INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 6, 2022, 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. 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of thirteen personnel records, it was determined that one employee hired as a counselor did not meet the qualification requirements for the position.
Employee #9 was hired as a counselor on December 13, 2021 and was current in that position at the time of the inspection. At the time of hire, the employee did not have a qualifying degree.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A waiver has been submitted to DDAP, from Pyramid Healthcare Hillside, requesting that Counselor's experience, education and continuing ed courses qualify her to move forward in the Counselor role. Counselor was approved and cleared by DDAP, in Dec 2021, to begin onboarding as a Counselor at Hillside. Assistant Program Manager has oversight of Counselor. Executive Director and Director of Compliance will continue to follow up with DDAP on the waiver submitted. Pyramid Healthcare will continue to follow qualification regulations when hiring new employees and reach out to the department on an as needed basis to hire qualified staff in the future.
If the waiver is not approved, Counselor will be moved to Counselor Assistant status. Pyramid Hillside will follow regulations, including supervision, in accordance with the Counselor Assistant position. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to maintain documentation that counselor assistants receive direct observation of the provision of counseling services as part of their close supervision, in two of four applicable records reviewed.
Employee # 11 was hired as a bachelor ' s level counselor assistant by the facility on October 4, 2021. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision from October 19, 2021 through February 11, 2022.
Employee # 13 was hired as a bachelor ' s level counselor assistant by the facility on August 22, 2021. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective February 2022, it was brought to the facility's attention that pertinent information was missing from individual supervision notes. Lead Clinicians began adding direct observation documentation, to the supervision notes, including the client number of the client whom was directly supervised. All clinical supervision notes, post Feb 2022, are documented to meet regulatory guidelines. Assistant Program Manager, and Executive Director, to have oversight to ensure the Lead Clinicians continue to document to meet compliance. |
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 thirteen personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that two applicable employees 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.
Employee #3 was hired as a counselor on August 2, 2021 and was due to have the communicable disease trainings no later than August 2, 2022. However, there was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #7 was hired as a counselor assistant on March 8, 2021 and was promoted to a counselor on May 29, 2022. The employee was due to have the communicable disease trainings no later than March 8, 2022. However, there was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 31, 2021 annual licensing inspections.
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Plan of Correction
Employee number three is scheduled for TB/STD training on 10/10/22 and HIV/AIDS training on 11/17/22 and 11/18/22.
Employee number seven is scheduled for TB/STD training on 10/10/22 and received HIV/AIDs training on 9/8/22 and 9/9/22.
Assistant Program Manager will monitor all trainings to ensure proper completion. A Smartsheet was developed in which employee training dates are tracked. Executive Director will also have oversight and monitor Smartsheet on a monthly basis. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for facility directors in one applicable record reviewed.
Employee # 2 was hired as been in the position of facility director since November 1, 2017. The facility's training year that was reviewed was from January 2021 through December 2021. Employee #2's personnel record only documented 2.5 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will ensure 12 hours of training per year occurs. Facility Director will login to Pyramid's online training site and complete all delinquent trainings. VP of Operations will have oversight and ensure training hours are met when completing employee's annual training plan. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on September 6, 2022, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom as neither were in any client bathroom in the detox unit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On the day of the physical plant inspection, paper towel holders were ordered. All will be installed by the 11/1/22 corrective action date. Paper towels will be refilled daily by housekeeping staff. Maintenance Supervisor is responsible for the ordering and installation of said holders. Housekeeping responsibility forms are scanned and emailed to the Executive Director daily. The refilling of the paper towel holders will be added to the responsibility form by 11/1/22. Executive Director to have oversight to ensure completion. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection on September 6, 2022, the facility failed to maintain each bathroom in a functional and clean manner as evidenced by the following:
Room 105 - appeared to be mold on the wall
- the sink was pulling tiles off the wall
- two tiles were missing on the floor
Room 216 - the ceramic surround of the sink was broken
Room 204 - hole in the shower wall
- broken light switch cover
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Room 105 - appeared to be mold on the wall (This was completed September 6)
- the sink was pulling tiles off the wall (This was completed September 7)
- two tiles were missing on the floor ( This was completed September 23 )
Room 216 - the ceramic surround of the sink was broken (This was completed on September 7 )
Room 204 - hole in the shower wall ( This is schedule to be completed on Tuesday September 27 )
- broken light switch cover ( This was completed September 6 )
The inspection and assessment of bathrooms takes place during monthly facility walk throughs by the maintenance supervisor. Maintenance Supervisor completes monthly building assessments on the Walkthrough Smartsheet, which is submitted to leadership. Adding an additional layer, Leadership now conducts daily room searches in which the conditions of the bedroom are inspected and reported to maintenance. Maintenance Supervisor to have oversight that monthly walk throughs are occurring. Executive Director will have oversight that monthly walk throughs and daily room inspections are occurring and maintenance is following through on all reported issues/projets. This will all be monitored via Smartsheet, which Executive Director is alerted by when submissions are entered.
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705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection on September 6, 2022, the facility failed to store the utensils in a clean enclosed area after each usage as they were in an unenclosed area in the dining room at 1:29 p.m., between the lunch and dinner meals.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
After each meal, the utensils will be brought in from the dining room and stored in a clean enclosed area. Pyramid Hillside does have a storage container with a lid that is utilized. On the day of the inspection, dietary failed to bring the utensils out of the dining room and store them in the container with a lid before a group came in for psycho-education group. Dietary Supervisor will have oversight and ensure the utensils are removed from the dining room after each meal and stored in a clean container with a lid. Executive Director will have oversight of dietary supervisor. |
705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a physical plant inspection on September 6, 2022, the facility failed to ensure that exits from rooms were unobstructed as the door of bedroom 210 locked upon closing and was unable to be unlocked from either the inside or outside for several minutes.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The broken door handle of room 210 was fixed the day of the facility walkthrough. All room handles, room doors and exits will be checked during the monthly walkthrough by Maintenance Supervisor. Executive Director is notified, via smartsheet alert, when the building safety walkthrough is completed. Maintenance Supervisor is responsible for walkthrough and ensuring all exits are unobstructed. Executive Director is responsible to ensure monthly walk throughs are occurring as scheduled one time per month. Target date is 11/1/2022. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection on September 6, 2022, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
The tag on the fire extinguisher located in the vestibule between a group room and an exterior exit, indicated that the most recent inspection and approval occurred in June 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Extinguisher inspections are part of the monthly safety walkthroughs at the facility. Maintenance Supervisor will ensure all fire extinguishers are inspected annually by checking the inspection tags once a month. Executive Director is alerted, via smartsheet notification, when the monthly safety walkthrough is submitted. Maintenance Supervisor is responsible for oversight. As for the current expired extinguisher, it was tested by staff and is operable.
Kistler O'Brien Fire Protection will be on site for inspection by Friday October 7, 2022. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of twelve client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in two of two applicable records reviewed.
Client #4 was admitted to the Rehab activity on June 27, 2022 and discharged Against Facility Advice (AFA) on July 10, 2022. The facility failed to follow their policy related to AFA discharges of calling the Emergency Contact within twelve hours.
Client #6 was admitted to the Rehab activity on January 14, 2022 and discharged Against Facility Advice (AFA) on January 31, 2022. The facility failed to follow their policy related to AFA discharges of calling the Emergency Contact within twelve hours.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
All BHT Leads and Supervisors, plus Nursing Leads, were re-trained in this area. Executive Director developed communication chains, including all members of leadership, Lead Nursing staff and Lead BHT staff and BHT supervisors. The purpose of said communication chains is for after hours and weekend notification of clients who choose to leave treatment AFA. Leadership instructs on site staff to contact emergency contacts immediately upon exiting the facility. Staff are instructed to document in the memo to chart section of the EMR that client's emergency contact was notified ensuring their is a valid ROI.
During the hours of 8am-4pm, Monday through Friday, the client's primary clinician is responsible for notifying the emergency contact of client's exit from the facility, ensuring there is a valid ROI on file, and also documenting in the memo to chart section of the EMR.
Assistant Program Manager and Executive Director ensure compliance to this policy by conducting daily chart audits of the day prior's AFA discharges. |
709.26 (a) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(3) Supervision of staff.
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Observations
Based on a review of personnel records, the facility failed to follow their written procedures for the supervision of staff in two of four applicable records reviewed.
Employee #11 was hired as a counselor assistant on October 4, 2021 and is current in that position. Per the policy of the Project, employee # 11 was due to have a semiannual evaluation by March 25, 2022; however, the semiannual evaluation was not completed until June 21, 2022 by the employee and July 25, 2022 by the supervisor.
Employee #13 was hired as a counselor assistant on August 22, 2021 and is current in that position. Per the policy of the Project, employee # 13 was due to have a semiannual evaluation by February 10, 2022; however, the semiannual evaluation was not completed until June 20, 2022 by the employee and July 25, 2022 by the supervisor.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Our UKG platform now notifies the manager that a semi-annual review is due for a Counselor Assistant; this notification is located in the type right hand corner in the shape of a bell. Once the employee completes his/her assessment, the Manager is notified, via email, that their self-assessment portion of the evaluation is completed. Assistant Program Manager has oversight and will be alerted. Once submitted, Executive Director will be notified of completion. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of twelve client records, the facility failed ensure that verbal orders were authenticated in writing by a physician or other medical professional within the regulatory timeframe.
Client # 5 was admitted to the Rehab activity on May 15, 2022 and discharged on August 2, 2021. A verbal order was given on June 15, 2022, but was not dated when signed by the Physician ' s Assistant.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following is Hillside's procedure for verbal orders:
1. After nurse assesses client, they contact provider for orders.
a. Nurse takes the verbal order, reads it back to confirm it with provider and the nurse signs, dates and time
2. When a provider is in the next day (on site), the order is signed (24 hour time frame).
a. Any time we sign a document in medical it should have your signature, date and time (this is not new)
3. Overnight shift conducts the chart checking.
a. An admission checklist was recently instituted to ensure verbal orders are reviewed.
Lead LPNs, Executive Director and Director of Nursing to have oversight of this process.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(8) Follow-up information.
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Observations
Based on a review of six client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include documentation of follow-up information in one of one applicable record reviewed.
Client #10 was admitted on April 19, 2022 and discharged on April 22, 2022.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective 11/1/2022, Intake Supervisor will complete daily chart audits, and smartsheet fact checking, to ensure the Case Coordination team is contacting former clients for their seven day follow up calls. All former clients are contacted and the documentation is entered into the memo to chart section of the EMR. With daily chart audits corresponding with the follow up call smartsheet, Intake Supervisor can accurately audit each chart listed on said smartsheet to ensure follow up call was made and documented. Executive Director will have overall oversight. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of six client records, the facility failed to include documentation of a psychosocial evaluation in two records reviewed.
Client #1 was admitted on July 11, 2022 and was active at the time of the inspection.
Client #3 was admitted on October 20, 2021 and was discharged on November 28, 2021.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
Effective 11/1/2022, Hillside's Assessment Counselors will complete all residential LOCAs, which include the client's psychosocial, within 24 hours of client's admission. For clients admitting to residential treatment, from the withdrawal management 3.7 level of care and/or discharging home from 3.7 level of care with aftercare, LOCAs, including the client's psychosocial, will be completed on day 5 of their withdrawal management admission date. Intake Supervisor to have oversight to ensure completion. Daily chart audits will be completed by Intake Supervisor to ensure compliance with above timeframes. Executive Director will have overall oversight. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of six client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include documentation of follow-up information in three of four applicable records reviewed.
Client #3 was admitted on October 20, 2021 and discharged on November 28, 2021.
Client #4 was admitted on June 27, 2022 and discharged on July 10, 2022.
Client #6 was admitted on January 14, 2022 and discharged on January 31, 2022.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective 11/1/2022, Assistant Program Manager will complete daily chart audits, and smartsheet fact checking, to ensure Hillside's CRS is contacting former clients for their seven day follow up calls. All former clients are contacted, and the documentation is entered into the memo to chart section of the EMR. Each morning, Assistant Program Manager will send correspondence out to Hillside's CRS, with data from Hillside's bedboard indicating AMA discharges from 3.7 LOC. With daily chart audits corresponding with the follow up call smartsheet, Assistant Program Manager can accurately audit each chart listed on said smartsheet to ensure follow up call was made and documented. CRS is responsible.
Assistant Program Manager to have oversight. Executive Director will have overall oversight. |