INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16, 2021 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, Monroe Outpatient 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of six personnel records, the facility failed to ensure that clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision.Employee #3 was hired on June 30, 2019 as the clinical supervisor and did not complete a core curriculum in clinical supervision within six months of hire. Employee #3 did not complete the training until February 19, 2021. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The identified employee completed clinical supervision training on February 19, 2021. Any clinical supervisor or lead counselor that is hired will be required to complete their training plan within the first two weeks of hire. The director will meet with the employee to complete the training plan and include registration for the clinical supervision training. If the training is unavailable or canceled, the supervisor will include the appropriate documentation in their file and register for the next available training. The director will monitor scheduling and training completion during monthly individual supervision to ensure it is completed within 6 months of hire. |
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 six personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee #4 was hired as a counselor on March 11, 2020 and was due to have the communicable disease trainings no later than March 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.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The identified employee is scheduled to complete the TB/STD training on November 8th, 2021. All new hires are required to have their yearly training plan completed within the first two-weeks of hire. The clinical supervisor will meet with the new hire within the first two weeks to develop the training plan and determine the need to complete any DDAP core curriculum trainings including the Mandatory Communicable Disease Training. Any DDAP required training that is needed within the first year of hire will be requested for registration by the clinical supervisor via the Pyramid intranet page managed by corporate. The clinical supervisor will monitor training completion by maintaining a training log that will be reviewed during individual supervision on a monthly basis. |
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 seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients related to follow up information in two of four applicable records reviewed.Client #2 was admitted on June 2, 2021 and discharged on July17, 2021. The follow up information documented in the client record surpassed the facility procedure of contacting the client within seven days of discharge. Client #4 was admitted on August 4, 2020 and discharged on September 28, 2020. The follow up information documented in the client record surpassed the facility procedure of contacting the client within seven days of discharge.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Pyramid Healthcare written policy for client discharge from the program is that all clients will be called within 7 days of the discharge date. To ensure proper completion of the 7-day follow-up calls, the clinical supervisor will print a discharge list for all clients discharged the week prior and present this list at weekly staff meeting. All staff will be provided with their list of clients to contact. Clinical supervisor will receive an e-mail report from all staff once calls have been completed. Clinical supervisor will do an end-of-the-week audit on 50% of the discharge list and confirm the call logs are completed. |