INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29-30, 2023 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on one of one applicable employee personnel record reviewed, the facility failed to provide documentation of at least two years' experience or the completion of a core curriculum in clinical supervision for employee # 2.
Employee # 3 was hired as a clinical supervisor on July 24, 2022 and was still in this position at the time of the inspection. Based on employee # 3's resume, there was no documentation of at least two years ' experience or the completion of a core curriculum in clinical supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2 no longer works for Pyramid Healthcare.
Employee #3's The employee's resume was updated to include her work at Pyramid Healthcare and the updated resume will show her prior experience over two of treatment planning and individual /group sessions.
All resumes are reviewed with the executive director and HR prior to being hired to ensure they meet the requirements of the position. Executive director will also have Quality Managers review all potential hires to ensure they meet requirements of the ASAM alignment. Person with oversight is ED.
Employee #3 will have the core curriculum training completed by 12/31/2023. Person with oversight is ED.
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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide written semiannual performance evaluation based upon measurable performance standards for employee # 11.
Employee # 11 was hired as a counselor assistant on March 28, 2022 and was still in this position at the time of the inspection. The only performance evaluation provided was dated June 30, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will meet with Regional Quality Manager to review the DDAP qualifications and supervisory needs for Counselor Assistants. This meeting will take place no later than August 20th.
Clinical Supervisor will track on a smartsheet all requirements of her staff. Including performance evaluations. Oversite by Executive Director. Implementation of the Smartsheet will start on 9/10/23
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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 three of four applicable employee personnel records reviewed, the facility failed to provide documentation of weekly supervision in employee records # 10, 11, and 12 and weekly supervision to include one hour of direct observation for a counselor assistant in employee records # 10.
Employee # 10 was hired as a counselor assistant on January 23, 2023 and was still in this position at the time of the inspection. Based on a review of employee # 10's personal record there was no documentation of weekly supervision for the weeks of:
January 22-28, 2023
January 29-March 18, 2023
March 22 and 29, 2023- no direct observation
April 5, 12, 19, 26, 2023- no direct observation
May 3, 10, 17, 31, 2023- no direct observation
Employee # 11 was hired as a counselor assistant on March 28, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 11's personal record there was no documentation of weekly supervision for the weeks of:
September 25- October 1, 2022
October 9-15, 2022
October 16-November 26, 2022
December 4-31, 2022
Employee # 12 was hired as a counselor assistant on December 25, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 12's personal record there was no documentation of weekly supervision for the weeks of:
December 25-31, 2022
January 8-February 4, 2023
February 5-May 20, 2023
June 4-17, 2023
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 27, 2022 annual licensing inspection.
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Plan of Correction
Clinical supervisor will meet with Regional Quality Manager to review the DDAP qualifications and supervisory needs for Counselor Assistants. This meeting will take place no later than August 20th.
Clinical Supervisor will track on a smartsheet all requirements of her staff. Including performance evaluations. Oversite by Executive Director. Implementation of the Smartsheet will start on 8/10/23
Clinical Supervisor and Executive Director will meet weekly and review her supervision schedule to ensure that all the counselors and counselor assistants are receiving the appropriate supervision. This meeting will take place no later than August 1. CS will meet with ED weekly to ensure that counselors and counselor assistants are receiving the appropriate frequency of supervision and observation.
All supervision documentation will be tracked on a Smartsheet and monitored by ED on a monthly basis beginning on 8/10/23
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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 staffing requirements facility summary report (SRFSR) and confirmation from facility staff, the facility failed to provide an individual training plan for employees # 13, 14, 17, 18, 19, 21, 22, and 23.
Employee # 13 was hired as a support staff on May 29, 2023 and was still in this position at the time of the inspection.
Employee # 14 was hired as a support staff on May 4, 2023 and was still in this position at the time of the inspection.
Employee # 17 was hired as a support staff on May 2, 2022 and was still in this position at the time of the inspection.
Employee # 18 was hired as a support staff on September 17, 2021 and was still in this position at the time of the inspection.
Employee # 19 was hired as a support staff on February 15, 1998 and was still in this position at the time of the inspection.
Employee # 21 was hired as a support staff on August 15, 2022 and was still in this position at the time of the inspection.
Employee # 22 was hired as a support staff on November 21, 2022 and was still in this position at the time of the inspection.
Employee # 23 was hired as a support staff on August 15, 2015 and was still in this position at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative Manager will track and monitor the completion of staff individual training plans for all employees on a Smartsheet. This will start no later than 9/1/23. Executive director will address the Supervisors of each department in Leadership meeting on July 28, 2023 to monitor their assigned staff for compliance of trainings through supervisions. On a quarterly basis the executive director will audit the trainings of the employees including the training plans. First audit will take place no later than 9/10/23 |
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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #15, 16, 20, 24, 25, 26, 27, and 28 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 # 15 was hired as a support staff on March 1, 2021and was still in this position at the time of the inspection. Employee # 15 was due to have the communicable disease trainings no later than March 1, 2023. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee # 16 was hired as a support staff on November 4, 2019 and was still in this position at the time of the inspection. Employee # 16 was due to have the communicable disease trainings no later than November 4, 2021. 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 # 20 was hired as a support staff on January 5, 2021 and was still in this position at the time of the inspection. Employee # 20 was due to have the communicable disease trainings no later than January 5, 2023. 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 # 24 was hired as a support staff on February 23, 2016 and was still in this position at the time of the inspection. Employee # 24 was due to have the communicable disease trainings no later than February 23, 2018. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection. HIV/AIDS training was not completed until March 13, 2023.
Employee # 25 was hired as a support staff on October 7, 2019 and was still in this position at the time of the inspection. Employee # 25 was due to have the communicable disease trainings no later than October 7, 2021. 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 # 26 was hired as a support staff on August 12, 2019 and was still in this position at the time of the inspection. Employee # 26 was due to have the communicable disease trainings no later than August 12, 2021. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee # 27 was hired as a support staff on September 19, 2017 and was still in this position at the time of the inspection. Employee # 27 was due to have the communicable disease trainings no later than September 19, 2019. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee # 28 was hired as a support staff on June 7, 2021 and was still in this position at the time of the inspection. Employee # 28 was due to have the communicable disease trainings no later than June 7, 2023. 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 July 27, 2022, September 9, 2021, July 14, 2020, August 8, 2019, and August 29, 2018 annual licensing inspections.
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Plan of Correction
The Office Manager will ensure that all new hire will take the HIV training within the first year of hire and will track training completion via a Smartsheet, with ED oversight. Executive Director will monitor this Smartsheet on a quarterly basis and the first audit will be completed no later than 11/1/23 all staff members with incomplete trainings will be signed up by December 31, 2023 and completed by July 1, 2024.
The Office Manager will insure that the new staff will sign up for the TB training with in their required time period based on their position and based on DDAP course availability.
All current staff will be monitor on the smartsheet to ensure they complete the required trainings by the office manager August 30th 2023, ED will oversee the smartsheet.
In the Leadership meeting on July 26 we will review the importance of the trainings and the supervisors will be responsible for having their employees signed up for all trainings.
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705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a physical plant inspection, the facility failed to maintain counseling areas with furnishings which are in good repair. Chairs in the administration group room were torn and in disrepair.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The chairs throughout the facility were inspected on 7/25/23 and any torn or disrepair chairs have been disposed of and new chairs have been ordered. Executive Director and Maintenance Supervisor will conduct monthly walk-throughs to inspect the furniture to ensure all furniture is in good conditions. The first walk-through will take place no later than 8/1/23. |
705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a physical plant inspection, the facility failed to ensure bunk beds are equipped with securely attached railings on each open side and open end of the bunk. The main house room #4 had a bunkbed that was missing a railing on either side of the top bunk bed. The Farmhouse women's unit rooms # 3 and # 4 had bunkbeds with loose railings that could be moved or removed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 27, 2022 annual licensing inspection.
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Plan of Correction
Maintenance Supervisor will replace the railings on the bunkbeds in rooms 3 and 4 in the Farmhouse and add a railing to the bed in room 4 of the Main House no later than 8/1/23. Monthly walk-throughs of the buildings will begin taking place no later than 8/1/23 and will include inspection of the bunk bed railings to ensure their safety. Walk-throughs will be documented on the maintenance Smartsheet |
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, the facility failed store all eating, drinking, and cooking utensils in a clean enclosed area. The kitchen area had cooking utensils hanging from hooks and overhead supports and were not being stored in a clean enclosed area.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The kitchen manager has moved all utensils to a clean and enclosed area. The Kitchen Manager provide a re-training to the kitchen staff on keeping utensils in an enclosed, clean area no later than August 3, 2023. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, the facility failed to store all food items off the floor. Boxes of food were stored on the floor in the outside walk-in freezer and containers of food were stored on the floor in the refrigerated area of the outside walk-in.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kitchen Manager ordered a wire shelf unit to ensure that food will not be placed on the floor. This shelf will be installed no later than 9/1/2023 In a team meeting no later than 8/1/23 Kitchen Manager will also discuss with staff the procedure for immediately putting deliveries of food away, as well as proper food storage guidelines. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed. The back emergency door to the detox unit was blocked with stacked chairs from the outside. Also, an emergency exit on the first floor of the Farmhouse was locked from the inside.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 27, 2022 annual licensing inspection.
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Plan of Correction
ED and Maintenance supervisor removed any hazard that prevented client from exiting the building, this was completed immediately.
ED and Maintenance supervisor will conduct monthly walk through to check for all safety hazard: first walk through will be on August 1st,2023. Walk throughs will be on the 1st of each month. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection, the facility ensures interior and exterior stairs are lit at all times. The interior stairway in the main house did not provide light to ensure the stairway is lit at all times.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance supervisor will install the light in the hallway to ensure that it is lit at all times. Target date for completion will be September 1, 2023.
Maintenance supervisor and executive director will complete monthly walk thoughts the ensure all safety measures are enforces and t make sure all stair ways are lit at all times. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill log from July 2022 through May 2023, the facility failed to provide documentation of an unannounced fire drill at least once a month. There was no documentation of a fire drill in May 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will review the regulation for fire drill completion in Leadership meeting on July 28, 2023. Moving forward the fire drills will be completed every month, on all shifts, and documented. Person responsible is the maintenance manager and oversight is Executive Director.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on one of one applicable client record reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in client record # 13.
Client # 13 was admitted on January 18, 2023 and discharged on February 9, 2023. There was no documentation in the client record notifying the client in writing of termination from the project.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 27, 2022 annual licensing inspection.
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Plan of Correction
Clinical Supervisor will review with clinical staff in group supervision the discharge letter document, which notifies a client in writing of their discharge date and type. The Clinical Supervisor discuss with her team no later than Aug 3, 2023. Discharge documentation completion is monitored on a monthly basis by the Quality Specialist via the internal chart monitoring tool and feedback is reviewed with the Clinical Supervisor each month. Clinical Supervisor will review this feedback each month with staff in individual supervision. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on four of seven residential client records reviewed, the facility failed to provide a physical examination on accordance with the facility policy and procedure manual. The facility policy and procedure manual indicates a physical examination occur within 72 hours of admission to any adult or adolescent inpatient drug and alcohol program.
Client # 8 was admitted on May 31, 2023 and was still active at the time of the inspection. A physical examination was due no later than June 3, 2023. The dated signature of the medical staff conducting the exam did not occur until June 4, 2023.
Client # 10 was admitted on June 7, 2023 and was still active at the time of the inspection. A physical examination was due no later than June 10, 2023. The dated signature of the medical staff conducting the exam did not occur until June 13, 2023.
Client # 12 was admitted on February 22, 2023 and was discharged on March 4, 2023. A physical examination was due no later February 25, 2023. There was no documentation of a physical examination in the client record.
Client # 13 was admitted on January 18, 2023 and was discharged on February 9, 2023. A physical examination was due no later January 21, 2023. The dated signature of the medical staff conducting the exam did not occur until February 7, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will meet with provider and review this feedback, as well as the regulation which states the H&P must be completed within 72 hours, on 7/26/2023. Timely H&P completion is monitored on a monthly basis by the Quality Specialist via the internal chart monitoring tool and feedback is reviewed with the Executive Director each month. Executive Director will review this feedback each month with providers in individual supervision. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on three of seven applicable residential client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a case consultation to occur within the first seven days of admission, when there is a change in level of care, or for therapeutic reasons.
Client # 8 was admitted on May 31, 2023 and was still active at the time of the inspection. A case consultation was due to occur no later than June 7, 2023. There was no case consultation documented in the client record.
Client # 9 was admitted on June 5, 2023 and was still active at the time of the inspection. A case consultation was due to occur no later than June 13, 2023. A case consultation did not occur until June 17, 2023.
Client # 13 was admitted on January 18, 2023 and was discharged on February 9, 2023. A case consultation was due to occur no later than January 25, 2023. There was no case consultation documented in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 27, 2022 annual licensing inspection.
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Plan of Correction
Clinical Supervisor will re-train clinical staff on expectations around Case Consultations no later than 7/27/2023. In this training, she will review the contents of the Case Consultation, as well as the timeframes and scenarios in which Case Consultations should be completed. Case Consultation completion is monitored on a monthly basis by the Quality Specialist via the internal chart monitoring tool and feedback is reviewed with the Clinical Supervisor each month. Clinical Supervisor will review this feedback each month with clinical staff in individual supervision. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on two of three applicable residential client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a discharge summary be completed within 7 days of discharge date.
Client # 12 was admitted on February 22, 2023 and was discharged on March 4, 2023. The discharge summary was due to be completed no later than March 11, 2023; however, the discharge summary was not completed.
Client # 13 was admitted on January 18, 2023 and was discharged on February 9, 2023. The discharge summary was due to be completed no later than February 16, 2023; however, the discharge summary was not completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will re-train clinical staff on discharge documentation and timelines no later than 7/28/2023. Discharge documentation completion is monitored on a monthly basis by the Quality Specialist via the internal chart monitoring tool and feedback is reviewed with the Clinical Supervisor each month. Clinical Supervisor will review this feedback each month with staff in individual supervision |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of Twenty-eight personnel records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing communicable disease trainings within regulatory times for staff was submitted and approved by the Department for the July 27, 2022, September 9, 2021, July 14, 2020, August 8, 2019, and August 29, 2018 annual licensing inspections. Completing communicable disease trainings within the regulatory timeframes was again found to be a deficiency in the June 29-30, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will meeting with all Department Supervisors to review the POC
on 7/26/23 and will meet monthly and review the progress of the POC due to repeat citations. Person responsible is Executive director.
Executive Director will meet with the Regional Director monthly to review the progress POC due to having repeat offences and will ensure Langhorne continues to monitor through out the year. person responsible is executive director
Example:
Langhorne has incorporated a new process to ensure trainings be completed by staff in all departments by:
The Office Manager ensuring that all new hire will take the HIV training within the first year of hire and will track training completion via a Smartsheet, with ED oversight. Executive Director will monitor this Smartsheet on a quarterly basis and the first audit will be completed no later than 11/1/23 all staff members with incomplete trainings will be signed up by December 31, 2023 and completed by July 1, 2024.
The Office Manager will insure that the new staff will sign up for the TB training with in their required time period based on their position and based on DDAP course availability.
All current staff will be monitor on the smartsheet to ensure they complete the required trainings by the office manager August 30th 2023, ED will oversee the smartsheet.
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