INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on July 31, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Ridgeview Adolescent Behavioral Health Center at Pittsburgh 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(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of seven personnel records, the facility failed to provide documentation of monthly meetings with one clinical supervisor to discuss their duties and performance for the first 6 months of employment in that position.
Employee # 3 was hired as clinical supervisor on March 8, 2020. There was no documentation of monthly meetings provided for this position in the personnel record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective week of August 10, 2020 the Executive Director will facilitate monthly documented meetings with the Clinical Supervisor for a minimum of six months. First scheduled session date is Wednesday, August 12,2020. Scheduled sessions will focus on duties, responsibilities and performance as it directly relates to the role of Clinical Supervisor. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of seven personnel records, the facility failed to provide documentation of one year of clinical experience in a health or human service agency for a counselor.
Employee # 5 was hired as a counselor on March 16, 2020. After a review of the application/ resume, there was no documentation of a year of clinical experience provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective August 10, 2020 Executive Director, VP of Central and West and Human Resources collaborated regarding the status of employee #5 who did not meet the regulatory requirements to function in the role of Counselor.
Effective August 23, 2020 employee #5 status has been adjusted to that of Counselor Assistant to accurately reflect their current documented clinical experience.
Employee#5 obtained her Master's degree officially on 6/26/2020. Due to the facility being closed temporarily it was not presented to HR until the last week of July 2020 when the employees returned to work.
Effective week of August 3, 2020, Employee will receive weekly individual documented supervision by the Clinical Supervisor first session being August 10, 2020 along with weekly monitoring of group facilitation for a minimum of three months and or until the necessary counseling competencies have been met and documented accordingly based on her Masters degree.
Executive Director will meet with Clinical Supervisor for monthly supervisory meetings where upon they will review supervisory practices with employee #5 are being met in accordance with licensing regulations and documented to ensure compliance. During these sessions, Executive Director and Clinical Supervisor will review a sample of the clinical supervision notes to ensure ongoing compliance in this area. A copy of the counselors degree can be made available upon request. |
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 ten personnel records, the facility failed to provide a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases training within the regulatory timeframe for three employees.
Employee # 8 was hired as a BH Tech on June 17, 2018. There was no documentation of at least 6 hours of HIV/AIDS training provided within the regulatory timeframe.
Employee # 9 was hired as Maintenance staff on July 3, 2017. There was no documentation of at least 6 hours of HIV/AIDS and 4 hours of TB/STD training provided within the regulatory timeframe.
Employee # 10 was hired as a Med Tech on April 16, 2018. There was no documentation of at least 6 hours of HIV/AIDS training provided within the regulatory timeframe.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following employees were found to be out of compliance as it directly relates to completing the mandatory communicable disease trainings within the regulatory time frame.
Employee #8 has registered for the six hour HIV/AIDS training offered by DDAP and scheduled for Thursday, December 3, 2020 from 9:00 to 4:00.
Employee #9 has registered for the six hour HIV/AIDS training offered by DDAP and scheduled for Thursday, December 3, 2020 from 9:00 to 4:00. Employee has also registered for the four hour TB/STD training offered by DDAP and scheduled for Thursday, November 5, 2020 from 9:00 to 1:00.
Pyramid Healthcare instituted an electronic training platform for employees that allows supervisors/managers to run reports on training status of their direct reports.
Effective August 10,2020 all managers on site will be required to run quarterly reports of their staff to ensure ongoing compliance with staff completing the required trainings within the regulatory time frame.
Executive Director will monitor these reports by reviewing with managers during monthly, documented supervision to ensure practice of running reports are completed within the established quarterly timeframes to ensure compliance. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill log provided from June 2019 through March 2020, the facility did not provide documentation of fire drills being conducted in April, May, and June 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Ridgeview facility had been temporarily closed during the months of April through August of 2020. As a result, fire drills had not been facilitated as there were no clients or staff occupying the facility. Regional leadership had not been aware of the regulatory standard of practice during this time the facility was empty.
Facility Maintenance Supervisor is responsible for facilitation and documentation of fire drills for the facility. Regulatory guidelines establish a minimum of one unannounced fire drills be facilitated at the program a minimum of one time a month.
Effective August 10, 2020 Maintenance Supervisor will conduct one unannounced fire drill per month and document accordingly on the fire drill log.
Executive Director will review the facilities fire drill log last week of each month, sign off that they were reviewed with the Maintenance Supervisor to ensure ongoing compliance.
Effective immediately, if there is an identified need for services to be disrupted, the facility will reach out to DDAP and obtain the necessary waiver/exception to ensure compliance. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the fire drill log provided from June 2019 through March 2020, there was no documentation of a fire drill during sleeping hours at least every 6 months. The last overnight drill occurred on March 13, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Ridgeview facility had been temporarily closed during the months of April through August of 2020. As a result, fire drills had not been facilitated as there were no clients of staff occupying the building. Regional leadership had not been aware of the regulatory standard of practice during this time the facility was empty.
Facility Maintenance Supervisor is responsible for facilitation and documentation of fire drills for the facility. Regulatory guidelines establish that the program conduct a fire drill during sleeping hours at a minimum of once every six months.
Effective August 10, 2020 the Maintenance Supervisor will conduct one overnight fire drill by January 1, 2021 and document accordingly on the fire drill log.
Executive Director will review the facilities fire drill log the last week of each month, and then sign off that it was reviewed with the Maintenance Supervisor to ensure ongoing compliance.
Effective immediately, if there is an identified need for services to be disrupted the facility will reach out to DDAP to obtain the necessary waiver/exception to ensure compliance. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of seven personnel records, the facility failed to provide documentation of an annual written individual staff performance evaluation reviewed and signed by the employee at the time of the annual performance evaluation.
Employee # 2 was hired on December 30, 2005 and promoted to current position on July 1, 2020. An annual performance evaluation was provided for September 2019, however, was not reviewed and signed by the employee until July 30, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective August 10, 2020 the Executive Director will be responsible to review and approve all staff's performance evaluations prior to the respective manager meeting with employees for their individual performance evaluation review.
All performance evaluations are completed in an electronic automated data platform which allows the Executive Director to review all evaluations completed by management prior to submission to Human Resources.
Upon successful completion of all program employees having participated in their individual performance evaluations with their respective managers, the Executive Director will collaborate with the Human Resource department via email/conference call to confirm all documents have been completed and signed accordingly to ensure compliance. |