INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 9, 2021 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 a review of eleven personnel records, the facility failed to ensure that 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.
Employee number #3 was hired as the clinical supervisor on January 4, 2021 and was current in that position at the time of the inspection. There was no documentation in the personnel file that a core curriculum in clinical supervision was completed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Executive Director will train all facility managers on the trainings that are required for their staff on November 10. The Executive Director and Clinical Director will review all staff training records twice a year once in the fall (November 18/2021) and one time in the spring ( May 2022). Each employee will have ample time to sign up for training and the clinical director will register staff for trainings.
The HR staff also completes yearly training plans to ensure all staff are up to date and will send reports to the Clinical Director and Executive Director
The CD or/and ED will register employees for trainings as needed. The Clinical Director and Lead Counselor will have the Supervisor Training requirement completed by 12/2021. They will attend the DDAP training from 12/13 to 12/18.
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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.
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Observations
Based on a review of eleven personnel records, the facility failed to ensure counselors met the educational and clinical experience in two records reviewed.
Employee #4 was hired as a counselor on April 5, 2021 and was still current in that position. Employee #4 has a bachelor' s degree in psychology but did not have clinical experience.
Employee #5 was hired as a counselor or April 12, 2021 and was still current in that position. Employee #5 has a bachelor' s degree in psychology but did not have clinical experience.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective immediately Employee #4 and #5 will be moved to counselor assistant positions.
Clinical Director will follow up with a training plan due by 10/25/21 and provide the correct supervision.
HR and Regional Quality Mangers will train the hiring manager on qualification of roles as counselor and assistant counselor. Completed by 11/1/21
Clinical Director and Executive Director will review the work experience of potential new hires.
If they qualify as a Counselor Assistance the CD and Lead Counselor will conduct the required supervision.
Regional Quality Manager will be notified of the potential candidates and CD and LC will review with RQMs to ensure all supervision and documentation will be completed.
All training plans will be review with Executive director to ensure proper supervision is occurring.
CD and LC will review with the ED all CA's supervision during bi-weekly leadership meeting.
Target date 11/1/21
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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 eleven personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that two 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 August 3, 2020 and was due to have the communicable disease trainings no later than August 3, 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 #8 was hired as a counselor on August 31, 2020 and was due to have the communicable disease trainings no later than August 31, 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.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Administrative Assistant for the facility will track/monitor completion of mandatory communicable disease training compliance for all employees.
All departments will be trained on required trainings and on using Relias.
All members of staff will review with appropriate supervisors their training plans to ensure the trainings are being completed. All department head will complete this training by November 15, 2021.
Regional Quality Team will contact Executive Director of any deficiency and the Executive Director and Clinical Director will ensure all staff member continue to remain in compliance.
Department managers will coordinate with HR to review reports of staff trainings to ensure 100%compliance This will be completed monthly.
Executive Director will ensure that all Department Supervisors monitor their assigned staff for compliance of training attendance through individual supervision and monthly group supervision.
The HIV/AIDS training and TB/STD will be completed by 11/15/21.
The department manager will ensure that employee #7 and #8 will complete the above courses.
Executive Director will over see that all staff remain in compliance with training and that the current staff completed the required courses.
Target date for completion is 11/20/21
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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, it was observed that the facility failed to ensure the safety and well-being of clients, staff, and visitors as evidenced by the following: the covers on the baseboard heater located in the main house, second floor closet and another walk-in closet on the second floor did not have a cover that was intact.
These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Maintenance Manager and the lead maintenance worker will cover all heaters and will conduct weekly walk through to ensure the safety of the clients in regards to building repairs. Any building concerns will be reported in the weekly leadership meeting.
All cover were intact as of 9/10/21
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection, the facility failed to store all trash, garbage and rubbish in noncombustible covered containers that prevent the penetration of insects and rodents. One of the two dumpsters located directly behind the main house had the side door open.
These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
The correction was complete the day of inspection.
ED Kitchen Manager will train the kitchen staff of the safety concerns of keeping the side doors of the dumpster closed.
Target date 10/1/21
Maintenance supervisor will conduct weekly walkthrough of the campus to ensure the safety of the client and compliance ofall trash can and dumpsters are proper.
Any issues will be reported to the ED during weeklyleadership meeting.
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen outside the counseling room. The art therapy room located in the administration building did not have a window treatment covering on the main door window, thus allowing unobstructed visual access.
These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
All windows of any counseling office were covered with frosting in order to maintain privacy completed by head of maintenance.
The a member of the maintenance team will complete monthly walk throughs to address any issues.
The maintenance manager will report any deficiency during the monthly meeting.
Executive directive will oversee these reports.
Target date 10/20/21 completed.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection. the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. During the inspection of the showers, used bars of soap were found and in one stall several used bars were sitting on top of one another.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All clients will be reminded to remove their belongings from the bathroom.
The head of housekeeping will train all housekeeping staff of the expectation of keeping the units clean and sanitary.
All units are cleaned daily.
Team meeting will occur on 10/20/21.
The department head of housekeeping will maintain a log and will report monthly to the executive director and problems or issues.
This will also be reviewed in monthly leadership meeting.
Executive Director will ensure the CAP is implemented.
The cleaning staff with discard any soap that is left behind.
Clients will be made aware of this expectation in community meeting. completed on 10/20/21 and will be addressed as needed.
Target date:
9/10/21
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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, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. A fire extinguisher located in the main house, second floor, back hallway did not have a tag that would establish it had been inspected annually.
These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
The maintenance team will completed weekly walkthrough of the campus to ensure all fire extinguisher are up to code and will report any concerns to the ED during the weekly supervision meeting. ED will complete monthly walk through to ensure all corrective measure are being followed.
The fire extinguisher was replaced on 9/10/21
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical plant inspection, the facility failed to ensure that the facility followed its medication control policy to include disinfects and drugs for external use are stored separately from oral and injectable drugs.
In the locked medication room, a cabinet located on the wall had medication that should be ingested beside a spray wound care. In several of the medication carts, there was bug spray, aloe vera and suntan lotion next to ingestible medications. In the medication refrigerator located in the detox building there was a staff members sandwich mixed with the client ' s medications.
These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
All medication will be stored properly:
Lead nurse/ Director of Nursing will train all other nurses and medication techs about medication storage. Training will occur in the nurses meeting on October 19th by the Director of Nursing.
All medication storage units including medication cart will be inspected by the nurse manager or Lead nurse monthly to ensure that the medication will be stored properly. Lead Nurse will report any concerns to the ED during monthly leadership meetings.
All carts and medication cabinets will have dividers in place to ensure ingestible medication will be separate from topical medication. This will be completed by 11/1/21
Target date 11/1/21
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709.63(a)(7) LICENSURE Discharge summary
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:
(7) Discharge summary.
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Observations
Based on a review of seven client records, the facility failed to provide a complete client record to include a discharge summary in two records reviewed.
Client #6 was admitted on February 16, 2021 and was discharged on February 20, 2021. The client record did not contain documentation of a discharge summary.
Client #7 was admitted on October 9, 2021 and discharged on October 14, 2021. The client record did not contain documentation of a discharge summary.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Discharge summaries will be present in all charts.
Clinical Director will train the clinical team on October 20th about documentation and timeframes and discharge summaries for all clients.
Clinical Director will ensure that all documentation including discharge summaries are included in charts by conducting weekly chart audits.
CD will review in staff meeting the expectation of completing discharge summaries on clients that are non-routine discharges and on detox discharges.
Target date of 11/1/21.
RQM will continue to audit the charts monthly to ensure all documentations present.
ED will conduct random chart audits to ensure all documentation is completed
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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 seven client records, the facility failed to provide a complete client record include a follow up in one of one applicable record reviewed.
Client #7 was admitted on October 9, 2021 and discharged on October 14, 2021. The client record did not contain documentation of a follow up.
These finding were discussed with facility staff during the inspection process.
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Plan of Correction
Effective 10/15/2021, Clinical Director and Executive Director will identify two staff members responsible for follow up calls. 1. Administrative Assistant, 2 Case Coordinator. On 10/18/21 Clinical Director and Executive Director will meet with assigned staff to develop a process for tracing calls made to discharged clients. All follow up calls will be documented in the electronic chart record. The identified staff will report the progress in the monthly leadership meeting to the Executive Director.
Also the CD will review charts on a monthly basis to ensure the completion all documentation including follow-up calls.
The ED will have oversight of the established process.
Target date 11/1/21
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in four records reviewed.
Client #9 was admitted on July 1, 2021 and was still active at the time of the inspection. The comprehensive treatment plan, dated July 2, 2021, indicated five group sessions per week and one individual session a week. The client's record of service and progress notes indicated that the client ' s last documented individual session was July 29, 2021.
Client #10 was admitted on July 29, 2021 and was still active at the time of the inspection. The comprehensive treatment plan, dated July 30, 2021, indicated five group sessions per week and one individual session a week. The client's record of service and progress notes indicated that the client had received no group session from July 29, 2021 until August 26, 2021.
Client #11 was admitted on August 6, 2021 and was still active at the time of the inspection. The comprehensive treatment plan dated August 9, 2021 indicated five group session per week and one individual session a week. The client' s record of service and progress notes indicated that the client received no group session from August 6, 2021 until August 26, 2021.
Client #12 was admitted on May 13, 2021 and was discharged on June 4, 2021. The comprehensive treatment plan dated May 14, 2021 indicated five group session per week and one individual session a week. The client' s record of service and progress notes indicated that the client received no individual sessions.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Clinical Director will conduct chart audits on a weekly basis. He will address any deficiencies during his weekly clinical meeting and during individual supervision.
CD will incorporate a daily time frame for the counselors to completed documentation until all deficiencies are completed.
Target date: 11/1/21.
Clinical Director will conduct a training on time management as well as chart documentation to ensure client records are completed properly. Training will occur on 10/21/21
Target date 11/1/21.
RQM will continue to conduct chart audits and inform CD and ED of progress in completing documentation.
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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 seven client records the facility failed to provide a complete record to include a follow up in two of three applicable records reviewed.
Client#12 was admitted on May 13, 2021 and discharged on June 4, 202.
Client #13 was admitted on March 30, 2021 and discharged on April 27, 2021.
These finding were discussed with facility staff during the inspection process.
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Plan of Correction
Effective immediately, Clinical Director and Executive Director will identify two staff members responsible for follow up calls. 1. Administrative Assistant, 2 Case Coordinator. On 10/8/21 Clinical Director and Executive Director will meet with assigned staff to develop a process for tracing calls made to discharged clients. All follow up calls will be documented in the electronic chart record. The identified staff will report the progress in the monthly leadership meeting to the Executive Director.
Also the CD will review charts on a monthly basis to ensure the completion all documentation including follow-up calls.
The ED will have oversight of the established process.
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