INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 21, 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 Inc. Pine Ridge 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 employee #9 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 #9 was hired as a maintenance staff on September 7, 2010 and was still in this position at the time of the inspection. Employee # 9 was due to have the communicable disease trainings no later than September 7, 2012. 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.
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Plan of Correction
Executive Director met with staff to review required trainings on June 29, 2023. Staff has been scheduled for HIV and SB/STD training, dates and times were reviewed with staff member. Executive Director will ensure all training hours are completed for all employees. All Supervisors will complete a written report monthly, reviewing staff's training needs. |
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 one of one 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 # 7 was admitted on October 13, 2022 and was discharged on December 7, 2022. 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
Executive Director and Lead Counselor reviewed protocol for notifying emergency contact when a client leaves treatment against facility advice, during clinical staff meeting on July 3, 2023. Executive Director and Lead Counselor will review this while completing discharge chart audits to ensure ongoing compliance. |
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 three applicable 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 within seven days after discharge by phone.
Client # 5 was admitted on March 1, 2023 and was discharged on March 10, 2023.
There was no follow-up information available in the client record.
Client # 7 was admitted on October 13, 2022 and was discharged on December 7, 2023.
There was no follow-up information available in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed follow up policy with administrative assistant on June 29, 2023. Discussed documenting within seven days of discharge. Discussed documenting if there was no forwarding information for the client, if they were unable to be reached. Executive Director and Lead Counselor will review compliance during monthly chart audits. Any additional concerns will be addressed in monthly supervision with the Executive Director. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on seven of seven client records reviewed, the facility failed to provide a complete client record to include verification that work done by the client at the project is an integral part of their treatment and rehabilitation plan.
Client # 1 was admitted on March 30, 2023 and was still active at the time of the inspection. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
Client # 4 was admitted on March 1, 2023 and was still active at the time of the inspection. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
Client # 5 was admitted on March 1, 2023 and was discharged March 10, 2023. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
Client # 6 was admitted on January 5, 2023 and was discharged April 5, 2023. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
Client # 7 was admitted on October 13, 2022 and was discharged December 7, 2022. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Lead Counselor reviewed utilization of work therapy in individual treatment plans at clinical team meeting on July 3, 2023. Clinical staff will ensure work therapy is added to treatment plans detailing involvement in employment, volunteer work, or lifeskills. Executive Director and Lead Counselor will complete monthly chart audits to review progress. Supervisors will address any ongoing concerns during individual supervision. |