INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on February 02, 2017 by staff from the Division of Accountability and Program Improvement. Based on the findings of the on-site complaint investigation, Pyramid Healthcare York Pharmacotherapy Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
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.
|
Observations
A physical plant inspection was conducted on February 2, 2017. Based on this review, the facility failed to prohibit facility heaters that are not permanently mounted or installed.
During the physical plant inspection, a portable electric heater was observed in use in the nurse's office.
|
Plan of Correction
Program Director will review policy with all staff regarding there is no use of any type of portable heater. Review in all staff meeting where everyone will sign off on the minutes. This will be monitored by managers checking their area daily for compliance. Compliance will be by 3/16/17. |
715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
|
Observations
A review of client records and the facility's grievance log was conducted on February 2, 2017. Based on this review, the facility failed to utilize its patient grievance procedure.
Client #1 filed a grievance in February 2016, there was no record of the grievance in the client file and no record of the grievance in the facility's grievance log.
|
Plan of Correction
Program Director will ensure a binder for grievances is maintained. All grievances will be filed in the binder in chronological order by date. This will be monitored monthly by Program Director. Compliance will be by 3/16/17 |