INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19, 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. - Pyramid Pittsburgh 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 form, the facility failed to ensure that support staff employees #16 through #30 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 of two years after hire for support staff personnel. There was no documentation in the personnel records of the trainings being completed. Employee #16 was hired on May 21, 2021 and did not have HIV/AIDS and TB/STD training.Employee #17 was hired on July 15, 2019 and did not have the HIV/AIDS and TB/STD training.Employee #18 was hired on April 28, 2021 and did not have the HIV/AIDS and TB/STD training.Employee #19 was hired on May 12, 2021 and did not have the HIV/AIDS and TB/STD training. Employee #20 was hired on March 17, 2021 and did not have the HIV/AIDS and TB/STD training.Employee #21 was hired on December 20, 2018 and did not have the HIV/AIDS and TB/STD training.Employee #22 was hired on May 3, 2021 and did not have the HIV/AIDS and TB/STD training.Employee #23 was hired on November 2, 2022 and did not have the HIV/AIDS and TB/STD training.Employee #24 was hired on March 8, 2021 and did not have the HIV/AIDS and TB/STD training.Employee #25 was hired on January 18, 2021 and did not have the HIV/AIDS and TB/STD training.Employee #26 was hired on June 26, 2017 and did not have the TB/STD training.Employee #27 was hired on November 9, 2017 and did not have the TB/STD training.Employee #28 was hired on January 25, 2013 and did not have the HIV/AIDS training.Employee #29 was hired on August 22, 2017 and did not have the HIV/AIDS training.Employee #30 was hired on August 12, 2019 and did not have the HIV/AIDS and TB/STD training.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director will meet with all department managers no later than 9/15/2023 to review regulation. Effective 9/15/2023, managers will review monthly training reports generated by Pyramid Training Department to ensure compliance for all staff within assigned department. All department heads, including PPIP Office Manager, will track/monitor completion of all staff's Communicable Disease training and review in monthly leadership meetings.
Any employee that is missing necessary trainings will complete trainings and/or register for necessary training no later than 10/15/2023. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom. The bathroom is room 316 did not have either one. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Maintenance/Housekeeping staff immediately replenished paper towels in client rooms following the inspection. Maintenance/Housekeeping staff will check the units daily and replenish as part of their rounding. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to keep hot water temperatures at or below 120 degrees Fahrenheit. The hot water temperature in room 320 was 132.2 degrees and in room 301 it was 127.5 degrees.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Maintenance Manager immediately adjusted the water temperature in the affected client rooms. Safety Committee/Maintenance Manager will complete monthly water temperature checks to ensure the client water is within the appropriate temperature ranges. |
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 and clean manner at all times. In shower room 3A, a puddle of water was found on the floor due to the shower curtain being too short and the water running onto the floor. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Maintenance/Housekeeping staff immediately cleaned up the water on the floor and adjusted the curtain rod so the shower curtain reached the ground. Maintenance/Housekeeping staff will check the shower rooms daily to ensure the curtain is at the appropriate length and/or clean up any residual water. |
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 client records, the facility failed to notify a client's emergency contact after the client left the facility against medical advice in one out of two applicable records reviewed. Client #6 was admitted on June 7, 2023 and left against medical advice on July 6, 2023. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 7/19/2023, Case Coordination team was trained on the process of clients who AMA from WM. Case Management Supervisor will conduct monthly random spot checks to ensure these calls are being completed. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one out of fourteen client records reviewed. Client #2 was admitted on May 22, 2023 and was still active at the time of the inspection. There was no release of information form to the funding source. Staff confirmed billing had occurred. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The staff that was directly involved by failing to have funding consent present and signed in client chart, was retrained immediately regarding this error.
All staff responsible for completing consents will be retrained by 9/1/2023. RQM team will monitor in monthly KPI chart audits to ensure this is being completed
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709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information in alignment with the purpose of the disclosure in seven out of fourteen records reviewed. The forms permitted the entire record to be released. Client #1 was admitted on June 16, 2023 and was transferred to a lower level of care on July 6, 2023. There were four releases, two to the funding source dated June 10 and July 18, 2023 and two to a state agency dated June 10 and July 18, 2023. Client #3 was admitted on May 16, 2023 and wa still active at the time of the inspection. A release dated May 16, 2023 was to a funding source. Client #4 was admitted on June 6, 2023 and was still active at the time of the inspection. Three releases, all dated June 6, 2023, were to two funding sources and a state agency.Client #6 was admitted on June 7, 2023 and discharged on July 6, 2023. Six releases, all dated June 7, 2023, were to probation, four funding sources and a state agency.Client #8 was admitted on July 14, 2023 and was still active at the time of the inspection. Two releases dated July 14, 2023 were to a funding source and a state agency.Client #9 was admitted on July 14, 2023 and was still active at the time of the inspection. Three released dated July 14, 2023 were to two funding sources and a state agency.Client #10 was admitted on July 13, 2023 and transferred to a lower level of care on July 19, 2023. Three releases dated May 5, 2023 were to two funding sources and a state agency. An additional release dated July 15, 2023 was to probation.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director will conduct a training on completion of the Release of Information (ROI) with staff members during a staff meeting no later than November 17, 2023. During this meeting, the Clinical Director will review a current process shift in the ROI completion. The training will review the need to discontinue selecting "Entire Record" on Releases of Information at this time. After the training this change will be effective.
Our Quality Specialist Team continues to complete monthly chart monitors and looks at the completion of Releases of Information. They will ensure that "Entire Record" for this program is not selected during their monitors. After the monthly monitors are completed, the facility leadership is met with to review the results of the audits and facility leadership will use this review to continue to keep an eye on these items as well. |