time of the inspection. A treatment plan update was completed on July 1, 2021 and the next update was due no later than August 1, 2021; however, was not one documented in the client record.
Client #4 was admitted on June 15, 2021 and was active at the time of the inspection. A treatment plan was completed June 28, 2021 and the next update was due no later than July 28, 2021; however, the next update not completed until August 2, 2021.
Client #5 was admitted on January 21, 2020 and was discharged on April 6, 2020. Client #5 had a treatment plan completed February 10, 2020 with the next update due no later than March 10, 2020: however, was not completed until March 11, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will monitory charts weekly and send emails to clinical staff with due dates of treatment plans.
Clinical supervisor will review during group supervision and individual supervision the importance of updating treatment plans and the timeframes within LOC.
Clinical team will participate in treatment plan trainings that are held through DDAP or lunch and learn series. |
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 a review of seven client records on August 4, 2021, the facility failed to document follow-up information in two out of three applicable client records.
Client #6 was admitted on December 31, 2019 and was discharged on March 10, 2020. There was no documentation of follow-up being completed.
Client #7 was admitted on July 31, 2020 and was discharged on October 1, 2020. There was no documentation of follow-up being completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Follow up calls are completed 7 days after D/C
Follow up calls were documented in a Call Log by staff member.
Follow up calls are tracked through a Smartsheet that identify: clients name, date call was made on, was call completed, call log was completed and comment section.
Facilitate training with staff with proper documentation for follow up calls. |