INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 15-16,2024 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 staff 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.
Staff #12 was hired as a Counselor Assistant on May 29, 2023, and was promoted to a Counselor position on May 26, 2024. This staff was due to have the communicable disease trainings no later than May 29, 2024. There was no documentation in the personnel file of the completion of the TB/STD training.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Executive Director met with staff to review required trainings on August 19, 2024. Staff has been scheduled for TB/STD training in September 12, 2024. Clinical Supervisor will ensure all training hours are completed for all clinical employees. All Supervisors will complete a written report monthly, reviewing staff's training needs. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of six applicable client records.
Client #1 was admitted on May 28, 2024, and was still active at the time of the inspection. A treatment plan update was completed on June 28, 2024, and the update was due no later than July 28, 2024; however, the next update was completed on July 31, 2024
Client #6 was admitted on April 22, 2024, and was discharged on July 29, 2024. A treatment plan update was completed on June 18, 2024, and the update was due no later than July 18, 2024; however, the next update was completed on July 24, 2024.
Client #7 was admitted on April 26, 2024, and discharged on July 13, 2024. A comprehensive treatment plan update was completed on April 29, 2024, and an update was due no later than May 29, 2024; however, the next update was completed on June 5, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor reviewed guidelines for treatment plan updates with clinicians during clinical staffing on August 19, 2024. Clinical Supervisor will monitor ongoing compliance/maintianing time frames for completion during monthly chart audits. Any ongoing issues will be address by clinical supervisor during monthly supervision. |