INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated inspection, client records were reviewed on September 29, 2020 and the physical plant inspection was conducted on October 30, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Pyramid Healthcare, Inc 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 inspection:
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Plan of Correction
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705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection, room 3 in the C wing did not have a fire-retardant mattress in good repair. There was a tear on the side of the mattress running the length of the mattress.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction implemented 10/30/2020. Mattress identified during inspection was replaced by end of day 10/30/2020 with new mattress meeting code 705.5. Executive Director and maintenance department worker will review all mattresses in facility no later than Friday 11/13/2020, and have all mattresses in poor condition replaced to meet code by 12/1/2020. |
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.
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Observations
Based on a review of unusual incident reports the facility failed to file a written unusual incident report with the Department within 3 business days.
An incident at the facility on May 22, 2020 required emergency personnel but was not reported to the Department until June 19, 2020.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
During review of unusual incident reports for the facility, unusual incident that occurred on 5/22/2020 was not reported to DDAP until 6/19/2020, not meeting code 709.34c of reporting within 3 business days. Moving forward, all DDAP unusual incident reports will be submitted within 3 business days. Pyramid Healthcare Quality Improvement Manager will complete supervision to review submission guidelines with Pyramid Healthcare Quakertown Executive Director and Risk lead no later than November 30, 2020, and verify compliance via electronic tracking form monthly. |