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. Part 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. Part 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 22, 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, Pyramid Healthcare, Inc-Pittsburgh 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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704.11(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
During a review of 131 staff listed on the Staffing Requirement Facility Summary Report provided by the facility on July 22, 2020, the facility failed to provide documentation that employee's #16, #21 , #23 , #26 , #42, #46, #50, #57, #60, #63, #69. #79, #87, #92, #93, #96, #106, #108, #113, and #120 received the minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee #16 was hired as a Counselor on February 4, 2019 and was due to have the communicable disease training no later than February 4, 2020. There was no documentation of the completion of the TB/STD training as of the date of the inspectionEmployee # 21 was hired as a Counselor on May 8, 2019 and was due to have the communicable disease trainings no later than May 8, 2020. There was no documentation of the completion of the HIV/AIDS training and TB/STD training as of the date of the inspection.Employee # 23 was hired as Aftercare on October 2, 2017 and was due to have the communicable disease trainings no later than October 2, 2019. There was no documentation of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.Employee # 26 was hired as an Assessment Counselor on July 11, 2018 and was due to have the communicable disease training no later than July 11, 2020. There was no documentation of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.Employee # 42 was hired as a BH Tech 1 on February 2, 2016 and was due to have the communicable disease trainings no later than February 2, 2018. There was no documentation of the completion of the HIV/AIDS training as of the date of the inspection.Employee # 46 was hired as a BH Tech 1 on February 6, 2017 and was due to have the communicable disease training no later than February 6, 2019. There was no documentation of the completion of the TB/STD training as of the date of the inspection.Employee # 50 was hired as a BH Tech 1 on March 21, 2017 and was due to have the communicable disease training no later than March 21, 2019. There was no documentation of the completion of the TB/STD training as of the date of the inspection.Employee # 57 was hired as a BH Tech 1 on July 2, 2018 and was due to have the communicable disease training no later than July 2, 2020. There was no documentation of the completion of the HIV/AIDS and the TB/STD training as of the date of the inspection.Employee # 60 was hired as a BH Tech 1 on November 9, 2017 and was due to have the communicable disease training no later than November 9, 2019. There was no documentation of the completion of the TB/STD training as of the date of the inspection.Employee # 63 was hired as a BH Tech 2 on February 6, 2017 and was due to have the communicable disease training no later than February 6, 2019. There was no documentation of the completion of the TB/STD training as of the date of the inspection.Employee # 69 was hired as a BH Tech 2 on January 16, 2017 and was due to have the communicable disease training no later than January 16, 2019. There was no documentation of the completion of the HIV/AIDS and TB/STD training as of the date of the inspection.Employee # 79 was hired as a Detox Specialist on November 12, 2016 and was due to have the communicable disease training no later than November 12, 2018. There was no documentation of the completion of the HIV/AIDS and TB/STD training as of the date of the inspection.Employee # 87 was hired as a Medication Admin on November 14, 2016 and was due to have the communicable disease training no later than November 14, 2018. There was no documentation of the completion of the HIV/AIDS and TB/STD training as of the date of the inspection.Employee # 92 was hired as a Dietary LDN on February 5, 2018 and was due to have the communicable disease training no later than February 5, 2020. There was no documentation of the completion of the HIV/AIDS and TB/STD training as of the date of the inspection.Employee # 93 was hired as a Dietary Worker 1 on May 8, 2017 and was due to have the communicable disease training no later than May 8, 2019. There was no documentation of the completion of the HIV/AIDS and TB/STD training as of the date of the inspection.Employee # 96 was hired as a Dietary Worker 1 on August 8, 2016 and was due to have the communicable disease training no later than August 8, 2018. There was no documentation of the completion of the HIV/AIDS and TB/STD training as of the date of the inspection.Employee # 106 was hired as Medical Records on June 26, 2017 and was due to have the communicable disease training no later than June 26, 2019. There was no documentation of the completion of the TB/STD training as of the date of the inspection.Employee # 108 was hired as a Receptionist on November 2, 2016 and was due to have the communicable disease training no later than November 2, 2018. There was no documentation of the completion of the TB/STD training as of the date of the inspection.Employee # 113 was hired as Transportation on June 12, 2018 and was due to have the communicable disease training no later than June 12, 2020. There was no documentation of the completion of the HIV/AIDS and TB/STD training as of the date of the inspection.Employee # 120 was hired as Lead Housekeeper on August 22, 2017 and was due to have the communicable disease training no later than August 22, 2019. There was no documentation of the completion of the HIV/AIDS training as of the date of the inspection.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
All staff listed will log into the DDAP training page to find the required training for them to take. They will also search for training's outside of DDAP to ensure their training requirements are being met. The following deficient staff will complete these training's by October 2020, due to lack of training opportunities. HR will inform all supervisors what training's their staff are in need of. All Supervisors will then track the training's and assist in getting their staff set up for training's. It will be the responsibility of the staff to find the training's, and give the training certificates to the supervisor and HR, to assist with this tracking. if there is a deficiency, staff will be taken off of the schedule until the deficiency is rectified. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
During a review of 131 staff listed on the Staffing Requirement Facility Summary Report provided by the facility on July 22, 2020, the facility failed to ensure that staff # 112, #114, #115, and #116 had CPR certification and first aid training provided so that at least one person trained in these skills was onsite during the project's hours of operation. Employee # 112 was hired as a Driver on October 7, 2019 and works alone and supervises clients while transporting per the job description. There was no documentation of the completion of the training as of the date of the inspection.Employee # 114 was hired as a Driver on March 4, 2019 and works alone and supervises clients while transporting per the job description. There was no documentation of the completion of the training as of the date of the inspection.Employee # 115 was hired as a Driver on June 20, 2011 and works alone and supervises clients while transporting per the job description. There was no documentation of the completion of the training as of the date of the inspection.Employee # 116 was hired as a Driver on July 6, 2016 and works alone and supervises clients while transporting per the job description. There was no documentation of the completion of the training as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
One of the 4 staff completed their CPR training and is in compliance currently. The remaining 3 staff will ensure that their training is completed by 8/24/20. Moving forward, if training cannot be completed on site by a Pyramid trainer, we will work on to have a trainer from another region provide training. If that is not possible, staff will complete training outside of Pyramid, so as not to be out of compliance. HR will inform all supervisors what training's their staff are in need of. All Supervisors will then track the training's and assist in getting their staff set up for training's. It will be the responsibility of the staff to find the training's, and give the training certificates to the supervisor and HR, to assist with this tracking. if there is a deficiency, staff will be taken off of the schedule until the deficiency is rectified. |
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 six fire drill logs on July 22, 2020, the facility failed to conduct unannounced fire drills at least once a month. There were no fire drills documented for the months of November 2019, March 2020 and June 2020 at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pyramid has implemented a new Fire Drill form that will go into effect for the month of August 2020. This form was distributed to maintenance, who preforms the fire drills. This was given to them on 8-7-2020. Executive Director will meet with the head of maintenance, and the Regional Manager for Maintenance on 8-11-20 and review the new form, along with the guidelines for fire drills. Executive Director will stress the importance of monthly fire drill compliance. Maintenance will ensure this happens beginning this month, and if for some reason, maintenance is unable to preform the fire drill, additional staff will be assigned to conduct the drill. Housekeeping staff and BHT Manager will be trained by the head of Maintenance by August 15, 2020, on how to adequately facilitate a fire drill, in the event that Maintenance cannot run a drill. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of six fire drill logs on July 22, 2020, the facility failed to document the time that the fire drill took place on April 17, 2020. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pyramid has implemented a new Fire Drill form that will go into effect for the month of August 2020. This form was distributed to maintenance, who preforms the fire drills. This was given to them on 8-7-2020. Executive Director will meet with the head of maintenance, and the Regional Manager for Maintenance on 8-11-20 and reviewed the new form, along with the guidelines for fire drills. We will review the form in its entirety, and review that all information must be filled out on each form, per fire drill. Maintenance will ensure this is accurately filled out beginning this month. Head of Maintenance will train housekeeping and a BHT Manager on how to properly fill out this form, in the event that they will have to facilitate the fire drill. |
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 six fire drill logs on July 22, 2020, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There was no sleeping fire drill documented between October 2019 through May 2020 at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pyramid has implemented a new Fire Drill form that will go into effect for the month of August 2020. This form was distributed to maintenance, who preforms the fire drills. This was given to them on 8-7-2020. Executive Director will meet with the head of maintenance, and the Regional Manager for Maintenance on 8-11-20 and reviewed the new form, along with the guidelines for fire drills in regards to having a drill during sleeping hours at minimum every 6 months. Maintenance will ensure this happens beginning this month, and if for some reason, maintenance is unable to preform the fire drill, additional staff will be assigned to conduct the drill. |