INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 1-2, 2011 by staff from the Division of Drug and Alcohol 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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705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and/or maintain each porch that has over an 18-inch drop with a well-secured railing.
The findings include:
A physical plant tour was conducted on November 2, 2011 at 3:30 PM. During the tour at 4:02 PM it was found that the stairs directly outside of the fire exit from the girl's unit, exceeding two steps, had a hand rail which was not secured at the end nearest to the ground.
The maintenance director was present during the tour and confirmed the findings.
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Plan of Correction
705.10 (a) (1) (iii)
FIRE SAFETY
Hand Rail which was not secured at the end nearest to the ground located outside of the fire exit from the girls unit will be repaired. The handrail located outside of the fire exit from the girls unit was secured by the Maintenance Director effective November 2, 20011. It will be the responsibility of the Maintenance Director to document regularly scheduled physical plant audits. These documents will be reviewed by facility Risk Teams on a monthly basis. Target date for completion is November 2, 2011.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policy and procedures manual, the facility failed to document a psychosocial evaluation accordance wit the facility's policy.
The findings include:
The facility's policy regarding biopsychosocial evaluations states:
The Biopsychosocial Evaluation shall be documented within five days of admission.
On November 2, 2011 seven client records were reviewed for documentation of a biopsychosocial evaluation. Seven client records did not include a dated biopsychosocial evaluation of the client, specifically records # 1, 2, 3, 4, 5, 6, and 7.
Client # 1 was admitted on September 26, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within five days.
Client # 2 was admitted on September 21, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within five days.
Client # 3 was admitted on September 27, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within five days.
Client # 4 was admitted on September 16, 2011 and discharged on October 11, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within five days.
Client # 5 was admitted on August 11, 2011 and discharged on September 12, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within five days.
Client # 6 was admitted on July 21, 2011 and discharged on September 2, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within five days.
Client # 7 was admitted on July 28, 2011 and discharged on September 8, 2011. Documentation of a biopsychosocial evaluation was included in the record, however it was undated and there was no way to determine if the evaluation had been completed within five days.
The clinical supervisor confirmed the findings.
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Plan of Correction
709.51(b)(6)
PSYCHOSOCIAL EVALUATION
The Bio-Psychosocial evaluation will be added to the Signature Verification Sheet which will require signatures from both the Primary Counselor and Clinical Supervisor verifying completion within five days of admission per facility policy. The Clinical Supervisor will review these changes with all clinical staff and monitor for compliance through bi-weekly documented supervision and by completing monthly chart audits. Target date for completion is December 20, 2011.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document the frequency of services in the individual treatment and rehabilitation plan in the client records.
The findings include:
On November 2, 2011 seven inpatient client records were reviewed for treatment plans that included the frequency of services. The facility did not document the frequency of services in the individual treatment and rehabilitation plans in five of seven client records reviewed, specifically, #1, 4, 5, 6 and 7.
Client # 1 was admitted on September 26, 2011. The treatment plan was completed on September 27, 2011 and did not include documentation of the frequency of treatment and rehabilitation services.
Client # 4 was admitted on September 16, 2011 and discharged on October 11, 2011. The treatment plan was completed on September 21, 2011 and did not include documentation of the frequency of treatment and rehabilitation services.
Client # 5 was admitted on August 11, 2011 and discharged on September 12, 2011. The treatment plan was completed on August 12, 2011 and did not include documentation of the frequency of treatment and rehabilitation services.
Client # 6 was admitted on July 21, 2011 and discharged on September 2, 2011. The treatment plan was completed on July 21, 2011 and did not include documentation of the frequency of treatment and rehabilitation services.
Client # 7 was admitted on July 28, 2011 and discharged on September 8, 2011. The treatment plan was completed on July 29, 2011 and did not include documentation of the frequency of treatment and rehabilitation services.
The findings were confirmed by the clinical supervisor and lead counselor.
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Plan of Correction
709.52(a)(2)
TREATMENT TYPE AND FREQUENCY
The clinical staff will document on every client's treatment plans the type and frequency of services in the individual treatment and rehabilitation plan located in each of the client records. The Clinical Supervisor will review these changes with all clinical staff and monitor for compliance through bi-weekly documented supervision and by completing monthly chart audits. Target date for completion is December 20, 2011.
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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 personnel records the facility failed to ensure the clinical supervisors and lead counselors with less than two years experience as supervisors in the provision of clinical services have completed a core curriculum in clinical supervision.
The findings include:
On November 1, 2011 personnel record #5, that of a lead counselor, was reviewed for clinical supervisory experience. Employee #5 was hired by the facility on May 27, 2008 and promoted to lead counselor on February 25, 2010. Employee #5's resume did not reflect any prior clinical supervisory experience and did not document a core curriculum in clinical supervision.
This was confirmed by employee #5 and the clinical supervisor.
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Plan of Correction
704.6(c)
SUPERVISOR TRAINING
Lead Counselor who did not meet the qualifications due to number of years experience in a supervisory role will attend and successfully complete the core curriculum in clinical supervision necessary to meet regulation qualifications of the position. Lead Counselor has registered for the BDAP five day Clinical Supervisor Training located in Lancaster, Pa. Training schedule is December 12th through the 16th. Target date for completion is December 16, 2011.
Human Resource Department and Clinical Supervisor will ensure future compliance of this standard by review of resume and years of experience prior to the selection of future candidates for said position. |
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, the facility failed to ensure that all staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum as per the timeframes of this standard.
The findings include:
On November 1, 2011, eight personnel records were reviewed for documentation of HIV/AIDS and TB/STD training. The facility failed to document the completion of four hours of TB/STD training in two of eight records reviewed, #9 & 11, and the completion of six hours of HIV/AIDS training in one of eight records reviewed, #9.
Employee # 9 was hired as a counselor assistant on October 18, 2010. A Department approved curriculum in HIV/AIDS and TB/STD training was due to be completed no later than October 18, 2011. Documentation of this training was not available during the review.
Employee # 11 was hired as a counselor on January 22, 2009. A Department approved curriculum in TB/STD training was due to be completed no later than January 22, 2010. Documentation of this training was not available during the review.
Human Resources staff were interviewed on November 2, 2011 and confirmed the findings.
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Plan of Correction
704.11(c)(1)
MANDATORY COMMUNICABLE DISEASE TRAINING
The two identified staff members, both of whom were counselors who did not meet the training requirements for obtaining a minimum of six hours of HIV/AIDS training within their first year of employment have been scheduled to attend this training on December 6, 2011. Target date for completion is December 6, 2011.
On an ongoing basis, the Program Director will ensure that all department supervisors monitor compliance with regard to meeting staff training requirements through individual and group supervision monthly and quarterly review of training records with Human Resource Department staff. |
704.12(a)(3)(ii) LICENSURE NonHosp Rehab/Adol
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(ii) Projects serving adolescent clients shall have one FTE counselor for every six clients.
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Observations
Based on a review of client schedules, the facility failed to provide treatment services that are not concurrent with school hours and that do occur during Department of Health approved primary care hours.
The findings include:
On November 2, 2011 a student schedule as reviewed. The schedule indicates:
Monday through Friday: 7:45-8:30 AM Period 1; 8:30-9:15 AM Period 2; 9:15-10:15 AM Group Therapy; 10:15-11:00 AM Period 3; 11:00 AM -12:30 PM Period 4 (half hour lunch); 12:30-1:15 PM Period 5; 1:15-2:00 PM Period 6; 2:15-3:00 PM Period 7
On March 23, 2011 a letter was presented to the Chief Operating Officer of Pyramid Healthcare from the Bureau of Special Education (BSE). The letter states that the BSE is requiring that students must receive 5.5 hours of educational instruction per day. Educational services cannot be shortened or interrupted for the convenience of therapeutic services during the time period that educational services are being conducted.
Based on the schedule presented students are not receiving 5.5 hours of uninterrupted educational instruction as therapeutic services are being conducted from 10:15 AM to 11:00 AM, Monday through Friday.
The Facility Director was interviewed and confirmed the student schedule to be accurate; however, the Facility Director indicated that he did not believe that the facility was noncompliant. He stated that the letter from the BSE did no state that the 5.5 hours were to be continuous, and although the therapy was provided in between the 5.5 hours of education, no students were taken out of classes to go to therapy, thus the facility was not interrupting educational instruction.
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Plan of Correction
704.12(a)(3)(iii)
NONHOSP REHAB/ADOL
The Bureau of Special Education requires students must receive 5.5 hours of non-interrupted educational instruction per day. A new schedule has been developed by a team consisting of the facilities Clinical Supervisor, BHT Supervisor, Lead Teacher and Program Director. The newly dev eloped schedule will allow for 5.5 hours of continuous educational services from 7:15am to 1:15pm. Clinical hours will be provided from 1:15pm to 5:00pm. The team of Department Heads will meet on a quarterly basis to evaluate the effectiveness of the schedule to ensure all programming needs of the clients are being met. Target date for completion is January 18, 2012.
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