INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 14, 2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site investigation, Pyramid Healthcare Inc. York Inpatient was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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 patient charts, the facility failed to follow a patient's physician's order. It was observed that patient chart #3 had a physician's order for blood pressure checks to be done 3 times per week, on Monday, Wednesday and Friday. During the week of Nov. 11th, there was no documentation of any blood pressure checks on this patient.
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Plan of Correction
All authorized staff members will be reeducated on following physician orders including monitoring of blood pressure as ordered. The physician orders will be monitored by the Nurse Manager through monthly chart monitors ? will review five charts over the next month to ensure compliance. Retraining will occur by 12/19/19. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
The facility failed to observe patients ingesting their medication. The facility's procedure is to check the mouth of patients when administering medication to prevent cheeking and diverting the medication. Patient interviews established that patients were and still are cheeking medication due to staff not following facility procedure.
The facility failed to follow it's policy which states that patients' medications are either delivered by the pharmacy or picked up by the facility staff in a timely manner. A review of patient grievance forms and staff and patient interviews confirmed that patients were not receiving medications within a timely manner. The facility director reported that the facility has an alternative pharmacy to use when the original pharmacy does not deliver medications within a day or two days. However, it was reported in staff interviews that the staff were not following this procedure so patients were not receiving their medications in a timely manner.
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Plan of Correction
All authorized licensed staff members will be reeducated to existing medication control policy. The policy includes: administration of medication, Narcotic Treatment Physician order for initial and subsequent dose, authorized personnel administering the medication, only authorized staff and client permitted in the dispensing area, only one client at a time in the dispensing area and observation of the client ingesting the medication. Administering and dispensing shall be conducted in a manner that protects the client from distraction. The nurse manager will conduct observation 5 per week over the next month of the medication administration process to ensure compliance to the policy. The physician orders will be monitored by the Nurse Manager through monthly chart monitors ? will review five charts over the next month to ensure compliance. Retraining will occur by 12/19/19.
All designated staff will be retrained on monitoring client medications in order to receive the medications in timely manner from pharmacy. Medication cart checks and chart checks will be completed nightly to ensure medications are present in the medication cart and physician orders are being processed in a timely manner. Designated staff will complete the pharmacy-tracking sheet utilized to track medications ordered which includes the date ordered. In the event the medication has not arrived in a timely manner, a call will be placed to the contracted pharmacy. The Nurse Manager will monitor the Physicians orders through monthly chart monitors ? will review five over the next month to ensure compliance. Nurse Manager will be informed immediately of any delay in processing orders passed the 24 hours timeframe. Retraining will occur by 12/19/19.
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