INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 19, 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 Lehigh Valley 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of nine personnel records, it was determined that one employee hired as a counselor did not meet the qualification requirements for the position.
Employee #4 was hired as a counselor on November 15, 2021 and was current in that position at the time of the inspection. At the time of hire, the employee did not have a bachelor's degree from an accredited college.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
During pre-submission, it was brought to Executive Director's attention that Employee #4 was hired as a counselor on 11/15/21 without a bachelor's degree from an accredited college.
Employee #4 was suspended pending investigation on 8/18/2022 and terminated on 8/22/22.
Effective 8/22/22, Executive Director and/or Clinical Supervisor will forward all counselor candidate resumes to Regional Quality Manager for thorough screening and to ensure the individual meets all qualifications prior to hire. |
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.
|
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 one of one applicable record reviewed.
Employee # 8 was hired as an Associate ' s degree level counselor assistant on August 16, 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.
|
Plan of Correction
On 8/24/2022, Clinical Supervisor and Regional Quality Manager reviewed appropriate documentation protocols for current and future counselor assistants.
Moving forward, CS will ensure that documentation accurately reflects when "direct" and "close" observation is facilitated. CS will upload supervision notes to Smartsheet on a weekly basis and Executive Director will review on a monthly basis until CA transitions to Counselor.
Additionally, when a CA is hired, CS and RQM will create a thorough on-boarding plan to outline the timeframe for necessary supervision and expectations of the same.
Employee #8 was promoted to Counselor due to earning a Masters in Art Therapy on May 2022. Her promotion was not due to completion of promotional requirements for a CA. Supervision will continue to occur routinely as it does for all Counselors: at least 1 monthly individual supervision and weekly group supervision. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
|
Observations
Based on a review of personnel records, the facility failed to provide documentation that counselor assistants documented to the facility director that they are working toward counselor status upon completion of each calendar year in one of one applicable record.
Employee # 9 was hired by the facility as a counselor assistant on May 20, 2019 and has remained in that position.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
During pre-submission, Clinical Supervisor and Regional Quality Manager identified that Employee #9 did not provide documentation that she is working towards counselor status upon completion of each calendar year.
At this, time Employee #9 is out on FMLA.
Upon employee's return to the office on 10/03/2022, CS will meet with employee and reiterate expectations regarding the timeline of CAs being promoted to Counselor. CS to ensure enrollment in a degree program within 90 days. |
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.
|
Observations
Based on a review of nine 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 #7 was hired as a counselor on May 10, 2021 and was due to have the communicable disease trainings no later than May 10, 2022. However, the HIV/AIDS training was not completed until June 30, 2022 and the TB/STD training was not completed until August 5, 2022.
Employee #9 was hired as a counselor assistant on May 20, 2019 and was due to have the communicable disease trainings no later than May 20, 2020. However, the TB/STD training was not completed until April 15, 2022.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 4, 2021 annual licensing inspection.
|
Plan of Correction
Executive Director will meet with all department managers no later than 10/11/2022 to review regulation. Effective 10/11/2022, managers will review monthly training reports generated by Pyramid Training Department to ensure compliance for all staff within assigned department. ED to monitor training hours on a quarterly basis.
All department heads, including Regional Managers and Lehigh Valley's Administrative Assistant, will track/monitor completion of all staff's Communicable Disease training and review in monthly leadership meetings. ED will ensure that all managers monitor their assigned staff for compliance via monthly, individual supervision.
Any employee that is missing necessary trainings will complete trainings and/or register for necessary training no later than 11/1. |
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.
|
Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one applicable record.
Employee # 5 was hired as a counselor on February 24, 2020 and has remained in that position. The facility's training year that was reviewed was from January 2021 through December 2021. Employee #5's personnel record only documented 22.8 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 8/24/2022, Clinical Supervisor will monitor clinical staff's training hours on a quarterly basis and provide Executive Director with an update regarding the same. During weekly group and monthly individual supervision, CS will ensure appropriate trainings are scheduled in a timely manner. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
Based on a physical plant inspection on August 19, 2022, the facility failed to keep the grounds of the facility in good repair at all times as the coil heating elements in client bedroom # ' s 201 and 302 were exposed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Repairs were made the day of inspection so that coil heating elements in client bedroom 201 and 302 were no longer exposed. Effective 10/1/2022, Facilities Supervisor and maintenance staff will inspect facility monthly during CARF self-inspection walkthroughs and repair/replace as necessary. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on a physical plant inspection on August 19, 2022, the facility failed to have hot and cold water under pressure in the bathroom of the last detox bedroom on the right-hand side of the first-floor hallway.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Repair was made at time of inspection ? Aerator was replaced. Effective 10/1/2022, Facilities Supervisor and maintenance staff will inspect facility monthly during CARF self-inspection walkthroughs and repair/replace as necessary. |
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.
|
Observations
Based on a review of fire drill logs from September 2021 through June 2022 and the client schedules presented by facility staff, the facility failed to conduct fire drills during sleeping hours at least every six months as the only drill conducted during sleeping hours was in September 2021.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Executive Director reviewed findings with Facilities Supervisor and Leadership Team on 8/24/2022, and identified that sleeping hours for clients as per the schedule are 10:30pm-6:15am. Effective 9/1/2022, all drills conducted during sleeping hours must fall within the appropriate timeframe, which will be recorded on established fire drill log. Facilities Supervisor and ED to meet monthly and identify scheduled fire drills and what hours they will be facilitated. ED and FS to review on a quarterly basis to ensure completion on each shift. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of fire drills logs from September 2021 through June 2022, the facility failed to prepare alternate exit routes to be used during fire drills, as each drill used the front exit.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 10/1/2022, the facilitation of fire drills and documentation of the same will include the exact location of where the fire occurred in the building, along with the specific exit route(s) utilized by clients and staff. Facilities Supervisor to monitor appropriate documentation with on-site maintenance staff. Alternate exit routes will be utilized each fire drill, across each shift, to ensure residents and staff are familiar with alternate exits. Executive Director and Facilities Supervisor will review fire drill logs on a quarterly basis to ensure compliance in this area.
At the time of inspection, illuminated exit signs are posted at both front and rear exits. |
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.
|
Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in three of three applicable records reviewed. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours.
Client #2 was admitted on January 3, 2022 and discharged Against Medical Advice (AMA) on January 5, 2022.
Client #4 was admitted on April 25, 2022 and discharged Against Medical Advice (AMA) on April 28, 2022.
Client #9 was admitted on January 1, 2022 and discharged Against Medical Advice (AMA) on January 20, 2022.
These findings were reviewed with the project staff during the licensing process.
|
Plan of Correction
On 8/22/2022, Executive Director and Clinical Supervisor met with clinical team to review findings and licensing regulation. ED reviewed regulation with all facility staff, via all-staff e-mail, on 8/22/2022. Effective on that same date, Clinical Supervisor will ensure the calling of Emergency Contact within twelve hours by reviewing client-chart on a weekly basis after notice of AMA/AFA. After consistent documentation during 90-day period, Clinical Supervisor will then monitor on a monthly basis. |
709.28 (c) (5) 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 must be in writing and include, but not be limited to:
(5) Dated signature of witness.
|
Observations
Based on a review of twelve client records, the facility failed to ensure that consent to release information forms included the dated signature of a witness in one record reviewed.
Client #3 was admitted on March 1, 2022 and was discharged on March 6, 2022. The record contained a consent to release information form to a government agency signed by the client on March 2, 2022, that was missing the dated signature of the witness.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Supervisor met with clinical team during group supervision on 8/24/22 to review finding and licensing regulation; as well as, completed re-training on how to fully complete releases of information in Electronic Record System, and importance of verifying completed ROI. Effective 8/24/22, all consents will reflect signatures from both client and witness. Compliance will be monitored monthly through chart audits completed by Regional Quality Management. |
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.
|
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 # 8 was admitted to the Rehab activity on August 18, 2021 and discharged on October 28, 2021. Verbal orders were given on September 30, 2021 and October 10, 2021, but were not were not dated when signed by the CRNP.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 8/22/2022, Executive Director and Director of Nursing reviewed findings and licensing regulation. Re-training of how to fully execute verbal orders will be completed by DON no later than 10/20/22. Effective 8/22/22, Nurse Supervisor will monitor appropriate documentation of verbal orders. |
709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
|
Observations
Based on a review of six client records, the facility failed to ensure that intake procedures included documentation of physical examinations within 24 hours of admission in two records reviewed.
Client #5 was admitted on August 14, 2022 and was active at the time of the inspection.
Client #6 was admitted on August 16, 2022 and was active at the time of the inspection.
These finding were discussed with facility staff during the licensing process.
|
Plan of Correction
The Director of Nursing will re-train all physicians on the required documentation of physical examinations to be completed during the intake process, no later than 10/20/22. The site's Nurse Supervisor is responsible for reviewing all necessary documentation after completion of the assessment within the appropriate timeframes (within 24 hours if a detox client and within 72 hours if a residential client). |
709.64(e) LICENSURE Follow-up policy
709.64. Project management services.
(e) The project shall develop a written client follow-up policy.
|
Observations
Based on a review of client records, the facility failed to follow their written client follow-up policy in two of four applicable records reviewed.
Client #2 was admitted on January 3, 2022 and was discharged on January 5, 2022. The client record did not contain documentation of follow up information with the client within 7 days of discharge.
Client #3 was admitted on March 1, 2022 and discharged on March 6, 2022. The client record did not contain documentation of follow up information with the client within 7 days of discharge.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 9/20/22, Clinical Supervisor and Executive Director identified staff responsible for follow-up calls after client's discharge. The Life Skills Specialist and in-house Certified Family Recover Specialist/Certified Recovery Specialist will develop an organized process for tracking discharged clients and documenting follow-up calls within seven days. Identified staff to report in monthly individual supervision to Clinical Supervisor outcome of phone calls for previous month. ED to have oversight of established process. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of six client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 15 days in two of six applicable records reviewed.
Client #8 was admitted on August 18, 2021 and discharged on October 28, 2021. A treatment plan update was completed on September 3, 2021 and another treatment plan update was due to be completed by September 18, 2021; however, the next treatment plan update was not completed until October 8, 2021.
Client #11 was admitted on July 19, 2022 and was active at the time of the inspection. The treatment and rehabilitation plan was completed on July 21, 2022 and a treatment plan update was due to be completed by August 4, 2022; however, the next treatment plan update was not completed until August 10, 2022.
These finding were discussed with facility staff during the licensing process.
This is a repeat citation from the August 4, 2021 annual licensing inspection.
|
Plan of Correction
On 8/22/2022, Executive Director and Clinical Supervisor met with clinical team to review findings and licensing regulation. Effective 8/22/2022, all treatment plans will require updates at least every 14 days. CS will monitor charts weekly and send e-mails to clinical staff, as appropriate, with due dates of treatment plans. CS and Regional Quality Manager to monitor charts monthly to ensure compliance to established timeframe. CS to provide audit outcomes to ED at monthly leadership meetings. |