Observations
Based on a physical plant inspection conducted on April 7, 2026, during a complaint investigation, the facility failed to maintain counseling furnishings in good repair.
DDAP staff were placed in an office located near the lobby, that had an office chair with worn and ripped leather-like material.
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Plan of Correction
ED followed up with maintenance department on 4/8 to inform regarding chair in disrepair. ED and maintenance supervisor discussed replacement of all chairs in disrepair or are worn. New chairs will be ordered and the chair in this office location will be replaced. ED spoke with Maintenance supervisor to follow up on when chairs will arrive. Chair order will be submitted by 4/30. Chair which was in disrepair was removed from facility and discarded on 4/9. |
Observations
Based on a review of client records and the Medication Administration policy, the facility failed to follow its written policy and procedures regarding the administration of medication in 4 of 5 records reviewed.
Per the Medication Administration policy, the responsibility of medication administration is that of registered nurses or licensed practical nurses.
Client # 1 was admitted on August 3, 2025, and discharged on August 12, 2025. A staff member, other than a registered nurse or licensed practical nurse, administered medication to this client at 8 a.m. on 8/4/25 - 8/8/25, and 8/11/25.
Client # 2 was admitted on September 6, 2025, and discharged on September 16, 2025. A staff member, other than a registered nurse or licensed practical nurse, administered medication to this client at 9 p.m. on 9/12/25 and 9/13/25.
Client # 3 was admitted on September 9, 2025, and discharged on September 26, 2026. A staff member, other than a registered nurse or licensed practical nurse, administered medication to this client at 8 a.m. on 9/10/25- 9/13/25, 9/15/25-9/17/25, and 9/19/25-9/26/25; 3 p.m. on 9/10, 9/12, 9/13, 9/19, 9/20 and 9/26/25; 9 p.m. on 9/12/25-9/13/25, 9/19/25-9/21/25, and 9/24/25.
Client # 4 was admitted on October 5, 2025, and discharged on October 20, 2025. A staff member, other than a registered nurse or licensed practical nurse, administered medication to this client at 8 a.m. on 10/7/2025-10/10/25 and 10/14/25 - 10/17/25; at 3 p.m. on 10/8/25 - 10/11/25, 10/17/25, and 10/19/25; at 9 p.m. on 10/9/25 - 10/11/25, 10/17/25, and 10/19/25.
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Plan of Correction
Pyramid Quakertown will enforce Pyramid SOPs regarding medication administration, effective 5/8/26.
ED and LPN supervisor to review with all medical department staff, including medication techs, and all BHTs by 5/8/26 the regulations and procedures around medication administration vs client self-administration.
This was completed by retraining for all medical and BHT staff that occurred on 4/23 and 4/30 that only licensed medical professionals, including LPNs and RNs, may administer medication, and define that the actions of "popping out" medications or placing medications in medicine cup is "administration," and is not permitted by unlicensed staff.
LPN Supervisor observed med passes with MA's on 4/27 and 4/30 to ensure proper administration compliance with policy. LPN supervisor is responsible for monitoring correct medication administration procedures by all staff, and above leader will conduct unplanned observation of medication passes for next two months to ensure compliance moving forward. |