INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated inspection, client records were reviewed on October 2, 2020 and the physical plant inspection was conducted on October 15, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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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(iv) Outdated drugs are removed.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 review of the medication storage area the facility failed to follow their procedures related to disposal of medications for clients that are no longer at the facility.
The facility had twelve boxes of Vivitrol that were previous client ' s medication that had the prescription label crossed off and were marked sample. The Nurse Practitioner confirmed those medications are being utilized for current clients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Executive Director will ensure all medication will be stored/disposed of in compliance to State and Federal Law.
1. The nurse practitioner has reviewed all the expectations of managing medication of clients that are no longer in the facility.
2. The medications will be returned to the pharmacy or disposed of properly.
Nurse practitioner or Nurse Manager will educate the medical team on State and Federal laws surrounding the storage /disposal of medications. In a team meeting completed by 12/11/2020
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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of unusual incident reports the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving a serious injury due to unusual circumstances.
An incident occurred on September 18, 2020 where a client was hit by a staff car and was injured. This incident was not reported to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/2/2020 The leadership team will review the policy on Incident reporting and the importance of reporting unusual incident reports.
Nurse Manger will review with all staff the importance of incident reports and the proper procedure for completing the reports.
She has conducted three training sessions to ensure all staff are trained in completing reports in a timely manner.
Nurse Manager will review all incident reports within 24 hours of the incident and will inform ED.
ED , NM or appropriate party will report on unusual incidents to DDAP within 24 hours.
Executive director will provide reports and updates on all Unusual incident reports.
Incident reports will be reviewed weekly in leadership to ensure 100% compliance
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of unusual incident reports the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
An incident occurred on February 2, 2020 that required ambulance personnel that was not reported to the Department.
An incident occurred on July 13, 2020 that required ambulance personnel that was not reported to the Department.
An incident occurred on July 23, 2020 that required ambulance personnel that was not reported to the Department.
An incident occurred on August 11, 2020 that required ambulance personnel that was not reported to the Department until August 25, 2020.
An incident occurred on August 30, 2020 that required ambulance personnel that was not reported to the Department until September 21, 2020.
An incident occurred on September 8 2020 that required ambulance personnel that was not reported to the Department until September 20, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/2/2020 The leadership team will review the policy on Incident reporting and the importance of reporting unusual incident reports.
Nurse Manger will review with all staff the importance of incident reports and the proper procedure for completing the reports.
She has conducted three training sessions to ensure all staff are trained in completing reports in a timely manner.
Nurse Manager will review all incident reports within 24 hours of the incident and will inform ED.
ED , NM or appropriate party will report on unusual incidents to DDAP within 24 hours.
Executive director will provide reports and updates on all Unusual incident reports.
Incident reports will be reviewed weekly in leadership to ensure 100% compliance
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