INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on January 30, 2020 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site complaint investigation, Pyramid Healthcare Inc. - Dallas was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
|
Observations
Based on the facility's unusual incidents, the facility failed to notified DDAP within 3 business day of the incident in the following unusal incidents.
#1
Date of the unusual incident 12/5/19
Date the unusual incident was sent to DDAP 12/11/19
#2
Date of the unusual incident 10/20/19
Date the unusual incident was sent to DDAP 11/12/19
|
Plan of Correction
In order to ensure that incidents are reported to DDAP within the 72 hour time frame the following procedures have been put into place. All incident reports will go directly to office manager for tracking. Office manager will record the date the incident occurred, type of incident, when the incident report was received as well as when a report is due to DDAP and/or payer sources. Incident reports will be given to Executive Director or designee for further review, investigation (if necessary), signature and DDAP report. Once completed this will be tracked on spreadsheet and will be monitored on a weekly basis to ensure all time frames are met. In addition all staff will be trained that incident reports are due prior to the end of their work shift and will be given to the shift supervisor for processing. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on the facility's unusual incidents, the facility failed to notified DDAP within 3 business day of the incident in the following unusal incidents.
#1
Date of the unusual incident 12/6/19
Date the unusual incident was sent to DDAP 12/11/19
#2
Date of the unusual incident 11/24/19
Date the unusual incident was sent to DDAP 12/2/19
#3
Date of the unusual incident 11/14/19
Date the unusual incident was sent to DDAP 11/20/19
#4
Date of the unusual incident 10/25/19
Date the unusual incident was sent to DDAP 10/30/19
#5
Date of the unusual incident 10/19/19
Date the unusual incident was sent to DDAP 10/23/19
#6
Date of the unusual incident 9/28/19
Date the unusual incident was sent to DDAP 10/3/19
#7
Date of the unusual incident 9/26/19
Date the unusual incident was sent to DDAP 10/3/19
#8
Date of the unusual incident 9/21/19
Date the unusual incident was sent to DDAP 9/27/19
#9
Date of the unusual incident 9/16/19
Date the unusual incident was sent to DDAP 9/25/19
#10
Date of the unusual incident 7/17/19
Date the unusual incident was sent to DDAP 7/24/19
|
Plan of Correction
In order to ensure that incidents are reported to DDAP within the 72 hour time frame the following procedures have been put into place. All incident reports will go directly to office manager for tracking. Office manager will record the date the incident occurred, type of incident, when the incident report was received as well as when a report is due to DDAP and/or payer sources. Incident reports will be given to Executive Director or designee for further review, investigation (if necessary), signature and DDAP report. Once completed this will be tracked on spreadsheet and will be monitored on a weekly basis to ensure all time frames are met. In addition all staff will be trained that incident reports are due prior to the end of their work shift and will be given to the shift supervisor for processing. |