INITIAL COMMENTS
|
This report is a result of a complaint investigation conducted on March 20, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the 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 investigation.
|
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
The facility failed to report an unusual incident within the required regulatory timeframe.
According to an incident report, submitted by the facility on March 25, 2020, there was an incident involving the presence of an ambulance that occurred at the facility. This incident occurred on March 18, 2020 and the incident report was due on March 23, 2020.
|
Plan of Correction
Effective 4/20/2020 all incident reports are to be completed and submitted by the individual completing the report to the Administrative Assistant by the end of the shift the incident occurred. If the Administrative Assistant is not present, a secured lock box has been installed outside the office to allow for confidential submissions in her absence.
Administrative Assistant will bring incident reports to the morning shift report facilitated daily by leadership members and clinical team to ensure all documents are completed appropriately along with determination of the need for external notification based on the type of the incident. Executive Director to sign off on all incident reports at the end of the meeting and submit to any/all external sources as applicable. If ED is not present, the Clinical Director will be responsible to submit to any external parties as appropriate. |