INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on August 8, 2019. Based on the findings of the on-site inspection, Pyramid Healthcare Inc- Pine Ridge was found to not 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
The facility failed to ensure staff receive a minimum of six hours of HIV/AIDS training using a Department approved curriculum within the first two years of employment.
Staff #7, who was hired as a Behavioral Health Technician on July 6, 2017 did not have their six hours of HIV/AIDS training at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #7 attended and completed HIV training on 8/9/19. Executive Director and BHT Supervisor will monitor compliance of employees regarding training requirements, ensuring they are scheduling and attend trainings as required. Facility Director will follow-up with Human Resource Coordinators and employee after said training date to ensure attendance. Human Resource Coordinators will monitor all employee files quarterly to ensure all employees attend the mandatory trainings within the required time frame. |
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
The facility failed to have a well-secured handrail for a stairway exceeding two steps.
The facility had no handrail for the three stairs used to exit from the kitchen leading to the outside in the B building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance installed a handrail on the stairwell entering from outside B House on 8/9/19. |
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
The facility failed to have a fire drill during sleeping hours at least every six months.
At the time of the inspection, the facility last had a fire drill during sleeping hours on December 28, 2018
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed regulations for fire drills with staff on 8/28/19, addressing sleep hour drills every six months. Executive Director will review fire drills logs monthly to ensure compliance. |
709.1-709.5 LICENSURE Subchapter A. General Provisions
Chapter 709. Standards for Licensure of Freestanding Treatment Activities
709.1. Scope.
(a) This chapter establishes the procedures for the issuance of a license by activity to freestanding drug and alcohol treatment facilities. The term, facility, applies to the physical location from which drug and alcohol services are provided. A facility may provide more than one service.
(b) This chapter provides standards by activity for the licensure of freestanding drug and alcohol treatment facilities, under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059).
709.2. Policy.
(a) Persons, partnerships and corporations, or other legal entities intending to provide drug and alcohol treatment services, shall first be licensed by the Department.
(b) No drug or alcohol freestanding treatment facilities may receive funds from the Department without a license issued under this chapter.
709.3. Legal base.
The authority of the Department to license drug and alcohol treatment activities is established under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059) as transferred to the Department by Reorganization Plan No. 2 of 1977 (P.L. 372) (71 P. S. subsection 751-25) and No. 4 of 1981 (P. L. 610) (71 P. S. subsection 751-31).
709.4. Exceptions.
(a) The Department may, within its discretion, and for good reasons, grant exceptions or extensions of time to this chapter when the policy objectives of this chapter are met, but no exception may be granted which contravenes the authorizing statute.
(b) The project director shall submit a written request for an exception which shall include the approval of the governing body.
(c) Exceptions will not be granted for a situation in which a provisional license would be appropriate.
709.5. Revocation of exceptions.
(a) An exception granted under this chapter may be revoked by the Department. Notice of revocation will be in writing and include the reason for the action of the Department and a specific date upon which the exception will be terminated.
(b) In revoking an exception, the Department will provide for a reasonable time between the date of written notice of revocation and the date of termination of an exception for the project to come into compliance with this part.
(c) If a project wishes to request a reconsideration of a denial or revocation of an exception, it must do so in writing to the Department within 30 days of receipt of the adverse notification.
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Observations
During a Project Wide review of the Policy and Procedures, the project failed to include sex and marital status in the Client Rights policy.709.30 (2), and also the project failed to include documentation of the reasons for removing sections from the record. 709.30 (3).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Forms Committee will be updating the form in Carelogic to include the missing information. The new form to be added to Carelogic for all programs by September 1, 2019. Program Director will ensure all staff are educated on the new form by September 15, 2019. |
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
During a review of client records on August 8, 2019, the facility failed to notify clients of all their civil rights in seven out of seven records.
Client #1 was admitted on February 28, 2019 and was current at the time of the inspection. Client #1 was not notified that the project may not discriminate on the basis of sex and color.
Client #2 was admitted on May 17, 2019 and was current at the time of the inspection. Client #2 was not notified that the project may not discriminate on the basis of sex and color.
Client #3 was admitted on January 29, 2019 and was current at the time of the inspection. Client #3 was not notified that the project may not discriminate on the basis of sex and color.
Client #4 was admitted on March 4, 2019 and was discharged on April 29, 2019. Client #4 was not notified that the project may not discriminate on the basis of sex and color.
Client #5 was admitted on February 20, 2019 and was discharged on May 29, 2019. Client #5 was not notified that the project may not discriminate on the basis of sex and color.
Client #6 was admitted on February 11, 2019 and was discharged on May 7, 2019. Client #6 was not notified that the project may not discriminate on the basis of sex and color.
Client #7 was admitted on April 17, 2019 and was discharged on July 2, 2019. Client #7 was not notified that the project may not discriminate on the basis of sex and color.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Forms Committee will be updating the form in carleogic to include the missing information. The new form to be added to Carelogic for all programs by September 1, 2019. Program Director will ensure all staff are educated on the new form by September 15, 2019. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire or ambulance personnel.
There was an unusual incident documented on August 18, 2019 involving the State Police. This unusual incident was not submitted to the Department of Drug and Alcohol Programs as specified in the regulations.
There was an unusual incident documented on August 19, 2019 involving the State Police. This unusual incident was not submitted to the Department of Drug and Alcohol Programs as specified in the regulations.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed protocol for reporting unusual incidents during clinical meeting on August 28, 2019. Reviewed forms to be completed and faxed within 72 hours of incident. Lead counselors and program director will be responsible for completion of reports. All incident reports upon completion will be uploaded to Pyramid Smartsheet, to be reviewed for accuracy and completion by Clinical Compliance team. Program Director and risk committee will review onsite incident reports weekly to ensure proper unusual incident reports are completed. |