INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16 - 17, 2012 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.
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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
Based on a review of the facility's staffing requirements facility summary report, the facility failed to provide documentation of HIV/AIDS training in one out of ten records reviewed.
The findings include:
Ten personnel records were reviewed on October 4 - 5, 2012. Per regulation, staff persons shall receive a minimum of four hours of TB/STD training and six hours of HIV/AIDS training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training within the first two years of employment.
Employee #10 was hired May 24, 2010 as support staff. This employee was required to obtain six hours of TB/STD the training by May 24, 2012. Employee # 10 failed to obtain the training as of the date of the inspection.
An interview with facility staff on October 17, 2012 confirmed the findings.
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Plan of Correction
The identified employee #10 who did not meet the training requirements for obtaining six hours of TB/STD by May 24, 2012 has been scheduled to attend this training on December 13, 2012.
The Program Manager will ensure that all Department Supervisors are monitoring compliance with regard to meeting staff training requirements through individual and group supervision monthly as well as quarterly reviews of training records with Human Resource Department Staff. Target date for completion is December 13, 2012. |
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 project director and the facility director in one of two personnel records.
The findings include:
Ten personnel records were reviewed on October 4-5, 2012. One personnel record pertained to the project director, #1. The facility's training year is January- December. The facility's 2011 training year was reviewed. Two personnel records required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 has been the project director since July, 1999. There were no training hours documented for the 2011 training year.
Human resources personnel were interviewed on October 5, 2012 and confirmed the findings.
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Plan of Correction
The identified Project Manager who failed to document the required twelve hours of annual training will complete twelve hours of training by November 30, 2012.
The Human Resource Coordinator will ensure completion. Target date for completion is November 30, 2012. |
704.12(a)(3)(ii) LICENSURE NonHosp Rehab/Adol
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(ii) Projects serving adolescent clients shall have one FTE counselor for every six clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on October 16, 2012, the facility failed to ensure that the project serving adolescent clients shall have one FTE counselor for every six clients.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on October 17, 2012. The form listed three counselor assistants, four counselors, a clinical supervisor, project director and facility director as clinical staff. The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based on the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week 40, and the total number of clients assigned to employees on October 16, 2012 exceeded the allowable maximum 6:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the client ' s treatment by the facility's standard workweek.
The number of hours per week devoted by clinical staff to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 290 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that clinical staff had 45 active clients on October 16, 2012
290/40 = 7.25 FTE 45 clients/7.25 FTE = 7:1 caseload
An interview with the facility director on October 16, 2012 confirmed the findings.
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Plan of Correction
The Clinical Supervisor and Program Manager will ensure that the facility serving adolescent clients will provide the adequate number of clinical staff to ensure that there will be one full-time counselor for every six clients in treatment.
Clinical Supervisor hired a full-time counselor effective October 29, 2012. Approval for the hire of an additional full-time counselor received by Eastern Vice President of Operations effective October 25,2012.
Human Resource Coordinator, Clinical Supervisor and Program Manager to ensure future compliance with this standard by reviewing any changes in staffing and following established hiring protocol to maintain ratio standards. Target date for completion is December 17, 2012. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection, the facility failed to provide slip resistant surfaces in several bathtubs and showers.
The findings include:
A physical plant inspection was conducted on October 17, 2012 . All bathtubs/showers are required to have slip resistant flooring. During the tour of the boys wing it was observed that all bathtubs/showers failed to have slip resistant surfaces in the following restrooms, #2, 3, 4 and 5. An interview with facility staff on October 17, 2012 confirmed the findings.
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Plan of Correction
Bathrooms #2,3,4 & 5 on the boys unit were without slip resistant flooring. Maintenance Director to provide slip resistant mats for bathrooms #2,3,4 & 5 located on the boys unit of the facility.
Bathroom #1&2 located on the girls unit of the faciity were without working exhaust fans. Maintenance Director to provide ventilation to bathroom #1&2 on girls unit by necessary repair or replacement of exhaust fans.
Maintenance Director to document regualr scheduled physical plant audits. These documented sudits will be reviewed at the RISK team meetings held on a monthly basis. Target date for completion is November 17, 2012. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant tour, the facility failed to provide an exhaust fan or window in two bathrooms.
The findings include:
The physical plant tour took place on October 17, 2012. The two bathrooms on the girls wing failed to have workable exhaust fans in the following bathrooms, #1 and 2. An interview with facility staff on October 17, 2012 confirmed the findings.
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Plan of Correction
Bathroom #1&2 on the girls unit of the facilit were without working exhaust fans. Maintenance Director to provide ventilation to bathroom #1&2 on girls unit by necessary repair and or replacement.
Maintenance Director to document regular scheduled physical plant audits. These documented audits will be reviewed at the RISK team meetings held on a monthly basis. Target date for completion is November 17, 2012. |
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 the fire drill record, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
The fire drill record was reviewed on October 16, 2012. Documentation of a fire drill conducted during sleeping hours is required once every six months. The fire drill record was reviewed from the last survey, November 2011 through September 2012. During that time frame, the facility documented only one fire drill during sleeping hours, August 23, 2012.
An interview with the facility director on October 16, 2012 confirmed the findings.
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Plan of Correction
Facility required conducting and documenting a fire drill during sleeping hours a minimum of every six months. Maintenance Director will orchestrate a fire drill during facility sleeping hurs a minimum of one time every six months and document the drills accordingly.
RISK/PI Coordinator will conduct fire drills with Program Manager and Maintenance Director and log outcomes accordingly. All identified parties to coordinate future fire drills at RISK team meetings on a monthly basis. Target date for next overnight fire drill to be coordinated and documented by November 17, 2012. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observation and a physical plant inspection, the facility failed to secure discharged client records within locked storage containers.
The findings include:
A physical plant inspection was completed on October 17, 2012. At the time of the physical plant inspection, there were boxes of discharged client records located in a storage area in the basement . The storage area was locked, and contained other items along with the unsecured boxes of client records.
An interview with the project director and facility staff on October 17, 2012 confirmed the findings.
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Plan of Correction
All discharged client records beyond three years to be boxed and stored with an off-site record and storage service company. All discharged client records that remain in the facility will be secured within locked storage containers in the designated medical records office.
Medical Records Personnel will be responsible to coordinate the labeling and pick-up of dishcarged recordsw with the identified storage company to ensure confidentiality of client records as well as maintaning and securing the client storage of records that remain at the facility in the appropriate containers. Program Manager to oversee coordination of record storage and remain in contact with both medical record personnel and storage company to ensure storage of records are meeting standards both on and off-site. Target date for completion is December 17, 2012. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to obtained informed and voluntary consents in fourteen of fourteen client records.
Findings:
Fourteen client records were reviewed on October 17, 2012. Consent to release forms were required in fourteen records.
Client #1 had consent to release form for a high school, but failed to include what was being released and whether or not the client knew they had a right to revoke their consent. The consent to release form was dated September 12, 2012.
Client #2 had consent to release form for a high school, but failed to include what was being released and whether or not the client knew they had a right to revoke their consent. The consent to release form was dated September 12, 2012. Also, the record contained consent for a government agency that exceeded 255.5 by allowing the government agency copies of the client ' s discharge summaries/aftercare plan and treatment plans. The consent to release form was dated September 12, 2012.
Client #3 had consent to release form for a government agency that exceeded 255.5 by allowing the government agency copies of the client's discharge summary/aftercare plan and treatment plans. The consent to release form was dated September 14, 2012. Also, the record contained consent to release form for a high school, but failed to include what was being released and whether or not the client knew they had a right to revoke their consent. The consent to release form was dated September 14, 2012.
Client #4 had consent to release form for a government agency that exceeded 255.5 by allowing the government agency copies of the client's discharge summary/aftercare plan and treatment plans. The consent to release form was dated September 26, 2012. Also, the record contained consent to release form for a high school, but failed to include what was being released and whether or not the client knew they had a right to revoke their consent. The consent to release form was dated September 26, 2012.
Client #5 had consent to release form for a government agency that exceeded 255.5 by allowing the government agency copies of the client's discharge summary/aftercare plan and treatment plans. The consent to release form was dated September 5, 2012. Also, the record contained consent to release form for a high school, but failed to include what was being released and whether or not the client knew they had a right to revoke their consent. The consent to release form was dated September 5, 2012.
Client #6 had consent to release form for a high school, but the consent failed to state whether or not the client knew they had a right to revoke their consent. The consent to release form was dated October 9, 2012. Also, the record contained consent for an insurance company that exceeded 255.5 by allowing the insurance company to receive a copy of the client ' s history/physical, psychosocial assessment, psychiatric notes, discharge summaries/aftercare plan and treatment plans. The consent to release form was dated October 12, 2012. A letter was also sent on October 12, 2012 "to whom it may concern", could not determine if there was a consent to release form in client #6's for this letter.
Client #7 had consent to release form for a government agency that exceeded 255.5 by allowing the government agency copies of the client's discharge summary/aftercare plan and treatment plans. The consent to release form was dated October 4, 2012. Also, the record contained consent to release form for a high school, but failed to include what was being released and whether or not the client knew they had a right to revoke their consent. The consent to release form was dated October 4, 2012. A consent to release form dated October 9, 2012 for client's family did not have what was being release to the family member and the witness did not sign or date the consent to release form.
Client #8 had consent to release form for a high school, but the consent failed to include what was being released and whether or not the client knew they had a right to revoke their consent. The consent to release form was dated September 13, 2012. Also, the record contained consent for a government agency that exceeded 255.5 by allowing the government agency copies of the client ' s discharge summaries/aftercare plan and treatment plans. The consent to release form was dated September 13, 2012.
Client #9 had consent to release form for a high school, but failed to include whether or not the client knew they had a right to revoke their consent. The consent to release form was dated August 31, 2012. A letter was sent out address "to whom it may concern" on October 8, 2012. Could not determine if there was a consent to release form in client #9's for this letter. Also, there were four adolescent placement summary sheets (APSS) that had exceeded 4 PA Code 255.5 of what can be given to insurance companies. The following ACPC's documented identifying information that exceeded what is required by law when it came to 4 PA Code 255.5 on the following dates; September 13, 2012, September 21, 2012, October 1, 2012 and October 8, 2012.
Client #10 had consent to release form for a high school, but failed to include whether or not the client knew they had a right to revoke their consent. The consent to release form was dated August 14, 2012.
Client #11 had consent to release form for a high school, but failed to include whether or not the client knew they had a right to revoke their consent. The consent to release form was dated June 27, 2012. On August 6, 2012 the client's discharge summary was fax the client's probation officer. Also, on August 6, 2012 the client's discharge summary was faxed to a treatment provided, but the facility failed to have a valid consent to release form filed in client #11's record.
Client #12 had consent to release form for a high school, but failed to include whether or not the client knew they had a right to revoke their consent. The consent to release form was dated July 27, 2012. On September 12, 2012 the client's discharge summary was fax the client's probation officer.
Client #13 had consent to release form for a high school, but failed to include whether or not the client knew they had a right to revoke their consent. The consent to release form was dated July 19, 2012.
Client #14 had consent to release form for a high school, but failed to include whether or not the client knew they had a right to revoke their consent. The consent to release form was dated June 29, 2012.
An interview with the facility director and facility staff on October 17, 2012 confirmed the findings.
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Plan of Correction
Informed and voluntary consent will be obtained from the client for the disclosure of information contained in th client record. All consents utilized by the facility will ensure that informed and voluntary consent will be obtained from the client for the disclosure of information contained in his/her record.
Corporate Compliance Officer to revise and approve all consents for use in facility client records. Only those consents that have been approved will be utilized.
Clinical Supervisor will review these changes with all clinical/admission staff responsible for filling out consent forms and will monitor for compliance by completing montly chart audits. Target date for revision of consent for school and government agency to be revised by Corporate Compliance Officer and permitted for use by November 17, 2012. |
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 client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in eight of fourteen client records.
The findings include:
Fourteen client records were reviewed on October 17, 2012. A psychosocial evaluation was reviewed in eight client records, #1, 2, 3, 4, 5, 6, 7 and 8.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's assets/strengths, coping mechanisms, support systems and negative factors towards treatment.
An interview with the facility director and facility staff on October 17, 2012 confirmed the findings.
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Plan of Correction
Clinical staff will provide a psychosocial evaluation that will include: client assests/strengths, positive support systems, coping mechanisms and negative factors that may inhibit treatment of the client. The clinical staff will document a complete/thorough psychosocial evaluation as part of the client record.
The Clinical Supervisor will review with clinical staff what is to be included in a complete psychosocial evaluation as part of the clinical record. The Clinical Supervisor will monitor for compliance through bi-weekly documented supervision and by the completion of monthly chart audits. Target date for completion is December 1, 2012. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to include components in the aftercare plan.
The findings include:
Fourteen client records were reviewed on October 17, 2012. Six discharge client records were required to have documentation of an aftercare plan, # 9, 10, 11, 12, 13 and 14. The following components are required to be documented on the aftercare plan; goals with time frames, support services, contact person and the reentry process. The facility failed to include time frames with the goals documented on the aftercare plans for client # 9, 10, 11, 12, 13 and 14.
Client #9 was admitted on August 31, 2012 and discharged on October 8, 2012.
Client #10 was admitted on August 14, 2012 and discharged on September 13, 2012.
Client #11 was admitted on June 27, 2012 and discharged on August 3, 2012.
Client #12 was admitted on July 27, 2012 and discharged on September 11, 2012.
Client #13 was admitted on July 19, 2012 and discharged on September 5, 2012.
Client #14 was admitted on June 29, 2012 and discharged on August 6, 2012.
An interview with the facility director and facility staff on October 17, 2012 confirmed the findings.
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Plan of Correction
All aftercare plans completed by the clinical staff will include goals with time frames, support services, contact persons and the reentry process.
Clinical Supervisor will review with clinical staff the need for established time frames to coincide with the goals that are identified and documented on client aftercare plans. Clinical Supervisor will monitor compliance through bi-weekly documented supervision and by completion of monthly chart audits. Target date for completion is December 1, 2012. |