INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pyramid Ridgeview Behavioral Health Center 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(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of two counselor assistant personnel records, the facility failed to provide a written semi-annual performance evaluation based upon measurable performance standards within the first year of employment in this position. Employee # 7 was hired as a counselor assistant on July 24, 2022 and was still in this position at the time of the inspection. The only performance evaluation provided by the facility was dated June 29, 2023.Employee # 8 was hired as a counselor assistant on July 24, 2022 and was still in this position at the time of the inspection. The only performance evaluation provided by the facility was dated June 27, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 8-1-23, corrections were made to the supervisors of the Counselor Assistants in UKG, allowing for the correct supervisors to be assigned to the counselor assistants in UKG. This change will allow the alert to complete the semiannual performance reviews within the correct time frames moving forward. The current semiannual reviews were completed within a year from hire, but were not completed within 6 months of hire due to incorrect supervisors being assigned to them in UKG. |
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 two applicable employee personnel records reviewed, the facility failed to provide documentation of weekly supervision and to also include one hour of direct observation for a counselor assistant in employee records # 7 and # 8. Employee # 7 was hired as a counselor assistant on July 24, 2022 and was still in this position at the time of the inspection. Supervision notes for the month December 2022, the weeks of January 4 and 25, and February 1, 8, 15, 23 did not include documentation of direct observation occurring at least one hour weekly. Employee # 8 was hired as a counselor assistant on July 24, 2022 and was still in this position at the time of the inspection. Weekly supervision was not documented to have occurred the weeks of October 2-8, 16-22, October 30-November 5, November 20-26, November 27-December 3, December 11-17, December 25-31, 2022, January 1-7, 15-21, 22-28, January 29-february 4, February 5-11, 19-25, February 26-March 4, March 12-18, March 26-April 1, 2023. Also, on the February 14, 2023 supervision note, one hour of direct observation was not documented. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor has gone back to weekly supervision for one of the CA's as opposed to bi weekly as this was reviewed with supervisors on 7-19-23. Supervision notes will adequately reflect the observation piece for both CA's and will be completed by the Clinical Supervisor and Executive Director, who currently supervise the CA's. Executive Director will be reviewing Clinical Supervisor's notes weekly to ensure adequate completion, and Executive Directors notes will be reviewed weekly by Clinical supervisor to ensure compliance. |
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 two applicable employee personnel records reviewed, the facility failed to provide documentation of at least 25 clock hours of annual training required for a counselor for the training year January-December 2022 in employee records # 4 and # 5.Employee # 4 was hired as a counselor on November 10, 2003 and was still in this position at the time of the inspection. After a review of employee # 4's personnel record, there were only 7.5 training hours documented.Employee # 5 was hired as a counselor on May 14, 2004 and was still in this position at the time of the inspection. After a review of employee # 5's personnel record, there were only 9.5 training hours documented. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 8-1-23, Supervisors will review training hours for all staff in each staff's individual monthly supervision. Any staff deficient in trainings will have designated training days each month that will allow them time to get their training hours completed during their work day, or allow supervisors to schedule them to be in trainings during those days. |
705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a physical plant inspection, the facility failed to provide bunk beds equipped with securely attached railings on each open side and open end of the bunk. Rooms # 3, 5, 6, and 12 had bunk beds without railings attached. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A maintenance check list was created that will be implemented beginning 8-1-23 and Executive Director will review the check list with Maintenance Supervisor. Maintenance Supervisor will do bi weekly walk through with this new check list and it will cover areas such as beds, window's, rooms, water temperature, etc. Maintenance Supervisor will keep this in a binder to track any issues being had. Executive Director will review maintenance ticket process during next staff meeting on 8-23-23 that when something is broken or not working within the facility, a maintenance ticket must be submitted. Pyramid updated our monthly facility walk through checklist to include the bunk bed rails. ED will use this form to complete them monthly, to ensure compliance with these deficiencies. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the bathroom in the Faith unit had a water temperature that was 130 degrees.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A maintenance check list was created that will be implemented beginning 8-1-23 and Executive Director will review the check list with Maintenance Supervisor. Maintenance Supervisor will do bi weekly walk through with this new check list and it will cover areas such as beds, window's, rooms, water temperature, etc. Maintenance Supervisor will keep this in a binder to track any issues being had. Executive Director will review maintenance ticket process during next staff meeting on 8-23-23 that when something is broken or not working within the facility, a maintenance ticket must be submitted. Pyramid updated our monthly facility walk through checklist to include the bunk bed rails. ED will use this form to complete them monthly, to ensure compliance with these deficiencies. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel are instructed in the use of the fire extinguishers upon staff employment and shall be documented by the facility upon employment. Employee # 8 was hired as a counselor assistant on July 24, 2022 and was still in this position at the time of the inspection. The fire extinguisher training provided was dated June 27, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All new hires complete a new hire orientation prior to them starting their shift. During this training, they sign all required paperwork, including fire extinguisher training. HR uploads all required documentation into Relias, our online training system. Beginning August 8th, all Supervisors will ensure proper documentation is uploaded into Relias by the start of a new hire's first shift. If the documentation is not uploaded, the supervisor will complete the fire extinguisher training with them, or ensure any missing documentaion is completed. |
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 two of two applicable client records reviewed, the facility failed to provide documentation of the emergency contact being notified when a client leaves against medical advice in accordance with the facility policy and procedure manual. The facility policy and procedure indicate the emergency contact be notified of the client leaving against medical advice no later than 12 hours after the client left and document in the client record.Client # 6 was admitted on January 19, 2023 and was discharged on March 6, 2023. There was no documentation of the emergency contact being notified of the client leaving against medical advice in the client record.Client # 8 was admitted on May 9, 2023 and was discharged on May 21, 2023. There was no documentation of the emergency contact being notified of the client leaving against medical advice in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new checklist was created for admits and discharges that reviews all consents needing completed, along with if the Emergency contact was contacted and if it was documented. Checklists will be emailed to Clinical Supervisor and Executive Director by day 3 after admission and 48 hours post discharge. Executive Director and Clinical Supervisor will double check everything is complete in chart and ensure calls are made, etc. Checklist was reviewed with Clinical team on 7-27-23 and was implemented on 7-31-23 |
709.28 (c) 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.
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Observations
Based on one of eight client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client record # 5. Client # 5 was admitted on March 2, 2023 and was discharged April 26, 2023. Authorizations for funding occurred on March 7, 2023. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source. Also, a letter to the same funding source providing discharge summary and aftercare information dated April 26, 2023 was documented in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new checklist was created for admits and discharges that reviews all consents needing completed, along with if the Emergency contact was contacted and if it was documented. For the purpose of Relase of information, Clinical staff will use checklists to ensure all proper releases are signed upon admit prior to making any contact with referall sources, family, funders, etc. Checklists will be emailed to Clinical Supervisor and Executive Director upon completion at admission. Executive Director and Clinical Supervisor will double check everything is complete in chart and ensure calls are made, etc. Checklist was reviewed with Clinical team on 7-27-23 and was implemented on 8-9-23 that they must be done upon admission. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of client records and the facility unusual incident reports, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident involving physical assault by staff or client. An incident involving a physical assault between clients occurred on February 28, 2023. The client that initiated the assault was administratively discharged on March 1, 2023 as a result of this incident.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A review of applicable reasons for unusual incident reports will be reviewed by Clinical Supervisor and Executive Director by 8-5-23. All applicable incidents will receive a unusual incident report completed by either Clinical Supervisor or Executive Director. |
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 two of four applicable residential client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur seven days from discharge.Client # 6 was admitted on January 19, 2023 and was discharged on March 6, 2023. There was no follow-up information available in the client record. Client # 8 was admitted on May 9, 2023 and was discharged on May 21, 2023. There was no follow-up information available in the client record. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 4, 2022 and August 5, 2021 annual licensing inspection.
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Plan of Correction
Executive Director created a smartsheet and Executive Director will update all discharges weekly. Smartsheet sends alerts to Administrative Assistant 5 days post discharge and sends an alert to the Executive Director and AA on day 7 post discharge. Executive Director will ensure calls are made by AA by day 7, and if they are not, she will make them. Clinical Supervisor and Lead Counselor also have access to the sheet and are able to make calls if Executive Director is unavailable. Smartsheet goes into effect 8-1-23 |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction for follow-up information were submitted and approved by the Department for the August 5, 2021 and October 4, 2022. Follow-up information was again found to be a deficiency for the July 19, 2023 annual licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A thorough review of last years plan of correction revealed that completing chart audits monthly did not allow for correction in real time. Moving forward, Administrative Assistant will use the smartsheet that was created by Executive Director, and this smartsheet will allow for checks and balances with the calls, and allow for reminders of the calls. |