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.
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.
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 16, 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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704.11(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 forty-six personnel records, the facility failed to provide a written individual training plan for employee # 18 for the 2019 training year.
Employee # 18 was hired as a counselor on May 8, 2000 and was still in this position at the time of the inspection. The last individual training plan provided was October 10, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will correct the deficiency by developing an individual training plan within 10 days of employee # 18 returning from furlough. An individual training plan will be completed no later than December 1, 2020.
All Supervisors will be re-trained with regard to developing individual training plans within the required time frame. Said training will be completed by November 1, 2020. Attendance will be verified by signature.
Supervisors will review regulatory deadlines bi-annual to verify on-going compliance.
Supervisory Training will be completed no later than November 1, 2020. Agenda and signature of attendance will serve as proof of compliance.
In addition, an electronic tracking system will be developed and implemented to track the training requirements as well as individual training plans within specified time frames. All supervisors will be trained with regard to utilizing this tracking system. Said training will be completed by November 1, 2020. Attendance will be verified by signature.
The Clinical Director will complete bi-annual audits of all clinical personnel files to ensure compliance.
HR will complete audits to ensure compliance of non-clinical personnel as well.
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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 forty-six personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that nineteen employees 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 # 7 was hired at the facility on April 7, 2014 and was due to have the communicable disease trainings no later than April 7, 2016. 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.
Employee # 28 was hired at the facility on January 11, 2016 and was due to have the communicable disease trainings no later than January 11, 2018. 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.
Employee # 30 was hired at the facility on February 19, 2018 and was due to have the communicable disease trainings no later than February 19, 2020. 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.
Employee # 31 was hired at the facility on March 4, 2018 and was due to have the communicable disease trainings no later than March 4, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee # 32 was hired at the facility on June 18, 2018 and was due to have the communicable disease trainings no later than June 18, 2020. 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.
Employee # 33 was hired at the facility on October 13, 2014 and was due to have the communicable disease trainings no later than October 13, 2016. 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.
Employee # 34 was hired at the facility on October 18, 2016 and was due to have the communicable disease trainings no later than October 18, 2018. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee # 35 was hired at the facility on June 11, 2018 and was due to have the communicable disease trainings no later than June 11, 2020. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee # 36 was hired at the facility on June 4, 2018 and was due to have the communicable disease trainings no later than June 4, 2020. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee # 37 was hired at the facility on April 3, 2017 and was due to have the communicable disease trainings no later than April 3, 2019. 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.
Employee # 38 was hired at the facility on January 8, 2018 and was due to have the communicable disease trainings no later than January 8, 2020. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee # 39 was hired at the facility on May 2, 2016 and was due to have the communicable disease trainings no later than May 2, 2018. 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.
Employee # 40 was hired at the facility on December 28, 2017 and was due to have the communicable disease trainings no later than December 28, 2019. 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.
Employee # 41 was hired at the facility on July 17, 2017 and was due to have the communicable disease trainings no later than July 17, 2019. 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.
Employee # 42 was hired at the facility on April 10, 2017 and was due to have the communicable disease trainings no later than April 10, 2019. 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.
Employee # 43 was hired at the facility on May 1, 2018 and was due to have the communicable disease trainings no later than May 1, 2020. 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.
Employee # 44 was hired at the facility on April 24, 2012 and was due to have the communicable disease trainings no later than April 24, 2014. 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.
Employee # 45 was hired at the facility on November 27, 2017 and was due to have the communicable disease trainings no later than November 27, 2019. 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.
Employee # 46 was hired at the facility on June 17, 2013 and was due to have the communicable disease trainings no later than June 17, 2015. 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 reviewed with facility staff during the licensing process.
This is a repeat citation from the August 16, 2019 licensing inspection.
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Plan of Correction
The facility will correct the deficiency by scheduling Employee #7, # 28, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46 to attend HIV/AIDS, TB/STD and other health related topics training no later than December 1, 2020
Attendance will be verified by completion certificates and signature of attendance.
All Supervisors will be re-trained with regard to required time-frames of training. Supervisors will be required to review training plans during monthly supervisory sessions. Progress will be reviewed and supports will be provided to ensure compliance with standard regulatory trainings.
Said training will be completed by November 1, 2020. Attendance will be verified by signature.
Supervisory documentation will be revised to include the regulatory trainings required and the time frames specified. Supervisor documentation will be revised and implemented no later than September 1, 2020.
Review of training plans during monthly supervisory sessions will begin no later than September 1, 2020.
In addition, an electronic tracking system will be developed and implemented so as to track the training completed and required. All supervisors will be trained with regard to utilizing this tracking system. Said training will be completed by November 1, 2020. Attendance will be verified by signature of attendee.
Supervisory Training with regard to training plan review regulatory trainings, time-frames and the electronic tracking system will be completed no later than November 1, 2020. Agenda and signature of attendance will serve as proof of compliance.
HR will complete audits to ensure compliance of non-clinical personnel as well.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on the review of forty-six personnel records, the facility failed to provide documentation of 25 clock hours of training annually for employee # 18 who is employed as a counselor.
Employee # 18 was hired on May 8, 2000 and was still in this position at the time of the inspection. There were only 5 hours of training documented in the employee record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will correct the deficiency by training employee # 18 with regard to the training requirement for counselors, upon returning from furlough. Training of employee #18 will be completed no later than December 1, 2020. Proof of attendance will be verified by signature.
All Supervisors and Counselors will be re-trained with regard to required regulatory training topics and said time-frames of training required of a Counselor.
Training will be completed no later than November 1, 2020. Agenda and signature of attendance will serve as proof of compliance.
In addition, an electronic tracking system will be developed and implemented so as to track the training completed and required regulatory training and time-frames.
All supervisors will be trained with regard to utilizing this tracking system. Said training will be completed by November 1, 2020. Attendance will be verified by signature.
Clinical Supervisors and the Manager of Clinical Services will conduct quarterly audits to ensure compliance.
HR will complete audits to ensure compliance of non-clinical personnel as well.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of forty-six personnel records, the facility failed to provide documentation of an annual written individual staff performance evaluation that was reviewed and signed for employee for employee # 7 and # 17.
Employee # 7 was hired in their original position on April 7, 2014 and promoted to current position on October 1, 2019. There was no documentation of an annual performance evaluation for the year 2019.
Employee # 17 was hired as a counselor on November 5, 2018 and was still in this position at the time of the inspection. A 2019 annual evaluation review was not signed by the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will correct the deficiency by having Employee #7 and #17 Employee review and sign an 2019 Annual evaluation no later than September 30, 2020.
All supervisors will be re-trained with regard to completing Annual Evaluations and having employees sign said Annual Evaluation within the required time-frame.
Training will be completed no later than September 30, 2020. Verification of attendance will be provided by signature of attendee.
HR will complete audits to ensure compliance of non-clinical personnel as well.
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