INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 8-10, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc.-Pyramid Pittsburgh, was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this investigation.
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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
The facility failed to ensure that the facility was free from danger to health and safety of clients, staff and visitors.*At the time of investigation, the maintenance room on the lower level had items stored on top of an operational dryer, as well as combustible materials stored in front of the dryer. There was a hot-plate, that was being used to cook food, which created a safety hazard. *The concrete loading dock area was broken and cracked which created a trip hazard. *There were loose wires, which had been damaged by a truck, hanging from the side of the building. *There were loose wires hanging from a heating unit and the cover of the unit was broken in the residential area of the building. *There were loose wires hanging from an electrical box in the basement linen closet. *There pipe insulation was in poor condition and falling off the pipes. *There was evidence of leakage in the basement on the sewage discharge pipe. *The HVAC system vents throughout the facility were rusted and caked with dust and debris. This deficiency was discussed with facility staff in order to eliminate the dangerous condition.
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Plan of Correction
All items were removed from the top of the dryer. The paint has been removed, used up or properly disposed of. Hot plate was permanently removed. All completed from 5/28-5/30/19. Maintenance Supervisor will monitor storage areas monthly to ensure appropriate items are stored in storage areas and this does not occur moving forward.
Contacted 3 contractors to give a quote to remove and replace loading dock area. Once quotes are received, Maintenance Supervisor will decide on contractor and move forward with completion of loading dock concrete project. The goal is to have a quote and decision by 6-20-19.Once an appropriate quote is received, Director of Maintenance for the Western Region will finalize plans to ensure loading dock is replaced.
Loose wires hanging from the side of the building were cut at the attachment to the building. Completed 5/30/19- Maintenance supervisor will do monthly checks of facility to ensure loose wires are not exposed in the future. Any staff who notices any deficiencies in the facility will fill out a maintenance request located at the front desk.
Loose wires hanging from wall heater unit in room 306- wires were reattached to the unit, covered and properly installed. Completed 5/28/19 Maintenance supervisor will do monthly checks of facility to ensure loose wires are not exposed in the future. Any staff who notices any deficiencies in the facility will fill out a maintenance request located at the front desk..
Loose wires hanging from an electrical box in linen closet were properly nutted off, tucked back into the box, and a metal cover plate was installed. Completed 5/29/19. Maintenance supervisor will do monthly checks of facility to ensure loose wires are not exposed in the future. Any staff who notices any deficiencies in the facility will fill out a maintenance request located at the front desk.
Removed approximately 12" length of old insulation. Added new, foam pipe wrap installation. Completed 5/31/19. Maintenance staff will continue to look at all pipes weekly to ensure all insulation is appropriate, and will fix anything that is needed. Maintenance staff will do monthly checks of facility to ensure no issues within the pipes. Any staff who notices any deficiencies in the facility will fill out a maintenance request located at the front desk.
Water was leaking from slop sink above pipe. Cleaned up all water puddling, wiped down walls and cleaned floor in slop sink closet and in basement. Completed on 5/31/19.Maintenance staff will continue to look at all pipes weekly to ensure all insulation is appropriate, and will fix anything that is needed. Maintenance staff will do monthly checks of facility to ensure no issues within the pipes. Any staff who notices any deficiencies in the facility will fill out a maintenance request located at the front desk.
All dirty, rusted or damaged vents are being replaced through the building. Housekeeping supervisor enacted a once per week cleaning to all vents facility wide as part of the housekeepers daily routine. Housekeeping supervisor will check all housekeepers work weekly.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
The facility failed to store trash, garbage and rubbish in covered containers. The dumpster near the loading dock at the rear of the facility was not covered.
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Plan of Correction
Maintenance Supervisor spoke with Housekeeping staff and Dietary staff and let them know to close dumpster lid after every time of putting trash in dumpster. Supervisor will check at the end of each shift to ensure dumpsters are closed.
Dietary Supervisor will ensure all trash lids are kept on trashcans in the kitchen at the end of each shift.
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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
The facility failed to ensure that each bathroom provided privacy in toilets.*The bathroom in the basement near the north entrance did not have a door on the first stall.
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Plan of Correction
Door was re attached on 5/29/19. Any staff who notices any issues within the facility, such as a missing door, or gets report from a client that something is deficient, will fill out a maintenance request at the front desk. This book is checked daily and all staff are aware how to fill them out. Housekeepers cleans all facility areas daily, and when something is deficient, they will notify Maintenance Supervisor immediately, so the situation can be rectified. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
The facility failed to ensure that each bathroom was maintained in a functional, clean and sanitary manner.*The bathroom in the basement near the north entrance had a clogged toilet and a broken toilet paper dispenser
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Plan of Correction
Bathroom toilet was unclogged on 5-10-19. Broken TP dispenser was replaced on 5-30-19. Housekeeping cleans all areas of the building and will notify maintenance immediately of any broken or non working areas so they can be rectified. All staff are able to fill out a maintenance request form if something is broken, or a client notifies them something is broken/not working. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
The facility failed to store eating utensils in a clean, enclosed area.*The facility utilizes plastic eating utensils; they were found to be left uncovered in the dining area.
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Plan of Correction
Utensils will be covered with plastic wrap when not in use after the final breakfast, lunch and dinner by kitchen staff. Lead Cook/Kitchen supervisor will ensure this is done by a staff member daily at the end of the final meal. Individual storage containers with lids will be ordered, by Corporate Food Service Supervisor, for utensils to have their own container and lid and should be in the facility by June 15, 2019. Upon receipt, Kitchen supervisor will ensure these are being used daily. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
The facility failed to light all interior exits and stairs at all times.*The south stairwell from the third floor to the second floor was not illuminated.*The landing on the rear stairway between the second and third floors was not illuminated.
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Plan of Correction
Burned out bulbs were replaced on 5-31-19. Housekeepers will note any further burned out lights during their daily walk through of cleaning. Any staff along with housekeeping will fill out a work order if a light is out so that maintenance will fix it. |