INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 6-7, 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. 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide close supervision by a trained counselor or clinical supervisor for the first 6 months of employment.
Employee #9 was promoted on December 10, 2023 to counselor assistant and was still employed at the time of the inspection. She had no documentation of direct supervision.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All counselor assistance will be matched up with a trained counselor or supervisor, who has the ability to observer and complete supervision based on the level needed. This will be completed by 7/5/24. Each mentor will complete a weekly tracking form/smartsheet that observation and supervision has occurred. The Clinical Director once hired will have over sight, until then the Executive Director will continue to monitor. To ensure observation and supervision has occurred it will be reviewed in Clinical meeting on Thursdays weekly meetings. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee in the required time frame, appropriate to that employee's skill level in one out of nine employee records reviewed.
Employee #4 was hired on January 1, 2024 as a counselor and was still in the position as of the date of the inspection. The plan is dated February 19, 2024.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the June 30, 2023 licensing inspection.
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Plan of Correction
Assistant Director will manager a smartsheet of all staff training plans started immediately. Upon hire the new employee will complete the training plan and review with the supervisor of their department. A training calendar will be completed by the new hire and follow up with their supervisor. Training alerts will be reviewed on a monthly basis in leadership meetings starting August 5, 2024. Langhorne leadership will conduct audits to ensure each department is completing their employees' training plans and assigned trainings. The training audits will be completed through Relias and followed up in supervision. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from June, 2023 through May, 2024 the facility failed to conduct a fire drill during sleeping hours at least every 6 months. A fire drill during sleeping hours was completed on November 30, 2023 and was due no later than May, 2024; however, none was completed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director and Facility Manager will set a schedule for the year that will include the regulated fire drills for all shift. This meeting will occur on July 16, 2024. The fire drill completion log will be reviewed monthly in the monthly leadership meeting to ensure they are being completed on the right shift in a timely manner. The staff responsible are Executive Director and Facility Director |
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 inpatient client records, the facility failed to notify the emergency contact of the client leaving the facility against medical advice.
Client #14 was admitted on January 10, 2024 and discharged on January 22, 2024.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All client that AMA or AFA will have their emergency contact called within 12 hours. The Executive Director will meet with the Leadership team and review the expectation of contacting the emergency contact on 07/11/2024. The department leadership will meet with their teams and review the process by 8/7/24,in an all staff meeting to ensure that all staff understand the proper protocol for contacting emergency contacts throughout treatment. Chart audits will be completed by nurse manager and clinical supervisor. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of detox client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client record.
Client #7 was admitted on September 22, 2023 and discharged on September 24, 2023.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 30, 2023 licensing inspection.
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Plan of Correction
Executive Director will review with the Clinical Director and BHT Manager the process of discharge and the importance of notifying a client in writing of the date and type of discharge. This will be completed by August 5, 2024. Staff will understand that this includes an involuntary discharge, therefore a paper document will be available to the BHTs/nursing staff to fill out and give the client upon them leaving the facility, that document will be placed in document library. Otherwise the counselor will complete all required documentation in Care-logic for a planned discharge. Staff responsible is Assistant Director, Leadership. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of inpatient client records, the facility failed to document that physical examination had taken place in three out of seven records reviewed.
Client #8 was admitted on April 26, 2024 and was still active at the time of the inspection.
Client #10 was admitted on May 3, 2024 and was still active at the time of the inspection.
Client #13 was admitted on February 15, 2024 and was discharged on April 10, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 30, 2023 licensing inspection.
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Plan of Correction
Executive Director will meet with the provider and set up weekly supervision to review documentation
on H&P. This meeting will occur on July 19, 2024. We will review the regulations that state the
completion of an H & P must be completed within 72 hours. The completion of the H& is being
monitored by a Performance Improvement using a monthly chart monitoring tool. Oversite of completion of H&P
will be the provider and the Executive Director. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of inpatient client records, the facility failed to document a complete psychosocial evaluation in three out of six applicable records.
Client #8 was admitted on April 26, 2024 and was still active at the time of the inspection.
Client #10 was admitted on May 3, 2024 and was still active at the time of the inspection.
Client #14 was admitted on January 10, 2024 and was discharged on January 22, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All LOCAs will be completed in withdrawal management. Any client admitting to rehab the LOCA will be completed within 24 hours by the intake workers. The intake supervisor will meet with all intake workers weekly to ensure the completion of LOCAs. The intake supervisor will alert executive director on the progress of completion during weekly supervision. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of inpatient client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in three out of six applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 72 hours following admission.
Client #8 was admitted on April 26, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 29, 2024; however, it was not completed until May 10, 2024.
Client #9 was admitted on April 17, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 20, 2024; however, it was not completed until April 26, 2024.
Client #13 was admitted on February 15, 2024 and discharged on April 10, 2024. A comprehensive treatment plan was due no later than February 18, 2024; however, it was not completed until February 22, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director will meet with the clinical team on July 11, 2024 and review the regulations of completing tx plans with in 72 hours with the client actively participating. To ensure the tx is being completed in a timely manner the Clinical Director, once hired will audits charts on a weekly basis and work with new hires on the expectation of clinical documentation. If the clinical Director is un available the executive director will complete this task. On a monthly basis the regional quality managers completes chart audits and reviews with both the CD and the ED on outcomes, which include the tx plan and tx plan updates. Any delinquencies will be address with the counselor in supervision. |
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 inpatient client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed by seven days following discharge.
Client #14 was admitted on January 10, 2024 and discharged on January 22, 2024. A follow up was due no later than January 29, 2024; however, it none was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will document follow up calls in a smartsheet that will be monitored by the assistant director monthly. The facility's administrative assistant will contact all discharging client with in the 7 day period and once completed it will be tracked on the smartsheet. Assistant direct will have oversite to ensure all calls are being completed. On a monthly basis the regional quality manager also complete chart audits that include follow up contacts. |