INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 7-9, 2013 by staff from the Division of Drug and Alcohol 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(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Reports, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Reports for the project's 14 facilities were reviewed on October 15, 2013. The project employed the equivalent of 105.275 full-time counselors, which would require the project to have at least 13 full-time clinical supervisors. The project failed to employ a full-time clinical supervisor for every eight full-time counselors as the project only employed 7 full-time clinical supervisors as of October 15, 2013.
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Plan of Correction
The Vice President of Clinical Services will ensure that the ratio of Clinical Supervisors for the project is within the defined regulation of 1 fulltime clinical supervisor for every 8 fulltime counselors or counselor assistants. The Project will re-evaluate its current system and restructure the project to include the appropriate number of clinical supervisors. Human Resources coordinators will identify the number of clinical supervisors, counselors, and counselor assistants within the system on a quarterly basis. Vice President of Clinical Services will be responsible to review staffing hours quarterly to ensure that ratio is maintained. Program Directors will notify the Vice President of Clinical Services should any changes in the ratio per site occur during the quarter. Restructuring of the Clinical Supervisor ratio will begin December 1, 2013. Clinical Supervisor ratio will be in 100% compliance by January 1, 2014. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of employee records, the facility failed to document the completion of 12 clock hours of annual training required for project directors in one of one employee records.
The findings include:
The facility training year runs from July 1 through June 30.
Fourteen employee records were reviewed on October 7, 2013. One employee record pertained to the project director and required the documentation of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in employee record # 1.
Employee # 1 has been the project director since July 1, 1999. The facility failed to document 12 clock hours of annual training for employee # 1 for the July 2012 - June 2013 training year as the record only contained documentation of 10.5 hours of training.
This is repeat citation from the 2012 licensing inspection.
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Plan of Correction
Project Manager will complete 12 hours of training annually. Project Manager will ensure needed documentation of completed trainings is presented to Human Resources to be recorded in Personnel File. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance. |
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
Based on a review of employee records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of five employee records.
The findings include:
The facility training year runs from July 1 through June 30.
On October 7, 2013, five counselor employee records were reviewed for the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in employee record # 13.
Employee # 13 has been employed as a counselor since May 24, 2004. The facility failed to document any clock hours of annual training for employee # 13 from July 2012 through June 2013.
The findings were discussed, confirmed and undisputed by the facility director on October 9, 2013.
This is repeat citation from the 2012 licensing inspection.
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Plan of Correction
Counselors will complete required 25 hours of training per year. Clinical Supervisors and Program Directors will be responsible for tracking counselors' training hours as part of clinical supervision monthly. HR coordinators will audit completed training hours quarterly and supply Program Directors with results to ensure training hours are being met. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of one client records.
The findings include:
Ten client records were reviewed on October 7-9, 2013. One of the discharged clients reviewed was involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 5.
Client # 5 was admitted into treatment on August 30, 2013 and was involuntarily terminated from the project on September 3, 2013. There was no documentation of written notification provided to the client as of the on-site inspection which was conducted on October 7-9, 2013.
An interview with the Facility Director, Director of Nursing and Nurse Supervisor took place on October 9, 2013. The findings were discussed, confirmed and were not disputed.
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Plan of Correction
Staff will notify the client in writing of a decision to involuntarily terminate his/her treatment. The notice of involuntary discharge form will be initiated and staff will be trained by 11/4/13. A copy of the notice will be provided to the client and the original will be placed in the client's chart. The nurse supervisor will monitor and ensure compliance. |
709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
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Observations
Based on an interview with the Facility Director, Director of Nursing and Nurse Supervisor, the facility failed to document individual physical examinations in 5 of 5 client records.
The findings include:
Five client records were reviewed on October 7-9, 2013. The vital signs (temperature, respirations, blood pressure and pulse) were identical in client records # 1, 2, 3, 4 and 5. The physical examinations contained in client records #1, 2, 3, 4 and 5 documented a temperature of 97, respirations of 18, blood pressure of 130/80 and pulse was 75.
An interview with the Facility Director, Director of Nursing and Nurse Supervisor took place on October 9, 2013 at which time the findings were discussed, confirmed and were not disputed.
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Plan of Correction
The nursing staff will provide the physician with vital signs on each individual client during each physical examination completed. DON informed physician of reinforcement of procedure with nursing staff. Nursing staff will be trained and procedure will be in effect by 11/4/13. The nurse supervisor will monitor and ensure compliance. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on an interview with the Facility Director, Director of Nursing and Nurse Supervisor, the facility failed to document individual physical examinations in 4 of 5 client records.
The findings include:
Five client records were reviewed on October 7-9, 2013. The vital signs (temperature, respirations, blood pressure and pulse) were identical in client records # 6, 7, 8, and 9. The physical examinations contained in client records # 6, 7, 8 and 9 documented a temperature of 97, respirations of 18, blood pressure of 130/80 and pulse was 75.
An interview with the Facility Director, Director of Nursing and Nurse Supervisor took place on October 9, 2013 at which time the findings were discussed, confirmed and were not disputed.
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Plan of Correction
The nursing staff will provide the physician with vital signs on each individual client during each physical examination completed. DON informed physician of reinforcement of procedure with nursing staff. Nursing staff will be trained and procedure will be in effect by 11/4/13. The nurse supervisor will monitor and ensure compliance. |