INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 3, 2020 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site investigation, Pyramid Healthcare 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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715.7(b) LICENSURE Dispensing or Administering Staffing
(b) Dispensing time shall be prorated for patient census. There shall be sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
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Observations
Clients did not recieve medication in a timely manner. During staff and client interviews, it was reported that clients in the rehabilitation unit often waited an hour in line to receive their medications.
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Plan of Correction
A new med line protocol will be implemented on 5/18/2020.
Staff will be trained in this new protocol by 5/11/2020
Adherence to this protocol is being monitored by the facility Nurse Manager on a monthly basis through observation. Retraining and revisions to the protocol will occur as needed to ensure compliance in this area. |