INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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 inspection:
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Plan of Correction
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to maintain each bathroom in a clean and sanitary manner. The shower located in swing #2, second bathroom had brown stains around the base of the shower floor. There were also used bars of soap found and in one stall several used bars were sitting on top of one another.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed cleanliness and supplies of all bathrooms with facilities supervisor 8/17/2021, and reviewed facility cleanliness checklist with all maintenance, housekeeping and behavioral health staff on 8/20/2021. A deep cleaning of all bathrooms was performed by contracted cleaner on 9/21/2021. |
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 review of the client records, the facility failed to inform the clients of all their rights. The client ' s rights forms given to the client did not identify that clients may not be discriminated against based on religion and creed in seven out of seven records.
These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
The policy and procedures manual was updated on 7/12/2021 by the Policy and procedure committee to include religion, creed instead of the previously stated religious creed. The new policy was made available to staff on that date via the Pyramid Healthcare intranet. The compliance officer, via email, informed all programs of the change on that date and all handbooks and consents for treatment were amended to reflect the change. This was implemented at this facility on 8/17/2021. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of the Medication Administration Record, the facility failed to ensure that there is proper documentation of the administration of medication. Client # 8 was admitted on May 25, 2021 and was still an active client at the time of the inspection. Client #8 is prescribed a medication that is to be administered two times a day. There is not proper documentation that on August 4, 5, 7, 8, 11, 12, 13 and 15, 2021 the client received the PM dose. There is not proper documentation that on August 16, 2021 the client received the AM dose.
These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective 9/29/2021, Executive Director and Regional Director of Nursing converted all paper Medication Administration Records to electronic medication administration recording with a software called CareSuite. The electronic MAR system records all staff signatures at time of administration, and includes ability to monitor if staff signatures are missed at time of medication administration. All medication administration staff were trained on new eMAR system on 9/27/2021 and 9/28/2021 to ensure compliance with this POC and new medication administration system. |