INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 5, 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 Ridgeview Behavioral Health Center 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:
|
Plan of Correction
|
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of fire drills from January 2020 thru June 2021, the facility failed to ensure that an unannounced fire drill was conducted at least once a month as there was no documentation for a July 2020 fire drill. These finding were discussed with facility staff during the inspection process.
|
Plan of Correction
Maintenance staff was not aware that while the facility had no clients, fire drills were still to be conducted. Executive Director met with Maintenance supervisor on 8/30/21 and reiterated monthly fire drill expectations. Since the facility re opened in August of 2020, all fire drills have been completed appropriately.
Ridgeview was not open March 2020, through July 2020, and re opened as an all male, young adult facility in August of 2020. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
Based on a review of fire drills from January 2020 thru June 2021, the facility failed to ensure there was documentation of the exit route used in fire drills from September 2020 thru June 2021. These finding were discussed with facility staff during the inspection process.
|
Plan of Correction
Executive Director met with Maintenance Supervisor on 8-30-21 to review that exit routes are documented on fire drill logs. The next fire drill will have this appropriately documented. Executive Director will review all fire drill logs moving forward to ensure they are being completed correctly. |
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.
|
Observations
Based on a review of client records, the facility failed to document follow-up information within seven days of discharge, per facility policy, in one of one applicable client records reviewed on August 5, 2021.Client # 4 was admitted May 12, 2021 and discharged June 8, 2021.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 2021 licensing inspection.
|
Plan of Correction
Clinical Supervisor is going to address follow up calls on 9-1-21 in Clinical meeting and Clinical Supervisor is going to address Clinical staff responsible for Client #4 in individual supervision. Supervision will take place no later than 9/15/21 and if follow up calls continue to be missed, disciplinary action will result for the Clinician. Clinical Supervisor will continue to conduct chart audits monthly for Clinicians to ensure follow up calls are taking place. |
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.
|
Observations
Based on a review of employee schedules from June 27, 2021 thru July 8, 2021, the facility failed to have at least one person trained in these skills is onsite during the project's hours of operation on all second and third shifts for weeks of June 27, 2021 thru July 8, 2021. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Executive Director reviewed schedule with BHT Manager. approximately 8 staff got their recertification for CPR on 8/12/21. An additional training was scheduled for the First week of September to ensure all staff are in compliance with their CPR Certification. Any staff who is unable to attend these trainings on site, will find a training at another Pyramid location, or off site. If they are unable to find training and are out of compliance, they will be taken off the schedule by their immediate supervisor until they are in compliance with CPR. Each staff member is responsible for scheduling their upcoming trainings, and their immediate Supervisor is to monitor compliance with trainings. With the class in September all staff who are non compliant will be in compliance. Moving forward all Supervisors will schedule CPR trainings to ensure staff stay in compliance. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and seven personnel records, the facility failed to document the completion of 30 clock hours of annual training required in one employee record reviewed. Employee #5 was hired as a counselor assistant on April 16th, 2018 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2020 through December 31,2020. Employee #5's employee record only documented 6 hours of annual training for the training year reviewed.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Supervisor will review training requirements with all Clinical Team by 9/7/21. Clinical Supervisor will review training hours completed during monthly supervision and come up with a plan for any deficient training hours to be caught up or scheduled. Any Staff continuing to be deficient in training, Clinical Supervisor or Director will schedule trainings for them to ensure hours are completed. |