INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 21-22, 2021 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 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure that counseling sessions cannot be seen or heard from outside of the counseling room as the Group room in building D1 had a door and window that was not covered, and group rooms 106 and 104 in building East 2 also had a door and window that was not covered while groups were taking place.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility manager ordered and installed the window coverings over the windows, and with the sound machines we had on site will provide an area, outside of the group room, to place sound machines while group is in progress. This will be done by who is facilitating the group. The Facility Manager will add checking all window coverings on their monthly facility inspection to make sure we continue to adhere to this POC. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection the facility failed to ensure that smoking was limited to designated smoking areas as an excessive amount of cigarette butts were located outside on the ground of each exit.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Facility staff were notified in email and supervision of the need to hold clients accountable to their smoke areas.
Cigarette butt receptacles will also be moved to the designated smoking areas limiting the amount of cigarettes butts.
The maintenance department added the monitoring and cleaning of the cigarette butts to their weekly cleaning schedule and monthly facility walk through
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection the facility failed to ensure that all exits from rooms and from the facility were unobstructed as the women ' s community room exit was blocked by four chairs during the physical plant inspection. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Clinical Director and BHT Manager will ensure the implementation of the action plan by ? informing their respective departments in phases. The process will begin Initially through emails(on 8/5/21) explaining the importance of making sure all exits from the women's unit are clear of chairs and that staff or clients are not allowed to block these areas. Secondly, by group supervision facilitated by the BHT Manager and Clinical director (on 8/20/21) to their respective departments they will reiterate the POC developed. Thirdly, our Risk Leader added our POC to the agenda for the monthly Performance Improvement meeting (8/31/2021). |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records and policy and procedure the facility failed to include within their client rights policy that the project may not discriminate in the provision of services on the basis religion or creed. These finding were discussed with facility staff during the inspection process.
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Plan of Correction
The policy and procedures manual was updated on 7/23/2021 by the Policy and procedure committee to include religion, creed instead of the previously stated religious creed. The new policy was made available to staff on that date via the Pyramid Healthcare intranet. The compliance officer, via email, informed all programs of the change on that date and all handbooks and consents for treatment were amended to reflect the change. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records and policy and procedure, the facility failed to include within their client rights policy that: Clients have the right to appeal a decision limiting access to their records to the director. These findings have been discussed with facility staff during the inspection process.
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Plan of Correction
The PHC compliance officer will be responsible for making an amendment to the electronic health record, specifically the consent for treatment, to include the client's right to appeal the decision limiting access to their records. The PHC compliance officer will ensure this change occurs and is shared with all staff by 9/1/2021. |
709.62(c)(3)(i) LICENSURE Medical history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of seven client records, the facility failed to ensure that all client records included a medical history in three client records reviewed. Client record #5 was admitted on June 28, 2021 and discharged on July 3, 2021. Client record #6 was admitted on June 11, 2021 and was discharged on June 16, 2021Client record #7 was admitted on July 12, 2021 and was discharged on July 16, 2021.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The ED Director of Client Support and Clinical Director collaborated on 8/19/21 regarding the ongoing development and training of the intake department to ensure the implementation of the Corrective Action Plan. The Director of Client support will educate the Assessment counselors (Who are responsible for the completion of the level of care Assessments) through Supervision of the regulations regarding the completion of level of care assessments. This process has started through supervision on 9/1/2021, and will continue through supervision and monitoring as we continue to hire staff. The Director of Client Support and the Clinical Director are collaborating with utilizing the clinical department as a support to complete the Level of Care Assessments until the intake department is capable of adhering to the regulations regarding the completion of Level of Care Assessments, in there totality. They are coordinating through staff meetings and email to help facilitate the ongoing completion of the level of care assessments. The Clinical Director is also helping to ensure compliance through monthly chart audits in which she will notify the Director of Client support of deficiencies in the completion of the Level of Care assessments according to DDAP regulations and PHC policy and procedures.
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709.62(c)(3)(ii) LICENSURE D & A History
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of seven client records, the facility failed to ensure that all client records included a drug or alcohol history in three client records reviewed. Client record #5 was admitted on June 28, 2021 and discharged on July 3, 2021. Client record #6 was admitted on June 11, 2021 and was discharged on June 16, 2021Client record #7 was admitted on July 12, 2021 and was discharged on July 16, 2021.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The ED Director of Client Support and Clinical Director will collaborate regarding the ongoing development and training of the intake department to ensure the implementation of the Corrective Action Plan. The Director of Client support will educate the Assessment Counselors (Who are responsible for the completion of the level of care Assessments while in Withdrawal Management). This will be completed through supervision and the education on the regulations regarding clients in the Withdrawal Management level of care. This will include that they need to be completed prior to their discharge or step down to their next level of care. This process has started through supervision for the Assessment Counselors during 9/21, and will continue through supervision and monitoring as we continue to hire staff.
The Director of Client Support and the Clinical Director are collaborating with utilizing the clinical department as a support to complete the Level of Care Assessments of clients in the Withdrawal Management Level of Care until the intake department is capable of adhering to the regulations regarding the completion of Level of Care Assessments, in there totality. They are coordinating through staff meetings and email to help facilitate the ongoing completion of the level of care assessments. The Clinical Director is also helping to ensure compliance through monthly chart audits in which she will notify the Director of Client support of deficiencies in the completion of the Level of Care assessments according to DDAP regulations and PHC policy and procedures.
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709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of seven client records, the facility failed to ensure that all client records included a personal history in three client records reviewed. Client record #5 was admitted on June 28, 2021 and discharged on July 3, 2021. Client record #6 was admitted on June 11, 2021 and was discharged on June 16, 2021Client record #7 was admitted on July 12, 2021 and was discharged on July 16, 2021.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The ED Director of Client Support and Clinical Director collaborated on 8/19/21 regarding the ongoing development and training of the intake department to ensure the implementation of the Corrective Action Plan. The Director of Client support will educate the Assessment Counselors (Who are responsible for the completion of the level of care Assessments which house the clients D/A history). This will be completed through supervision and the education on the regulations regarding clients in the Withdrawal Management level of care. This will include that they need to be completed prior to their discharge or step down to their next level of care. This process has started through supervision for the Assessment Counselors during 9/21, and will continue through supervision and monitoring as we continue to hire staff.
The Director of Client Support and the Clinical Director are collaborating with utilizing the clinical department as a support to complete the Level of Care Assessments of clients in the Withdrawal Management Level of Care until the intake department is capable of adhering to the regulations regarding the completion of Level of Care Assessments, in there totality. They are coordinating through staff meetings and email to help facilitate the ongoing completion of the level of care assessments. The Clinical Director is also helping to ensure compliance through monthly chart audits in which she will notify the Director of Client support of deficiencies in the completion of the Level of Care assessments according to DDAP regulations and PHC policy and procedures.
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of seven client records, the facility failed to ensure that all client records included a psychosocial evaluation in three client records reviewed. Client record #5 was admitted on June 28, 2021 and discharged on July 3, 2021. Client record #6 was admitted on June 11, 2021 and was discharged on June 16, 2021Client record #7 was admitted on July 12, 2021 and was discharged on July 16, 2021.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The ED Director of Client Support and Clinical Director collaborated on 8/19/21 regarding the ongoing development and training of the intake department to ensure the implementation of the Corrective Action Plan. The Director of Client support will educate the Assessment Counselors (Who are responsible for the completion of the level of care Assessments which houses the Psycho-social). This will be completed through supervision and the education on the regulations regarding clients in the Withdrawal Management level of care. This will include that they need to be completed prior to their discharge or step down to their next level of care. This process has started through supervision for the Assessment Counselors during 9/21, and will continue through supervision and monitoring as we continue to hire staff.
The Director of Client Support and the Clinical Director are collaborating with utilizing the clinical department as a support to complete the Level of Care Assessments of clients in the Withdrawal Management Level of Care until the intake department is capable of adhering to the regulations regarding the completion of Level of Care Assessments, in there totality. They are coordinating through staff meetings and email to help facilitate the ongoing completion of the level of care assessments. The Clinical Director is also helping to ensure compliance through monthly chart audits in which she will notify the Director of Client support of deficiencies in the completion of the Level of Care assessments according to DDAP regulations and PHC policy and procedures.
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