INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and complaint investigation conducted on July 10-11, 2024, 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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704.11(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 staff 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.
Staff #18 was hired as a Counselor Assistant on February 5, 2023, and was due to have the communicable disease trainings no later than February 5, 2024. 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.
Staff #19 was hired as a Behavioral Health Tech Supervisor on September 6, 2021, and was due to have the communicable disease trainings no later than September 6, 2023. This staff completed the TB/STD training on March 26, 2024.
Staff #20 was hired a Behavioral Tech Driver on March 22, 2021, and was due to have the communicable disease trainings no later than March 22, 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.
Staff #21 was hired as a Housekeeper on March 24, 2022 and was due to have the communicable disease trainings no later than March 24, 2024. 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.
Staff #22 was hired as an Administrative Assistant on December 28, 2020, and was due to have the communicable disease trainings no later than December 28, 2022. 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.
Staff #23 was hired as Maintenance staff on October 18, 2021, and was due to have the communicable disease trainings no later than October 18, 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.
Staff #24 was hired as a Housekeeper on February 13, 2019, and was due to have the communicable disease trainings no later than February 13, 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.
Staff #25 was hired as the Dinning Services Supervisor on October 18, 2021 and was due to have the communicable disease trainings no later than October 18, 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.
This is a repeat citation from the August 3, 2023 and September 6, 2022 licensing insepctions.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
To address non-compliance with mandatory communicable disease training, the facility has developed a comprehensive plan of correction. This includes creating a detailed, accessible Standard Operating Procedure (SOP) to guide staff through the registration process. A Training Champion will be appointed to oversee training completion, conduct monthly audits, and report directly to the Executive Director. The existing Smartsheet will be used to track training completion, with hiring managers ensuring new employee details are entered promptly to set a 90-day completion goal, coinciding with the probationary period. It should be noted this refers to being "registered" for the course, not necessarily completing it within 90 days. Monthly audits will assess progress, and a policy will prevent employees from completing probation without finishing the training as outlined in the SOP. To evaluate success, the Training Champion will submit reports detailing completion rates and challenges, discussed in monthly staff meetings. Immediate actions involve developing the SOP and appointing the Training Champion by September 15, 2024, with ongoing data entry and audits beginning immediately. The aim is to achieve a 100% completion rate by November 30, 2024, through continuous follow-up and remediation for staff facing challenges. This structured approach with clear timelines and dedicated oversight ensures compliance and enhances training effectiveness. |
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.
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Observations
Based on a physical plant inspection on July 11, 2024, the facility failed to keep the grounds clean, safe, and in good repair. The Department staff witnessed the depletion of water supply resulting in no available water for toilets, showers, kitchen and everyday use. The facility did provide drinking water. Documentation provided by the facility showed this has been an ongoing issue since May 14, 2024.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To address deficiencies in the maintenance of the building exterior and grounds per regulation 705.2, we implemented immediate corrective actions and established preventive measures. The main water tank's leaking line was repaired by United Well & Pump Services on 7/10/2024, and these repairs were documented by the Maintenance Manager. Future issues will be addressed within an hour by maintenance staff, with semiannual inspections scheduled, starting on 1/10/2025, and weekly monitoring conducted by the maintenance team[TD1] . Monthly reports prepared by the Maintenance Manager will be reviewed by the Executive Director, while weekly reports will track water usage[TD2] . Quarterly education sessions for residents and staff, starting on 8/20/2024, will be led by a Behavioral Health Technician to prevent intentional clogs. We aim for a comprehensive review of compliance and monitoring systems by 9/30/2024, ensuring effective oversight and adherence to safety and sanitary standards. Additionally, regarding the advisement by United Well & Pump services to repair the well in the near future, has precipitated an investigation of the well water performance over in the Engineering Department for their engineering analysis of the well water system/performance testing, we expect the resultant data to be available by 9/30. From this analysis we will be able to assess the viability of the current wells output versus the water demand for the facility. |
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, it was determined that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
Fire extinguishers located in the dining room, lobby of the dining room, near the rear exit of the annex and near the gym in the basement did not have inspection tags.
This finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
To address the citation under regulation 705.10 (c) (3), a comprehensive corrective plan for fire safety was implemented. On July 15, 2024, Kistler O'Brien conducted a thorough inspection and tagging of all fire extinguishers, supervised by the Maintenance Manager. Any extinguishers found inoperable will be repaired or replaced within 48 hours. An annual contract with Kistler O'Brien ensures inspections each July, with the next scheduled for July 2025. Monthly internal checks by maintenance staff will verify functionality and tag integrity, with a log maintained for review. Staff will receive annual fire safety training, starting October 5, 2024, facilitated by the Maintenance Manager and Risk/PI Team. Key target dates include completing immediate inspections by August 11, 2024, replacing or repairing inoperable extinguishers by August 13, 2024, and signing an annual inspection contract by August 15, 2024. This plan remediates current deficiencies, enforces routine inspections, and promotes staff awareness, ensuring compliance and enhanced safety. The Maintenance Manager, supported by the Risk/PI Team, is responsible for ongoing oversight of adherence to this plan. |
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 detox and residential client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in three of six applicable client records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in DDAP Licensing Alert 02-21.
Client # 10 was admitted to the inpatient non-hospital detoxification activity on March 26, 2024, and was discharged against medical advice on March 28, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client #18 was admitted to the inpatient non-hospital rehabilitation activity on April 24, 2024, and was discharged against medical advice on April 28, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client #20 was admitted to the inpatient non-hospital rehabilitation activity on February 1, 2024, and was discharged against medical advice on February 5, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To address the citation related to § 709.24 (a) (3), the facility is reinforcing its Non-Routine Discharge (NRD) procedures by requiring all staff to review and sign an updated Standard Operating Procedure (SOP) that mandates notifying the emergency contact within 12 hours of a non-routine discharge, documenting this in Carelogic (EMR), and using a new Smartsheet form (NRD_EC_Hillside) for documentation. The Nurse Manager and BHT Manager will oversee staff training, which is to be completed by September 1, 2024. The BHT Manager will ensure daily form use and, alongside BHT Supervisors, monitor compliance checks starting the same date. Weekly audits by the BHT Manager, beginning September 8, 2024, will assess compliance, with findings reviewed in monthly leadership meetings led by the Executive Director, who will also address any issues promptly. These measures are designed to ensure adherence to client treatment management procedures and enhance coordination in client care and discharge processes. |
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 detox client records, the facility failed to provide a complete client record, which is to include follow-up information in four out of six applicable discharged records reviewed. The facility's policy is to follow-up with discharged clients within seven days of discharge.
Client #6 was admitted on February 1, 2024, and was discharged on February 6, 2024. A follow-up contact was to be completed no later than February 13, 2024; however, it was not completed until February 19, 2024.
Client #7 was admitted on January 20, 2024, and was discharged on January 25, 2024. A follow-up contact was to be completed no later than February 1, 2024; however, it was not completed until February 5, 2024.
Client #8 was admitted on June 19, 2024, and was discharged on June 20, 2024. There was no documentation of a follow-up contact in the client record.
Client #10 was admitted on March 26, 2024, and was discharged on March 28, 2024. There was no documentation of a follow-up contact in the client record.
This is a repeat citation from the August 3, 2023, and September 6, 2022 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address the citation under § 709.63(a)(8), the facility has enhanced its 7-Day Follow-Up procedure for discharged detox clients. All case coordination staff will receive training on the updated SOP by August 12, 2024, overseen by the Case Coordination Manager. The manager will ensure each discharged client is added to the 7-Day Follow-Up Smartsheet, containing details like client name, discharge date, and follow-up status. This process is effective immediately. Weekly audits of the follow-up sheet will begin on August 12, 2024, to ensure timely and documented outreach within seven days post-discharge. This will occur the first 90 days and then transition to by month. Compliance will be tracked in real-time, with outcomes reviewed weekly and discussed in monthly management meetings. Any issues detected will prompt further training or procedural adjustments, overseen by the Executive Director and the Case Coordination Manager, starting the initial review on September 1, 2024. These efforts are intended to ensure complete and compliant client records with prompt follow-up information. |
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 the review of rehab client records, the facility failed to document a complete psychosocial evaluation in four out of seven applicable records. The facility's policy is to complete the psychosocial evaluation within twenty-four hours of admission to the non-hospital rehab.
Client #12 was admitted on June 11, 2024, and was still active at the time of the inspection. A psychosocial evaluation was due to be completed no later than June 12, 2024; however, it was not completed until June 17, 2024.
Client #15 was admitted on December 20, 2023, and was discharged on January 11, 2024. A psychosocial evaluation was due to be completed no later than December 21, 2023; however, it was not completed until January 8, 2024.
Client #16 was admitted on February 6, 2024, and was discharged on March 8, 2024. A psychosocial evaluation was due to be completed no later than February 7, 2024; however, it was not completed until February 13, 2024.
Client #17 was admitted on May 24, 2024, and was discharged on June 21, 2024. A psychosocial evaluation was due to be completed no later than May 25, 2024; however, it was not completed until June 20, 2024
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To address the citation under § 709.51(b)(6), the facility has reinforced its procedure for completing psychosocial evaluations within 24 hours of admission. The responsibility for this task is assigned to clients' primary counselors, under the oversight of the Clinical Director, with immediate implementation starting August 1, 2024. Counselors must meet clients promptly to integrate evaluations with treatment planning. The Clinical Director will manage compliance by providing clinical leads with an Excel sheet tracking admissions and required tasks, with compliance checks starting September 1, 2024. Weekly audits of client records will be conducted to ensure evaluations are completed within the required timeframe, with compliance updates shared via email. Success will be measured by weekly compliance rates, tracked in monthly reports beginning October 1, 2024, and discussed in clinical supervisions to address any issues. This process aims to ensure timely and accurate documentation of psychosocial evaluations, maintaining facility compliance and enhancing client treatment quality. |
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 a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy is that case consultations must be completed within seven days of admission.
Client #11 was admitted on May 28, 2024, and was still active at the time of the inspection. There was no documentation of a completed case consultation in the client record.
Client #12 was admitted on admitted on June 11, 2024, and was still active at the time of the inspection. There was no documentation of a completed case consultation in the client record.
Client #14 was admitted on January 12, 2024, and was discharged on March 25, 2024. A case consultation was due no later than January 19, 2024; however, a case consultation was not documented until February 9, 2024.
Client #17 was admitted on May 24, 2024, and was discharged on June 21, 2024. There was no documentation of a completed case consultation in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In response to the citation under § 709.53(a)(8), the facility has developed a refined process to ensure case consultation notes are completed within seven days of admission, as required by policy. The process involves a new Standard Operating Procedure (SOP) to secure second signatures on consultation notes, with the Clinical Director and two Clinical Leads responsible for signing. Implementation begins September 1, 2024, with regular monitoring using the "My Alerts" feature in Carelogic three times a week to identify missing signatures. On these days, the responsible parties must confirm signature completion via Microsoft Teams. Weekly compliance will be tracked, and any issues promptly addressed in meetings led by the Clinical Director. Bi-weekly audits will commence on September 8, 2024, with outcomes discussed in monthly supervisions to ensure adherence and improve client records. |
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 rehab client records, the facility failed to provide a complete client record, which is to include follow-up information in five out of seven applicable discharged records reviewed. The facility's policy is to follow-up on discharged clients within seven days of discharge.
Client #14 was admitted on January 12, 2024, and was discharged on March 25, 2024. There was no documentation of a follow-up contact in the client record.
Client #16 was admitted on February 6, 2024, and was discharged on May 8, 2024. There was no documentation of a follow-up contact in the client record.
Client #18 was admitted on April 24, 2024, and was discharged on April 28, 2024. There was no documentation of a follow-up contact in the client record.
Client #19 was admitted on May 9, 2024, and was discharged on May 29, 2024. There was no documentation of a follow-up contact in the client record.
Client #20 was admitted on February 1, 2024, and was discharged on February 5, 2024. There was no documentation of a follow-up contact in the client record.
This is a repeat citation from the August 3, 2023 and September 6, 2022 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address the citation under § 709.53(a)(11), the facility has enhanced its follow-up process for discharged rehab clients, ensuring all follow-up actions occur within seven days of discharge. The case coordination team, led by the Case Coordination Manager, will oversee this process, with all staff trained on an updated 7-Day Follow-Up SOP by August 12, 2024. Immediately, each finalized discharge plan will be entered into a 7-Day Follow-Up Smartsheet, tracking client details and follow-up status. The Case Coordination Manager will audit this sheet every Monday and Friday to confirm prompt entries and task completion. Compliance will be tracked through these audits, starting August 12, 2024, ensuring completion rates are up-to-date, and discrepancies are addressed. Weekly reviews of follow-up compliance will be discussed in monthly management meetings, with corrective training or adjustments made as necessary under the guidance of the Executive Director and Case Coordination Manager, beginning September 1, 2024. This process aims to consistently maintain comprehensive client records aligned with facility policies and regulations. |
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 the review of patient records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction for mandatory communicable disease training were submitted and approved by the Department for the August 3, 2023 and September 6, 2022 annual licensing inspections. Mandatory communicable disease training was again found to be a deficiency in the July 10-11, 2024 licensing inspection.
A plan of correction for a complete client record that includes follow-up information were submitted and approved by the Department for the August 3, 2023 and September 6, 2022 annual licensing inspections. Follow-up information was again found to be a deficiency in the July 10-11, 2024 licensing inspection.
This is a repeat citation from the August 3, 2023, licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To address the recurring deficiencies in compliance with the Department's approved plans of correction, our facility is implementing comprehensive strategies focused on sustainable improvements. This includes deploying structured tracking systems and dedicated oversight roles to prevent compliance gaps, particularly in mandatory communicable disease training and follow-up information in client records. We've developed a detailed Standard Operating Procedure (SOP) and integrated an advanced Smartsheet system for real-time tracking of training completion among staff. A newly appointed Staff Trainings Champion will oversee the execution of this program, ensuring training is completed on schedule and fostering accountability and continuous improvement. Simultaneously, we are enhancing our client follow-up processes with a new 7-Day Follow-Up SOP, using Smartsheet technology to ensure timely documentation and follow-up within a week post-discharge. Early results of these implementations show promise, streamlining processes and boosting compliance and efficiency. The combination of these initiatives not only remedies immediate deficiencies but also acts as a long-term safeguard against future compliance issues, ensuring our facility adheres to high standards of care and regulatory compliance. |