INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on 09/27-10/01/21 by staff from Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pyramid Pittsburgh 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, interviews with housekeeping staff and nurses, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents. Findings:Weekends and some evenings when housekeeping has finished working for the day, it is left to the nursing staff to clean the rooms before assigning a new client to a room. This does not always happen. The findings were reviewed with facility staff during the complaint investigation process.
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Plan of Correction
All responsible staff will be scheduled and trained so all rooms are cleaned to the appropriate standards. Training will be complete by 12/1/2021. Housekeeping Supervisor will conduct weekly, random inspections to ensure rooms are acceptable. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on interviews with the Facility Director, techs, and clients, the facility failed to ensure privacy so that counseling sessions or client personal information cannot be heard outside the counseling room or office. Findings: The tech office door has been removed to make sure the techs are always accessible to the clients. When techs are speaking to each other or to a client while in the office, the clients sitting or standing outside can sometimes hear what was said. The findings were reviewed with facility staff during the complaint investigation process.
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Plan of Correction
The tech office door was replaced on 9/30/2021. During the monthly Tech Staff meeting on 10/20/2021, BHT Manager reviewed the importance of client confidentiality and discussed any conversations regarding clients should occur privately. They were also reminded that any breach of client confidentiality will be handled with progressive discipline, per Pyramid Policy. Moving forward, no BHT office doors will be removed to ensure clients have a confidential space to speak about client issues. |