INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 29-30, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc. 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report and personnel/training records on November 29-30, 2017, the facility failed to ensure that an individual training plan was developed for Employee #9, #21 and #22.
This information was reviewed with the facility staff during the licensing inspection.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the December 8 through 9, 2017 licensing inspection.
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Plan of Correction
The Administrative Assistant for the facility will work with the regional Human Resources Department to monitor the completion of training plans for all staff members. The Program Director will ensure that all department supervisors are monitoring staff compliance with training plan guidelines through monthly documented supervision. Human Resource Coordinators will complete monthly reviews of employee files to ensure training plan compliance. Target date for completion is January 15, 2018. |
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 the facility's Staffing Requirements Facility Summary Report and personnel/training records, the facility failed to ensure that Employee #6 and #10 through 20 received the required trainings in the appropriate time frame.
Employee #6 was hired on August 3, 2015 as a Counselor and was required to have 6 hours of HIV/AIDs training by August 3, 2016. There was no documentation at the time of the inspection.
Employee #10 was hired as a Needs Assessment Co-coordinator on August 4, 2015 and was required to have 6 hours of HIV/AIDs and 4 hours of TB/STD by August 4, 2017. There was no documentation at the time of the inspection.
Employee #11 was hired as a Nursing Secretary on May 6, 2015 and was required to have 6 hours of HIV/AIDs training by May 6, 2017. There was no documentation at the time of the inspection.
Employee #12 was hired as UR Coordinator on August 3, 2015 and was required to have 6 hours of HIV/AIDs and 4 hours TB/STD training by August 3, 2017. There was no documentation at the time of the inspection.
Employee #13 was hired as a BHT on October 6, 2014 and was due to have 6 hours of HIV/AIDs training by October 6, 2016. There was no documentation at the time of the inspection.
Employee #14 was hired as a BHT on April 17, 2015 and was required to have 6 hours of HIV/AIDs and 4 hours of TB/STD on April 17, 2017. There was no documentation at the time of the inspection.
Employee #15 was hired as BHT Supervisor on July 21, 2015 and was required 6 hours of HIV/AIDs and 4 hours of TB/STD training by April 17, 2017. There was no documentation at the time of the inspection.
Employee #16 was hired as a Detox Specialist on August 6, 2015 and was required to have 6 hours of HIV/AIDs by October 6, 2017. There was no documentation at the time of the inspection.
Employee #17 was hired as a Dietary Kitchen Supervisor on September 21, 2015 and was required to have 6 hours of HIV/AIDs and 4 hours of TB/STD training by September 21, 2017. There was no documentation at the time of the inspection.
Employee #18 was hired in Housekeeping on September 9, 2015 and was required to have 6 hours of HIV/AIDs and 4 hours of TB/STD training by September 2017. There was no documentation at the time of the inspection.
Employee #19 was hired as Maintenance Manager on June 8, 2015 and was required to have 6 hours of HIV/AIDs training by June 8, 2017. There was no documentation at the time of the inspection.
Employee #20 was hired as a Maintenance Worker on June 18, 2015 and was required to have 6 hours of HIV/AIDs training by June 18, 2017.
This information was reviewed with the facility staff during the licensing inspection.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the December 8 through December 9, 2016 licensing inspection.
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Plan of Correction
The Administrative Assistant for the facility will work with the Regional Human Resources Department to monitor the completion of HIV/AIDS and TB/STD trainings for all employees in accordance with state regulations. The Program Director will ensure that Department Supervisors are appropriately monitoring staff for compliance with training guidelines through monthly documented suoervision. The Human Resources Coordinators will complete monthly reviews of employee files to ensure compliance with training standards. Target date for completion is February 1, 2018.
Employee #6 will be scheduled to attend HIV/AIDS training on March 1, 2018.
Employee #10 will be scheduled to attend TB/STD training on February 8, 2018. Employee #10 will be scheduled to attend HIV/AIDS on March 1, 2018.
Employee #11 will be scheduled to attend HIV/AIDS training on March 1, 2018.
Employee #12 will be scheduled to attend TB/STD training on February 8, 2018. Employee #12 will be scheduled to attend HIV/AIDS training on March 1, 2018.
Employee #13 will be schedulled to attend TB/STD training on February 8, 2018. Employee #13 will be scheduled to attend HIV/AIDS training on March 1, 2018.
Employee #15 will be scheduled to attend TB/STD training on February 8, 2018. Employee #15 will be scheduled to attend HIV/AIDS training on March 1,2018.
Employee #16 will attend HIV/AIDS training on March 1, 2018.
Employee #17 will be scheduled to attend TB/STD on February 8, 2018. Employee #17 will be scheduled to attend HIV/AIDS training on March 1, 2018.
Employee #19 will be scheduled to attend HIV/AIDS training on March 1, 2018.
Employee #20 will be scheduled to attend HIV/AIDS training on March 1, 2018.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel/training records on November 29-30, 2017, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of three personnel/training records.
Employee #4 was hired on July 22, 2013 as a counselor. The training year is from January 1 to December 30, 2016. Employee #4 completed 17 clock hours of training for the 2016 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective January 2, 2018, Pyramid's Regional HR Coordinator will be utilizing a newly developed data base to track on going training requirements regionally for every employee. The HR Coordinator will share this information with respective leadership of designated teams quarterly to ensure training needs are discussed during supervision and subsequently met. Any training requirements and due dates will be noted in supervision documentation.
Employee #4 will be scheduled to attend trainins on Confidentiality, Ethics, HIV/AIDS, Cultural Diversity, and the new ASAM level of care placement tool. These trainings are already scheduled from January 15, 2018 through May 21, 2018 except for the ASAM which is to be announced. It is expected that Employee #4 will have accumulated the required 25 training hours for the current year before July 1, 2018. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Graff, Tina
Based on a review of personnel/training records on November 29-30, 2017, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in one new employee record reviewed.
Employee #7 was hired on April 3, 2017 as Facility Director. There was no documentation that Employee # 7 was trained to perform assigned tasks during emergencies.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective January 2, 2018, Pyramid's Regional HR Coordinator will be utilizing a newly developed data base for the facility to specifically track initial and yearly training requirements regionally for all staff. This information will now be forwarded to the facility's Office Manager who will in turn send email notifications to all department supervisors regarding staff training requirements and dates of available trainings. Supervisors will review training needs with respective staff as a part of their individual supervison to ensure compliance.
Employee #7 will be participating in Pyramid Health Care's general Safety Training on January 5, 2018 |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records on November 29-30, 2017, the facility failed to verify the individual had reached 18 years of age, the individual's identity including name, address, date of birth, and emergency contact in four of six patient records.
Patient #1 was admitted to treatment on 11/25/2017 and was administered 2mg of Subutex on 11/26/2017 at 8am. There was no identification or other form of verification documented in the patient record.
Patient #2 was admitted to treatment on 11/25/2017 and was administered 2mg of Subutex on 11/26/2017 at 8am. There was no identification or other form of verification documented in the patient record.
Patient #3 was admitted to treatment on 8/28/2017 and was administered 2 mg of Subutex on 8/29/2017 at 10 am. There was no identification or other form of verification documented in the patient record.
Patient #5 was admitted to treatment on 11/21/2017 and self-administered 8 mg of Suboxone on 11/22/2017 at 8am. There was no identification or other form of verification documented or an emergency contact release in the patient record.
Employee #6 was admitted to treatment on 6/18/17 and self-administered 8 mg of Suboxone on 6/20/2017 at 8am. There was no identification or other form of verification documented in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of the call, Pyramid's Central Intake/Admissions Department will notify any potential admission of the requirement to provide photo identification upon arrival to their respective facility. Upon the client's arrival to the facility, Intake staff will obtain photo identification and scan into the client electronic record. The Admissions Department was informed on December 4, 2017 regarding the requirement to verify an individual's name, adress, and DOB and to scan that information into the client's electronic record. If the client fails to provide necessary identification, proper notification will be provided to the detox specialist to ensure on going efforts to secure said needed identification.
Patients #1, #2, #3,#5, and #6 have all completed thier 3a level of care and are no longer residing at the faciity. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of client records on November 29-30, 2017, the facility failed to obtain an informed, voluntary, written consent before an agent being administered for detoxification in four of six client records.
Client #1 was admitted to treatment on 11/25/2017 and was still an active client. A consent for buprenorphine treatment was dated 11/25/2017, but was not signed by the client at the time of the inspection.
Client #2 was admitted to treatment on 11/25/2017 and was still an active client. A consent for buprenorphine treatment was dated 11/25/2017, but was not signed by the client at the time of the inspection.
Client #3 was admitted to treatment on 8/28/2017 and transferred to rehabilitation on 9/2/2017. A consent for buprenorphine treatment was dated 8/28/2017, but was not signed by the client at the time of the inspection.
Client #4 was admitted to treatment on 9/15/2017 and transferred to rehabilitation on 9/20/2017. A consent for buprenorphine treatment was dated 9/15/2017, but was not signed by the client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility does have an informed, voluntary, written consent in place that is given to every Detoxification client assigned to the 3a level of care. Rather than completing an electronic signature, the Nursing Department now has electronic signature pads available which will allow for every client to physically sign off on the document and have this reflected in the client's chart. This has been in effect since December 15, 2017. If ever an electronic signature pad is not available, a paper consent form will be provided to the client by the nursing department and subsequently scanned into the client's electronic record. The Admissions Coordinator at the facility will oversee the procedure of having all clients sign a consent form upon their arrival. The facility Nurse Manager will also look into the client's electronic record to ensure that a consent was properly signed and placed into their chart.
Clients #1 and #2 were provided with a paper consent form to sign as they were current clients at the time of inspection. Clients #3 and #4 had dated but unsigned consent forms that could not be secured becasue they were no longer at the facility. |
709.54(a)(2) LICENSURE Receiving/storing/preserving
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(2) Receiving, storing and preserving of food stuff.
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Observations
Based on the physical plant tour, the facility failed to ensure that the policy and procedure for receiving, storing and preserving of food stuff were being followed by kitchen staff.
The physical plant tour took place on November 29, 2017. During the tour of the dry goods storage area, there was a large container of salad dressing that was dated to expire October 10, 2017.
Also, while in the walk in refrigerator, boxes of food items with a receiving date of November 27, 2017 were stored on top of boxes with receiving date of October 10, 2017.
The facility director stated that it appeared that the policy and the procedure of proper rotation were not being followed by kitchen staff.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility policy and procedure for dietetic services to receive, store, and preserve food involves the FIFO method (First in, First Out). Older dated items need to be first on the self whether that be on the top or in the front of newer products. This way it can be accessed first and clearly labeled. The newer items always go in the back behind older dated items. When food orders are received, they should be put away according to this FIFO rule. That way the stock is properly put away and items are being used appropriately thus ensuring the freshness of the product.
The facility's Lead Dietary Worker, who is Serve Safe trained, will ensure that all delivered food products will be stored using the FIFO method and document accordingly. The Regional Dietary Manager will oversee this rocess with weekly visits to the facility, and work in conjunction with the Lead Dietary Worker on development of a tracking log that requires supervisory sign off to ensure the process is being followed. Further staff training regarding the FIFO method commenced during the week of December 24, 2017. The FIFO log will be developed and implemented no later than the week of January 21, 2018. |