INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and complaint investigation conducted on August 25, 2022, 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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704.8(c) LICENSURE Full Caseload Assignment
704.8. Qualifications for the position of counselor assistant.
(c) In addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level.
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Observations
Based on the review of one applicable counselor assistants ' personnel records, the facility failed to document a supervisor's positive assessment of the counselor assistant's individual skill level prior to the assignment of a full caseload.
Employee #14 was hired with a master ' s degree as a counselor assistant on April 25, 2022 and was still current in that position. Documented individual supervision notes dated June 6, 2022, June 13, 2022, June 20, 2022, and June 27, 2022 indicated employ #14 was carrying a full caseload. There was no documentation of a supervisor's positive assessment of the counselor assistant's individual skill level prior to June 6, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director facilitated a re-training on 9/7/2022. The positive assessment was reviewed during this training. It was made clear to the clinical supervisors that the positive assessment must be completed prior to a counselor assistant before carrying a caseload. A caseload may be carried during close supervision, just not a full caseload. Additionally, it was reviewed that counselor assistant's may not carry more than 7 clients on a caseload. Monthly supervision notes are uploaded to a Smart Sheet where the Clinical Director and Regional Quality Manager will review positive assessments to ensure completion on a monthly basis. Daily caseload assignments will be managed by Clinical Supervisors to ensure that no more than 7 clients are assigned to a counselor assistant. |
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 four counselor assistants, the facility failed to ensure they only counsel clients under the required level of supervision appropriate to their education.
Employee #5 was hired with a bachelor ' s degree on May 5, 2021 as a counselor assistant and promoted to a counselor on July 19, 2022. Employee #5 was required to have six months of close supervision with a bachelor ' s degree. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Employee #5 received weekly supervision, however there was only documentation of a total of one hour of direct observation and five formal case reviews from July 21, 2022 - February 18, 2022.
Employee #14 was hired with a master ' s degree as a counselor assistant on April 25, 2022 and was still current in that position. Employee #14 was required to have three months of close supervision with a master ' s degree. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Employee #14 received weekly supervision, however there was no documentation of direct observation or formal case reviews from April 25, 2022 - July 11, 2022.
Employee #15 was hired with a GED as a counselor assistant on March 28, 2022 and was still current in that position. Employee #15 was required to have three months of direct observation and nine months of close supervision with a GED. Direct observation is defined by regulation as follows: " In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities " . Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Employee #15 only had three documented individual counseling sessions from March 14 to present. The individual supervision notes provided by the facility for July 15, 2022, July 21, 2022, and July 28, 2022, did not have documentation of any direct observation or formal case reviews.
Employee #16 was hired with a high school diploma on March 14, 2022 and was still current in that position. Employee #16 was required to have three months of direct observation and nine months of close supervision with a high school diploma. Direct observation is defined by regulation as follows: " In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities " . Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Employee #16 only had six documented individual counseling sessions. The individual supervision notes provided by the facility for April 26, 2022, May 6, 2022, May 11, 2022, May 20, 2022, June 2, 2022, and June 14, 2022 did not have documentation of any direct observation or formal case reviews.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director facilitated a re-training on 9/7/2022. Counselor assistant supervision was reviewed during this training. Counselor assistants must receive two full hours of clinical supervision per week. One must be individual supervision with the clinical supervisor during which time a specific client will be discussed and/or clinical documentation. The note must contain the client's name. The second hour of supervision must be direct observation of the counselor assistant facilitating either group therapy for an individual session. The presence of the clinical supervisor must be noted in the DAP notes. All supervision notes are uploaded to a Smart Sheet that both the Clinical Director and Regional Quality Manager review on a monthly basis to ensure compliance. |
705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection on August 25, 2022, the facility failed to have at least one living room or lounge for the free and informal use of clients, their families and invited guests.
The area designated as the lounge area in women ' s unit in building D, did not contain any furniture.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Furniture was placed in the lounge on Building D on 8/1/ 2022. Monitoring of furniture presence and condition in client lounges will be part of the monthly facility inspection completed by the Facility Manager. The monthly facility inspections are logged into a Smart Sheet which allows the Facility Manager to identify any needed repairs and/or replacements. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on August 25, 2022, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom.
The bathrooms in the women ' s unit in building D did not have individual paper towels or a mechanical dryer.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Bi-fold paper towel dispensers will be purchased by 9/30/2022 and installed in Building D. Housekeeping will fill the paper towel dispensers during daily unit cleanings. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection on August 25, 2022, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The bathroom in the training room on the second floor had a large hole in the wall.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The hole in the wall in the bathroom in the training room was repaired as of 9/12/2022. Maintenance tickets will be submitted for any physical facility damages. These tickets are received by the maintenance department. Repairs for any identified damages will begin within 7 days of ticket submission. |
705.7 (b) (4) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
Based on a physical plant inspection on August 25, 2022, the facility failed to ensure that storage areas for foods are free of food particles, dust and dirt.
There were loose pieces of sausage on the floor of the freezer.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Dietary Manager facilitated a re-training with all dietary staff over the course of September 12, 2022 to September 24, 2022. During this time it was reviewed that all areas of the kitchen, including storage areas, are to be checked for fallen food, dirt, and dust. Daily audits of the kitchen will be conducted at the beginning, middle, and end of each shift. These audits are to be completed by the Kitchen Manager and Kitchen Supervisor. In their absence these audits will be completed by Lead Cook and delegated to other dietary workers if needed. Audits will be recorded on a designated checklist and reviewed/maintained by Kitchen Manager. |
705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection on August 25, 2022, the facility failed to store all food items off the floor.
There was a box of food underneath the storage shelf on the floor in the walk-in cooler.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Dietary Manager facilitated a re-training with all dietary staff over the course of September 12, 2022 to September 24, 2022. During this time proper storage of food was reviewed. All food is to be stored at least 6 inches off of the floor and maintained at the appropriate temperature. Daily audits of the kitchen will be conducted at the beginning, middle, and end of each shift. These audits are to be completed by the Kitchen Manager and Kitchen Supervisor. In their absence these audits will be completed by Lead Cook and delegated to other dietary workers if needed. Audits will be recorded on a designated checklist and reviewed/maintained by Kitchen Manager. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from July 2021 to June 2022, the facility failed to conduct unannounced fire drills at least once a month in several buildings.
The fire drill logs for July 2021 and April 2022 were checked off as announced for Main Building.
The fire drill logs for July 2021 was marked as announced for the Gym, and the January 2022 fire drill was missing documentation that any drill occurred.
The fire drill log for East 2 for July 2021 was checked off as announced.
The fire drill log for East 1 for July 2021 and April 2022 were checked off as announced.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Manager conducted a re-training with the maintenance department on 9/16/2022. During this time it was reviewed that all fire drills must be unannounced and indicated as so on the fire drill log. In addition, it was reviewed that if a fire drill is indicated as announced it is not sufficient as a monthly fire drill. Facility Manager will review fire drill logs monthly to ensure appropriate documentation and completion of drills. |
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 fire drill logs from July 2021 to June 2022, the facility failed to maintain a written fire drill record including the number of persons in the facility at the time of the drill.
The fire drill logs for the gym from February 2022 - June 2022 did not include the number of persons in the facility at the time of the drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Manager conducted a re-training with the maintenance department on 9/16/2022. During this time it was reviewed that fire drills in the gym must indicate how many persons were present during the drill to be considered a valid fire drill and evacuation. Facility Manager will review gym fire drill logs monthly to ensure appropriate documentation and completion of drills. |
709.28 (c) (5) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the dated signature of witness in one record reviewed.
Client number #1 was admitted on July 13, 2022 and was still current at the time of the inspection. An informed and voluntary consent signed by the client on July 6, 2022, for the disclosure of information to a PCP did not include the dated signature of a witness.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Client Support facilitated a re-training on September 19, 2022 with the admission tech staff, case management, and assessment counselors. During this training all required parts of a consent were reviewed including; client's full name, agency's full name including address and phone number, relationship to the client, extent of information for disclosure, purpose of disclosure, begin and end date, whether a copy was accepted or rejected by client, and signatures by both staff and client. The Regional Quality Manager will continue to review chart audit outcomes for key performance indicators with Duncansville leadership on a monthly basis. This monitoring system includes the review of up to 30 charts, both active and discharged, where all releases of information are reviewed to ensure compliance. |