INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on December 1, 2020 through December 3, 2020 by staff from the Bureau of Program Licensure. 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.
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Plan of Correction
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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.
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Observations
During the complaint investigation November 1, 2020 through November 3, 2020, the facility failed to ensure that heaters, that are not mounted, were removed from the facility. A space heater was observed in an administrative office.
The findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
All staff have been re-educated regarding the regulations surrounding space heaters and that they are not to have them in any office at any time. The space heater in question was removed from the building on 12/3/2020 by maintenance supervisor upon the exit interview conclusion. Executive Director, maintenance and Leadership team will walk through the building on a weekly basis at random to check office spaces for space heaters to ensure compliance with the regulation. |
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.
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Observations
Based on a review of the facility's 2020 unusual incident reports on December 1, 2020, the facility failed to submit the following unusual incidents of physical or sexual assault by staff and/or clients within the required time frame.
The following unusual incident reports were reviewed and should have been submitted to DDAP:
2/11/2020
4/28/2020
9/30/2020
10/15/2020
10/16/2020
The findings were reviewed to facility staff during the complaint investigation.
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Plan of Correction
Executive Director and Office Manager met to develop a work flow for the timely completion of DDAP required notifcation of unusual incidents and timeframes for completion of these reports. Any incident that occurs that requires a report will be completed by staff prior to the end of their shift and will be submitted to the office manager. Office Manager will review report and give to the appropriate supervisor for review and signature. Supervisor will review and sign the report within 24 hours and will hand back to the office manager. Office Manager will give all reports to the Executive Director for review and Executive Director will complete the DDAP Unusual Incident report and submit within 24 hours. This report will then be returned to the office manager to be uploaded to the appropriate incident report spreadsheet for tracking purposes and a hard copy of the report will be replaced in the binder. This process will occur effective immediately and will be reviewed each month during the risk management meeting for the site. |
709.53(a)(6) LICENSURE Ind. Tx. Plan
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:
(6) Individualized treatment and rehabilitation plan.
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Observations
Based on a review client records on December 2, 2020, the facility failed to document a treatment plan in client record, # 3. The facility's policy and procedure states that, for inpatient rehabilitation clients, treatment plans will be developed within 72 hours of admission.
Client #3 was admitted into detox on 5/3/2020 and transferred to inpatient rehabilitation on 5/7/2020, she was discharged on 5/12/2020.
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Plan of Correction
Executive Director and Regional Quality Management staff have met with all staff regarding the need to complete all treatment plans within the required timeframes. The initial treatment plan for detox will be completed by the nursing staff upon admission and will be signed by the client as required. All residential treatment plans will be completed within 72 hours of admission and will be documented in the chart and signed by the client as required. Clinical Director will be completing chart audits of 10% of residential population each month in addition to the quality/compliance audits completed by the regional quality management team. These results are share with Executive Director and Region Vice President. These charts will be chosen at random and will include both open and closed charts each month. In addition the Executive Director will be completing random chart audits for both residential and detox each month of up to 8 charts to check for compliance to regulations. All staff have been re-educated (week of 1/4/2021) of the expected standards. Chart audits/monitoring have begun week of 1/4/2021 and will be ongoing. Staff will be provided with the results of these audits for necessary clinical content as well as compliance to standards as part of ongoing supervision and quality improvement plans. |