INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
Part 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
Part 2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on July 14, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) 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.
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Observations
Based on a review of ten clinical personnel records on July 14, 2020, the facility failed to ensure that one person met the requirements for the counselor position.
Staff # 9 was hired on March 8, 2018 as a counselor assistant and was promoted to counselor on December 30, 2019. Staff #9 did not have a qualifying degree to be a Counselor at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #9 will revert back to counselor assistant position effective immediately. The Executive director will review regulations and train clinical supervisor on qualifications of staff according to the regulations by 7/17/2020. In addition, executive director will contact DDAP to review candidates to ensure they meet the qualifications of the position before hiring if there is any question. |
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 63 clinical and support staff on July 14, 2020, the facility failed to provide documentation that employee's # 49 and #51 received the minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee # 49 was hired as a Behavioral Tech Supervisor on January 1, 2018 and was due to have the HIV/AIDS training no later January 1, 2020. There was no documentation of the completion of the HIV/AIDS training as of the date of the inspection.
Employee # 51 was hired as a Case Coordinator on May 29, 2018 and was due to have the communicable disease training no later May 29, 2020. There was no documentation of the completion of the communicable disease training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from licensing inspections on August 29, 2018 and August 8, 2019.
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Plan of Correction
Staff will receive the proper training required for their job function by 11/1/2020. Clinical supervisor and BHT manager will monitor all staff training via a log to ensure that all staff receive the required trainings in the proper time frame for their job function. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of nine fire drills, the facility failed to document problems encountered during the fire drill on the fire drill record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director will update the fire drill record form to include the required section of "problems encountered on the fire drill" by 8/1/2020. Executive director will monitor the monthly drills to ensure that the record is being completed in its entirety. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of nine fire drill logs on July 14, 2020, the facility failed to set off a fire alarm or smoke detector during each fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director will update the fire drill record to ensure that the record includes a section for "was the fire alarm or smoke detector set off during the drill" by 8/1/2020. Executive director will monitor the monthly logs to ensure it is being completed in its entirety. |