INITIAL COMMENTS
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This report is a result of an on-site compliant investigation conducted on September 23, 2019 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site compliant investigation, the allegations made against Pyramid Healthcare York Pharmacotherapy Services were partially substantiated and 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. The following deficiencies were identified during this complaint investigation:
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Plan of Correction
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715.7(b) LICENSURE Dispensing or Administering Staffing
(b) Dispensing time shall be prorated for patient census. There shall be sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
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Observations
Based on a discussion with the facility director and interviews with patients, the facility failed to ensure that all patients are medicated within fifteen minutes of arrival at the dispensing area.
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Plan of Correction
Director or designee will ensure a nursing coverage plan is in place within the next 30 days for cases of emergency or disruption in dosing. The coverage plan will identify potential on-call nurses who are trained on the dispensing system that can be contacted for purposes of dosing when the automatic dispensing system is in-operable. The director will also confirm IT technical support is contacted immediately for updates and assistance in order to rectify the issue in a timely manner. Lastly, the facility will utilize support staff, including the clinical staff members, for milieu coverage. This may be reflected in the addition of therapeutic services, including group and individual therapy, to best meet the needs of the population served. An unusual incident report will be submitted to DDAP within 48 hours when there is a significant disruption in services. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a discussion with the executive director, the facility failed to notify the department within 48 hours of a significant disruption of services that caused dosing times to exceed the fifteen minute mark.
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Plan of Correction
Each unusual incident, including significant disruption of services, will require the Director to complete an Unusual Incident Report. This report will subsequently be sent to the Department of Drug and Alcohol Programs for review. A copy of the incident will be kept in a record log to review annually. A copy verifying completed transmission to DDAP will be kept alongside the Unusual Incident Report to review annually. |