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. 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 fifteen personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that four applicable 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 #10 hired as a Counselor on April 18, 2021 and was due to have the communicable disease trainings no later than April 18, 2023. There was no documenation in the personnel file of the completion of TB/STD training as of the date of the inspection.
Employee #13 was hired as a Facilities on May 24, 2021, and was due to have the communicable disease trainings no later than May 24, 2023. There was no documentation in the personnel file of the completion of the HIV/AIDS training until June 21, 2023 and no documentation of the completion of TB/STD training as of the date of the inspection.
Employee #14 was hired as a Behavior Tech on March 25, 2021 and was due to have the communicable disease trainings no later than March 25, 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 #15 was hired as Behavior Tech on November 11, 2019 and was due to have the communicable disease trainings no later than November 11, 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 reviewed with facility staff during the licensing process.
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Plan of Correction
All staff cited will
complete outstanding
required communicable
diseases by 12/31/23.
Moving forward, ED
and facility will create
mandated training
online tracking tool for
all facility employees by
9/30/23. ED and
department heads will
monitor completed and
outstanding mandated
trainings each month
during facility
leadership meetings. |
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 that counseling could not be seen or heard from outside of the counseling room as " Classroom 01 " had a window not covered on the door and main community group room had a window into the hallway that was not covered.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 7/19/23, facility
maintenance staff
installed window
coverings in Classroom 1
and all other counseling
group rooms to ensure
compliance with
regulation 705.4(3). Maintenance will repair or replace window coverings as needed moving forward. |
705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility's freezer #8 temperature was measured at 10 degrees. In addition, the facility's black refrigerator located in the kitchen temperature was measured at 50 degrees with the top freezer of the same refrigerator measuring at 10 degrees.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
ED and dietary
supervisor closed fridge and freezer at time of kitchen area inspection and
monitored temperatures throughout 7/19/23.
New temperature gauges
were installed in both
areas on 7/19/23.
Freezer # 8 reached
regulation temperature
by end of day 7/19/23, as
did black fridge.
Moving forward,
maintenance and dietary
departments will repair
or replace any fridges
which are not following
regulated temperature
outlined in 705.7 (b) (5).
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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 ten inpatient client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in four charts reviewed.
Client #3 was admitted on June 25, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, dated June 25, 2023, indicated 1 individual session weekly and group daily. The chart's record of service and progress notes indicated that the client only received individual sessions on July 12, 2023 and July 16, 2023.
Client #4 was admitted on July 2, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, dated July 6 2023, indicated 1 individual session weekly and group daily. The chart's record of service and progress notes indicated that the client only received individual sessions on July 7, 2023 and July 18, 2023. The record of service indicated no group sessions at the time of the inspection.
Client #5 was admitted on June 30, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, dated July 3, 2023, indicated 1 individual session weekly and group daily. The chart's record of service and progress notes indicated that the client did not receive any individual sessions.
Client #6 was admitted on June 28, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, dated July 2, 2023 , indicated 1 individual weekly and group daily. The chart's record of service and progress notes indicated that the client received no individual sessions at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met with clinical team during group supervision on 8/1/23 to review
finding, reviewed licensing regulation, and completed retraining on 8/1/23 on
documentation requirements and mandatory completion timelines. Retraining
occurred on 8/1/23 and 8/8/23 on how to create and document objectives in clinical
treatment plans. Compliance with regulation will be monitored monthly through
internal chart audits completed by Clinical Director and Pyramid Quality Specialists. |