INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 31, 2022, 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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704.7(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 nine personnel records, it was determined that one employee hired as a counselor did not meet the qualification requirements for the position.
Employee #8 was hired as a counselor on September 14, 2021 and was current in that position at the time of the inspection. At the time of hire, the employee had a qualifying bachelor's degree, but only one month of clinical experience, not the required minimum of one year.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As per discussion with PHC Director of Compliance and DDAP representative 9/9/22, employee will retain counselor position as she has completed one year of clinical experience. Clinical Director will provide and document in clinical supervision notes equivalent of 6 months close supervision to employee by March 15, 2023 to meet full counselor requirements. Executive Director will monitor POC and documented supervision in monthly supervision with CD . Moving forward, all counselor candidates will have resume reviewed by Regional Quality Manager to ensure they meet counselor regulation. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report and personnel records, there was no documentation that 3rd shift staff had CPR certification between July 7, 2022 and July 9, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
POC: Executive Director will provide supervision to Behavioral Health Technician Manager no later than 10/1/22 on the importance of timely CPR certification for all BHTs to ensure compliance with this regulation, and work schedule for BHTs will begin to reflect in writing on staff schedule all staff who are CPR trained on all shifts no later than 10/1/22. BHT manager will monitor compliance with this regulation weekly through schedule development. In the event that a CPR staff calls off, BHT will ensure another CPR trained staff will be present on shift. |
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 personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two applicable records.
Employee # 4 was hired as a counselor on March 18, 2019 and has remained in that position. The facility's training year that was reviewed was from January 2021 through December 2021. Employee #4's personnel record only documented 16.3 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will meet with all department managers no later than 10/15/22 to review regulation, provide supervision on monthly training reports generated to all managers by Pyramid Training department, and identify how to monitor training hours quarterly to ensure compliance for all staff. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on August 31. 2022, the facility failed to ensure that heaters were permanently mounted as four space heaters were found in a closet in the basement.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Space heaters were removed day of inspection. Effective 10/1/2022, maintenance staff will inspect facility for any freestanding heaters monthly during CARF monthly self inspection walkthrough and remove any found |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from September 2021 through June 2022 and the client schedules presented by facility staff, the facility failed to conduct fire drills during sleeping hours at least every six months as the only drill conducted during sleeping hours was in September 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed findings with maintenance and leadership staff on 9/1/22, reflecting that sleeping hours for clients as per schedule are 1045pm-645am, and effective 9/1/22, all drills conducted during sleeping hours must fall within the appropriate timeframe, which will be recorded on established fire drill log. Facilities Supervisor will identify in writing beginning 10/1/2022 to ED date and time fire drill will be planned for month to ensure ED monitoring to comply with this regulation. |
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 follow their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable records reviewed. The facility failed to follow their policy related to AFA discharges of calling the Emergency Contact within twelve hours.
Client #2 was admitted on February 28, 2022 and discharged Against Facility Advice (AFA) on March 23, 2022. There was not documentation in the client record that the emergency contact was called.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
POC: Clinical Director met with clinical team during group supervision on 9/6/22 to review finding, and reviewed licensing regulation. Executive Director reviewed regulation with all facility staff on 9/16/22 via all staff email, and all contact made with emergency contacts after AFA discharge, as well in event of no emergency contact list in EMR or client has revoked consent, will be documented by primary counselor moving forward. CD will monitor by having all clinical staff route emergency contact documentation notification to him in electronic record when completed, and will review monitoring process with clinical team no later than 10/1/22. |
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 a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client #3 was admitted on April 28, 2022 and was discharged on July 7, 2022. The record contained documentation that personally identifying information was released to another treatment provider on May 10, 2022, with no consent to release information form signed by the client.
The 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 9/6/22 to review finding, and reviewed licensing regulation, and completed retraining on how to fully complete release of information in EMR, and importance of verifying fully executed ROI prior to disclosure from chart. Clinical Director also will review findings by 10/1/22 with internal support of Client Navigation Team to ensure they are aware of how to review for fully completed ROI in chart prior to disclosure. Compliance with regulation will be monitored monthly through internal chart audits completed by Pyramid Quality Specialists. |
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 client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information in one of two applicable records reviewed.
Client #3 was admitted on April 28, 2022 and was discharged on July 7, 2022. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director trained staff responsible for follow-up calls, Administrative Assistant, on 9/15/22, and reviewed regulation finding and compliance expected moving forward.
Clinical Director and or Pyramid Quality Specialist will monitor compliance in this area through monthly documented supervision with clinical staff and completion of a monthly open and closed chart audits
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