INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 14-15, 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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704.11(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 and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that staff 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.
Staff #12 was hired as a Counselor Assistant on June 26, 2023, and was promoted to a Counselor position on June 23, 2024. This staff was due to have the communicable disease trainings no later than June 26, 2024. There was no documentation in the personnel file of the completion of the TB/STD training. Additionally, this staff completed the HIV/AIDS training on July 12, 2024.
Staff #23 was hired as a Behavioral Health Tech on August 11, 2019, and was due to have the communicable disease trainings no later than August 11, 2021. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Staff #24 was hired as a Behavioral Health Tech on October 22, 2018, and was due to have the communicable disease trainings no later than October 22, 2020. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Staff #25 was hired as a Behavioral Health Tech 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.
Staff #26 was hired as a Medical Assistant on July 18, 2022, and was due to have the communicable disease trainings no later than July 18, 2024. There was no documentation in the personnel file of the completion of the HIV/AIDS and the TB/STD training as of the date of the inspection.
Staff #27 was hired as a Behavioral Health Tech Supervisor on May 30, 2022, and was due to have the communicable disease trainings no later than May 30, 2024. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Staff #28 was hired as a Case Coordination on December 27, 2021, and was due to have the communicable disease trainings no later than December 27, 2023. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Staff #29 was hired as a Medical Assistant on August 12, 2022, and was due to have the communicable disease trainings no later than August 12, 2024. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Staff #30 was hired as a Housekeeper on August 19, 2020, and was due to have the communicable disease trainings no later than August 19, 2022. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection. Additionally, the HIV/AIDS training was not completed until November 30, 2023.
Staff #31 was hired as a Housekeeper on April 5, 2022, and was due to have the communicable disease trainings no later than April 5, 2024. There was no documentation in the personnel file of the completion of the HIV/AIDS and the TB/STD training as of the date of the inspection.
Staff #32 was hired as a Housekeeper on February 1, 2021, and was due to have the communicable disease trainings no later than February 1, 2023. There was no documentation in the personnel file of the completion of the HIV/AIDS and the TB/STD training as of the date of the inspection.
Staff #33 was hired as a Housekeeper on October 11, 2021, and was due to have the communicable disease trainings no later than October 11, 2023. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection. Additionally, the HIV/AID training was not completed until July 15, 2024.
This is a repeat citation from the July 26, 2023 licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
A new leadership facilitated Smartsheet was developed to track training of all new hires to ensure this is completed within the designated time-frames. The Smartsheet will track employee name, date of hire, hiring manager and dates of annual individual training plans. Additionally, the Smartsheet will house the dates of completion, provider, and number of hours completed for TB/STD training, HIV/Aids training, and CPR certification.
On 9/12/24, a meeting with facility leadership will occur to review manager expectations for this tracking sheet as well ensure that the Relias training system provides the employee with a compliant target date of completion. The Smartsheet will be reviewed by leadership during the first leadership meeting of each month to ensure tracking is completed consistently.
Additionally, the facility is seeking training opportunities for facility staff to be approved trainers as it was identified that external training opportunities for Communicable Diseases were limited based on the geographical locations that were reasonably accessible to facility staff.
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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 the July 28, 2023, through June 21, 2024, fire drill logs the facility failed to set off the fire alarm or smoke detector during each fire drill.
The facility reported on each of the twelve fire drills completed that a hand held drill button was executed in lieu of sounding the alarm or smoke detector.
The facility does not currently have an exemption waiver in place for this regulatory requirement.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Exception request will be submitted by 9/15/24, to request approval from DDAP for the use of the non-sprinkler alarm system in the East buildings and Gym when completing fire drills. Facility will follow all guidance or requests made by DDAP upon their review of the facility's exception request. |
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 residential client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of four applicable discharged records reviewed. The facility's policy is to follow-up with discharged clients within seven days of discharge.
Client #11 was admitted on June 28, 2024, and was discharged on July 1, 2024. A follow-up contact was to be completed no later than July 8, 2024; however, it was not completed until July 9, 2024.
Client #12 was admitted on May 7, 2024, and was discharged on May 24, 2024. A follow-up contact was to be completed no later than May 31, 2024; however, it was not completed until June 21, 2024.
This is a repeat citation from the July 26, 2023 licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Lead Case Manager has been identified as primary individual to audit and track all follow up calls. Upon review of specific charts identified in this citation, it was identified that individualized training was needed for a specific case manager. Additional measures of accountability for this individual were developed and weekly supervisions are being provided to ensure effectiveness of this performance improvement plan. Broader measures will also be taken through monthly KPI chart audits which will be completed by the compliance team. This will provide an additional layer of monitoring and tracking of follow up calls. This will be reviewed monthly with the compliance and clinical team as well as facility leadership. |