INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26, 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 Healthcare Lehigh Valley was found to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. No deficiencies were identified during this inspection and no plan of correction is required.
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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 thirteen personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that five applicable 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 #8 was hired as a Behavioral Health Tech on November 4, 2019 and was due to have the communicable disease trainings no later than November 4, 2021. 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 #9 was hired as a Behavioral Health Tech on April 15, 2020 and was due to have the communicable disease trainings no later than April 15, 2022 . There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #10 was hired as a Behavioral Health Tech on June 21, 2021 and was due to have the communicable disease trainings no later than June 21, 2023. 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 #11 was hired as a Dietary on January 6, 2020 and was due to have the communicable disease trainings no later than January 6, 2022. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #12 was hired as a Behavioral Health Tech on June 5, 2021 and was due to have the communicable disease trainings no later than June 5, 2023. 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 #13 was hired as a Behavioral Health Tech on November 30, 2020, and was due to have the communicable disease trainings no later than November 30, 2022. 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.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 4, 2021 and August 19, 2022 annual licensing inspection.
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Plan of Correction
A smartsheet will be developed for each leadership member to efficiently track the training needs of their departments. For already existing staff, each staff will be added to the smartsheet with their corresponding due date of the required trainings. For newly hired staff, they will be added to the smartsheet upon hire in order to effectively track the required training due dates. Each leadership member is responsible for oversight. The Executive Director is responsible for overall oversight of the leadership team members. |
709.64(e) LICENSURE Follow-up policy
709.64. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of client records, the facility failed to follow their written client follow-up policy in two of five applicable detox client records reviewed.
Client #10 was admitted on January 28, 2023 and was discharged on February 4, 2023. The client record did not contain documentation of follow up information with the client within 7 days of discharge.
Client #11 was admitted on May 18, 2023 and was discharged on May 19, 2023. The client record did not contain documentation of follow up information with the client within 7 days of discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A plan has since been developed to track 7-day follow up calls on a smartsheet. LV's CFRS/Case Coordinator is responsible for this area of the record. Upon admission, all clients are added to the smartsheet. Their admission and then discharge dates are tracked. A date is entered for the 7 day follow up call. Reminders are set on said smartsheet to notify CFRS/Case Coordinator and Clinical Supervisor for the CFRS/Case Coordinator to conduct the 7 day follow up call. Once the call is completed, and the date is entered, a notification is sent to the Clinical Supervisor and Executive Director that the task is completed. CFRS is responsible. CS and ED have overall oversight. Target date 9/1/23. |
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 client records, the facility failed to follow their written client follow-up policy in one of two applicable inpatient client records reviewed.
Client #7 was admitted on March 2, 2023 and was discharged on April 5, 2023. The client record did not contain documentation of follow up information with the client within 7 days of discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A plan has since been developed to track 7-day follow up calls on a smartsheet. LV's CFRS/Case Coordinator is responsible for this area of the record. Upon admission, all clients are added to the smartsheet. Their admission and then discharge dates are tracked. A date is entered for the 7 day follow up call. Reminders are set on said smartsheet to notify CFRS/Case Coordinator and Clinical Supervisor for the CFRS/Case Coordinator to conduct the 7 day follow up call. Once the call is completed, and the date is entered, a notification is sent to the Clinical Supervisor and Executive Director that the task is completed. CFRS is responsible. CS and ED have overall oversight. Target date 9/1/23. |
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 the review of client records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction was submitted to the Department for inspections occurring on August 4, 2021, August 19, 2022 and June 26, 2023, addressing the requirement to provide 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.
A plan of correction was submitted to the Department for inspections occurring on August 4, 2021, August 19, 2022 and June 26, 2023, addressing the requirement to follow their written client follow-up policy.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A smartsheet will be developed for each leadership member to efficiently track the training needs of their departments. For already existing staff, each staff will be added to the smartsheet with their corresponding due date of the required trainings. For newly hired staff, they will be added to the smartsheet upon hire in order to effectively track the required training due dates. Each leadership member is responsible for oversight. The Executive Director is responsible for overall oversight of the leadership team members. |