INITIAL COMMENTS
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This report is a result of an off-site unusual incident investigation conducted on August 5-6, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pyramid Healthcare, Inc. 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of facility policy and procedures, the facility failed to follow their Nursing Rounds policy in one of one client recordreviewed. Per the facility Discharge Planning and Process policy, which states nursing will complete one observation every 2 hours of each client and document client location.
Client # 1 was admitted on 7/13/24 and discharged on 7/15/24. The client chart contained documentation of nursing notes on 7/15/24 at 1:54 am, 5:03 am, 6:30 am and 9:11 am. There was no documentation of nursing notes for an observation of the client between 1:54 am and 5:03 am nor between 6:30 am and 9:11 am.
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Plan of Correction
Direct care staff will 30 minute observation and Nursing staff will conduct one observation every 2 hours of each client activity/location in withdrawal management. In the event that there is no other direct staff, nursing will be responsible for the 30 minute observations. This will be documented on the Withdrawal Management 30 minute Observatory Flow Sheet. Flow sheet will be placed in the client medical record upon completion. Training will began 8/13/24 with implementation of observations beginning midnight 8/13/24. This was monitored through random chart audits by facility DON or Designee by reviewing 3 charts daily for 2 weeks to ensure completion. Chart audits began 8/14/24. |