INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 4, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pyramid Ridgeview Behavioral Health Center 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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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill log from September 2021 thru July 20222 the facility failed to ensure that the fire drills included exit route used for the fire drills for December 2021, January 2022, February 2022, March 2022, April 2022, June 2022 and July 2022.
These findings were discussed with facility staff during the licensing process.
This is a repeat citation for an onsite inspection on August 5, 2021.
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Plan of Correction
We have new maintenance staff in place currently. Executive Director will meet with maintenance staff who is conducting the fire drills by 10-14-22 and review the correct way to conduct fire drills and document them. Executive Director will review the forms monthly to ensure they are completed appropriately. If Director finds the forms are not adequate, she will review with maintenance staff so they can correct the form. |
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 a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of two applicable records reviewed.
Client #6 was admitted on March 31, 2022 and was discharged on May 16, 2022.
Client #7 was admitted on March 15, 2022 and was discharged on April 27, 2022.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation for an onsite inspection on August 5, 2021.
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Plan of Correction
Administrative Coordinator has been given the role of completing follow up calls. Executive Director reviewed this with her and how to adequately complete this task, along where to document it. Executive Director met with her on 10-6-22 for supervision to revisit this part of her role. We discussed a day of the week, per week she conducts the follow up calls and where she documents this. This will be the Clinical Supervisors responsibility if the Administrative coordinator is off. Executive Director and Clinical Supervisor will review follow up calls during monthly chart audits. |