INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, 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 on-site inspection, a physical plant inspection was conducted on October 28, 2020 and a review of client records was completed March 1-16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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. Pine Ridge 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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705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection conducted on October 28, 2020, the facility failed to ensure that in each residential facility bedroom, each resident shall have a bed with solid foundation and fire retardant mattress in good repair.
In D House Room 17 the mattress was not in good repair as I was torn.
In E House Room 19 the mattress was not fire retardant.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
Maintenance replaced mattresses in room 17 and 19 on 3/01/21. Risk committee will check mattresses during their monthly physical plant walk thru, starting immediately. All mattresses will be replaced as needed by maintenance. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection conducted on October 28, 2020, the facility failed to ensure the hot water temperature did not exceed 120F.
The water temperature in the bathrooms in C House was 130F.
The water temperature in the bathroom in E House was 124F.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
Maintenance adjusted water temperatures day of inspection. Maintenance will continue to monitor on a monthly basis to ensure temperatures are regulated. These monthly checks will be documented in a water temp log binder. |
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 one of three applicable client records reviewed, the facility failed to provide a complete client record to include follow-up information according to the facility policy and procedure manual in client records # 6.
Client # 6 was admitted on July 22, 2020 and discharged December 26, 2020. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Executive Director will spot check closed charts each month to ensure aftercare calls are being made and clients treatment is being followed, effective immediately. Executive Director reviewed aftercare call policy with administrative assistant (who completes the follow up call) on 3/30/21. If administrative assistant continues to be deficient in this matter, this will be discussed, a plan of action to be completed and documented in monthly supervision by Executive Director. |