INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and complaint investigation conducted on August 27-28, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Although the complaint allegations were unable to be substantiated, based on the findings of the onsite licensure renewal 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(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
During a licensing inspection conducted on August 27-28, 2019, the facility failed to provide documentation of supervision for the first six months in the position of Clinical Supervisor.
Employee # 3 was hired as the Clinical Supervisor on July 15, 2019 and was still in this position at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will hold (at minimum) monthly supervisory meetings with the Clinical Supervisor and document accordingly through January 2020. |
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
During a licensing inspection conducted on August 27-28, 2019, the facility failed to provide documentation of weekly supervision to include direct observation of counselor assistants for the first six months of employment for employee's # 11 and 12.
Employee # 10 was hired as a Counselor Assistant on October 15, 2018 and was still in this position at the time of the inspection.
Employee # 11 was hired as a Counselor Assistant on February 22, 2019 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
Employee #10 will meet with either the Clinical Supervisor or Lead Counselor for weekly supervision. This will be documented weekly and signed by both parties. Employee #10 will need a bi-annual and annual review along with these weekly meetings in order for promotion to Counselor in October 2019. This is be completed by 10/31/19.
Employee #11 will meet with either the Clinical Supervisor or Lead Counselor for weekly supervision. This will be documented weekly along with weekly documented observations. |
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
During a licensing inspection conducted on August 27-28, 2019, the facility failed to provide documentation of training plans for employee's # 12, 13, 14, 15, 16, 18, 19, 21, 22, 23, 24, 26, 30, 31, 32, 33.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon hire, each new employee will complete an individualized training plan along with their immediate supervisor. The training plan will be sent to Human Resources to be included in the employees' personnel file and the employee may revise their individual training plan throughout the year. Training plans will be updated annually for all employees. |
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
During a licensing inspection and review of the facility's Staffing Requirement Facility Summary Report (SRFSR) form, conducted on August 27-28, 2019, the facility failed to ensure that employee's # 10, 20, 25, 27, 28, and 29 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 # 10 was hired as a support staff on January 1, 2015 and promoted to a counselor assistant on October 15, 2018 and was due to have the communicable disease trainings no later than January 1, 2017. There was no documentation in the personnel file of the completion of the HIV/AIDS training.
Employee # 20 was hired as a support staff on July 21, 2015 and was due to have the communicable disease trainings no later than July 21, 2017. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training.
Employee # 25 was hired as a Housekeeper on July 27, 2017 and was due to have the communicable disease trainings no later than July 27, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training.
Employee # 27 was hired as a Driver on October 17, 2016 and was due to have the communicable disease trainings no later than October 17, 2018. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training.
Employee # 28 was hired as Maintenance on January 18, 2016 and was due to have the communicable disease trainings no later than January 18, 2018. There was no documentation in the personnel file of the completion of the HIV/AIDS training.
Employee # 29 was hired as a UR Coordinator on August 3, 2015 and was due to have the communicable disease trainings no later than August 3, 2017. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Executive Director will review training requirements monthly with entire management team in an effort to develop an improved training tracking system. This will be a standing agenda item and be documented in the monthly meeting minutes. Employees will monitor DDAP trainings through the DDAP website and register for the any/all appropriate trainings, including HIV/Aids and TB/STD. |
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.
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Observations
During a licensing inspection conducted on August 27-28, 2019, the facility failed to provide documentation of the completion of 25 clock hours of annual training required for counselors in employee's # 6 and # 9's employee record.
Employee #6 was hired as a counselor on April 24, 2016 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2018 through December 31, 2018. Employee #6's employee record only documented 12.5 hours of annual training for the training year reviewed.
Employee #9 was hired as a counselor on August 5, 2015 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2018 through December 31, 2018. Employee #9's employee record only documented 24 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will review training requirements in the monthly management meeting which will be a standing agenda item and documented in the meeting minutes. Department managers will develop training tracking systems in order to effectively monitor their employee training hours as well mandatory trainings. |
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
During a licensing inspection conducted on August 27-28, 2019, the facility failed to provide proper storage of utensils during non-eating hours. There was silverware and cooking utensils left uncovered in the kitchen area.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Dietary Manager ordered storages bin with lids called bus pan boxes. These storage containers will safely and properly store all silverware and cooking utensils. Containers will be received and in use by 9/30/19. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(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.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
During a Project Wide review of Policy and Procedures, the facilities Client Rights policy was missing - sex and marital status in 709.30 (2), and Reasons for removing sections shall be documented in the record in 709.30 (3).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedures manual will be updated by the Policy and procedure committee to include sex and marital status in section 709.30. Chief Compliance Officer will ensure completion of policy by Sept 1, 2019. The program director will be responsible to ensure that the new policy is shared with all staff by Sept 15, 2019.
The Clinical Forms Committee will be updating the form in Carelogic to include the missing information. The new form to be added to Carelogic for all programs by September 1, 2019. Program Director will ensure all staff are educated on the new form by September 15, 2019.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a licensing inspection conducted on August 27-28, 2019, the project failed to provide documentation that unusual incidents were being reported to The Department within 3 business days.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed the need for employees to complete DDAP unusual incidents reports for all reportable incidents during the 9/12/19 monthly management meeting. Copies of the DDAP unusual incident reports, along with the fax transmission page, will be stored with the internal incident reports. Unusual incidents will be reviewed monthly in the management meetings and be a standing agenda item. |
709.84(a) LICENSURE Project management services
709.84. Project management services.
(a) The partial hospitalization project shall operate at least 5 days of the week and for a minimum of 40 hours per week. Additional hours should be appropriate to the population served by the partial hospitalization project.
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Observations
During a licensing inspection conducted on August 27-28, 2019, the facility was unable to provide a location to provide Partial hospitalization services separate from the inpatient services.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pyramid Hillside has identified the 2nd floor clinical group room as an identified separate location to provide Partial hospitalizations services for clients. This location will be serve as the clinical space to offer PHP clinical treatment to clients for 4 hours per day. The executive director and clinical supervisor will monitor the PHP program when clients have been identified for this level of care. No other clinical groups currently operated out of the clinical group room-this will ensure separation between the PHP clients and the inpatient clinical programming. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
During a licensing inspection conducted August 27-28, 2019, the narcotic treatment program was unable to provide documentation of a face to face or determination of addiction in Patient record # 1.
Patient # 1 was admitted on August 28, 2018 and was still active at the time of the inspection.
The findings were reviewed with program staff during the licensing process.
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Plan of Correction
Executive Director held a medical provider meeting on 9/5/19 and reviewed the need to complete for all new admissions the following within 24 hours: history & physical as well as the determination of addiction. This will be monitored through monthly chart audits completed by the Regional Director of Nursing. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
During a licensing inspection conducted on august 27-28, 2019, the facility failed to provide documentation of a comprehensive treatment and rehabilitation plan developed on July 18, 2018 was signed by the client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review appropriate documentation timeframes with the clinical team during the bi-monthly clinical meeting on 9/26/19. Monthly clinical chart monitoring will be conducted by the Clinical Supervisor and bi-monthly chart audit reviews will be conducted by the Regional Clinical Coordinator. |