INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 28 - 30, 2021 by staff from the Bureau of Program Licensure.Based on the findings of the on-site inspection, Pyramid Healthcare, Inc. - Pyramid Pittsburgh 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the Staffing Requirement Facility Summary Report and a review of staff files, the facility failed to have a sufficient number of staff persons, so that at least one person trained in CPR is onsite during the hours of operation. On July 18, 2021 and July 21, 2021, the facility failed to ensure a sufficient number of staff persons were trained in CPR between the hours of 3pm and 11pm. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Nurse Manager has been trained to be our in house CPR trainer (08/11/2021) as well as a BLS instructor (09/25/2021).
All staff members who are required to have CPR training will be scheduled and trained by 12/31/21. The nurse manager will ensure the proper number of qualified CPR trained staff are scheduled for each shift moving forward.
Leadership staff will be required to check Relias trainings for updated CPR needs for their teams. Leadership will share CPR training needs with Nurse Manager so they can be trained. Nurse manager has pre-scheduled CPR trainings that occur every 2 weeks.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to ensure written acknowledgment that no client may be deprived of a civil right solely by reason of treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute in fourteen of fourteen records.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Vice President of Clinical Services was notified immediately (9/28/2021) and took this information to our Carelogic team to update the verbiage. Forms will be revised, trained on and rolled out by 1/1/2022.
Clinical staff will meet with current clients by 12/1/2021 to inform/review these changes.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to ensure written acknowledgment that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in fourteen of fourteen records.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Vice President of Clinical Services was notified immediately (9/28/2021) and took this information to our Carelogic team to update the verbiage. Forms will be revised, trained on and rolled out by 1/1/2022.
Clinical staff will meet with current clients by 12/1/2021 to inform/review these changes.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to ensure written acknowledgment that clients have the right to appeal a decision limiting access to their records to the director in fourteen of fourteen records.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Vice President of Clinical Services was notified immediately (9/28/2021) and took this information to our Carelogic team to update the verbiage. Forms will be revised, trained on and rolled out by 1/1/2022.
Clinical staff will meet with current clients by 12/1/2021 to inform/review these changes.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical plant inspection, the facility failed to properly store medication and dispose of outdated medication located in the medical director ' s office on the 3rd floor. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Medication was immediately disposed of by Nurse Manager on 09/28/2021. Director of Nursing reviewed the process with Nurse Manager and manual was given to her to keep as reference (09/28/2021).
Medication disposal will be reviewed with all nursing staff by 12/1/2021.
Nurse Manager/Charge Nurses will conduct monthly rounds to ensure all refrigerators (including personal) are in compliance.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on a review of client records, the facility failed to have a complete client record. Follow up information missing in two of three records. There was no documentation of follow up at the time of the inspection. Client # 5 was admitted on August 18, 2021 & discharged on August 24, 2021. There was no follow-up information in the client record. Client # 6 was admitted on July 11, 2021 & discharged on July 17, 2021. There was no follow-up information in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative Assistant (AA) will be trained by Executive Director/ Clinical Director on the process of contacting clients who were discharged. The AA will utilize the discharge calendar to ensure all clients are being followed up within the seven day timeframe.
AA will then document the attempts at reaching out.
These will be checked for completion by the Clinical Supervisors during the weekly chart audit.
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to have a complete client record. Follow up information missing in two of four records. There was no documentation of follow up at the time of the inspection. Client # 13 was admitted on June 29, 2021 & discharged on August 14, 2021. There was no follow-up information in the client record. Client # 14 was admitted on July 24, 2021 & discharged on July 30, 2021. There was no follow-up information in the client record.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the annual inspection conducted on May 21, 2021.
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Plan of Correction
Administrative Assistant (AA) will be trained by Executive Director/ Clinical Director on the process of contacting clients who were discharged. The AA will utilize the discharge calendar to ensure all clients are being followed up within the seven day timeframe.
AA will then document the attempts at reaching out.
These will be checked for completion by the Clinical Supervisors during the weekly chart audit.
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