INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 17 - 19, 2020 by staff from the Bureau of Program License. Based on the findings of the on-site complaint investigation, Pyramid Healthcare Inc. - Pyramid Pittsburgh in Wilkinsburg 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
The facility failed to maintain the building in good repair. The following was observed during a physical plant inspection conducted on November 17-18, 2020.Cleaning chemicals containing alcohol were observed to be unsecured. The cleaning chemicals were observed in unlocked utility closets in the male and female residential units and in two client bedrooms. Client bedroom # 223 was missing a thermostat dial.Client bedrooms # 232 and # 311 were missing thermostat covers.Client bedroom # 231 had a loose lightswitch plate.Client bedroom # 218 was missing a lightswitch plate.Client bedroom # 336 was missing the front panel of the heating unit. The panel was located on the floor in front of the heater.Electrical outlet covers were missing from the following areas: The 2nd floor Tech Office, the 2nd floor hallway, the 3rd floor lounge and client bedrooms #324 and # 311. TV cables were hanging out of the wall in client bedrooms # 203 and 207. A phone jack cord was hanging out of the wall in the 2nd floor lounge in the female unit.Phone jack wires were exposed in client bedroom # 245.
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Plan of Correction
In regards to the cleaning chemicals, facility maintenance team will ensure that all chemicals are stored in a locked closet in accordance with all regulations.
Client rooms will be inspected for thermastat dials, lightswitch plates and the froint panel of all heating units. All areas will be replaced with current or new fixtures.
The 2nd floor Tech Office, the 2nd floor hallway, the 3rd floor lounge and client bedrooms #324 and # 311 will have all electrical outlet covers replaced.
TV cables in client bedrooms # 203 and 207 will be removed.
The phone jack cord in the 2nd floor lounge in the female unit will be removed.
Phone jack wires exposed in client bedroom # 245 will be removed.
All repairs will be completed by 1/15/2021 by maintenance staff.
Workgroup has been created to ensure all plan needs are addressed in a timely fashion.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection November 17-18, 2020 the facility did not have functioning ventilation in all of the client bathrooms. The bathroom exhaust fans in client bedrooms 227 and 245 were observed to not be functioning.
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Plan of Correction
All client bathrooms will be inspected for functioning ventilation. Client rooms 227 and 245 will be replaced.
All repairs will be completed by 1/15/2021 by maintenance staff.
Workgroup has been created to ensure all plan needs are addressed in a timely fashion.
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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's client bathrooms were not properly maintained. Based on a physical plant inspection November 17-18, 2020 a black mold-like substance was observed in and around the showers in the client community shower rooms in the male and female residential units.The bathroom sink was observed to be leaking a steady stream of water from the pipe onto the floor in the client bedroom #330.In client bedroom #222, a large hole was observed in the bathroom door. In client bedroom #219 the bathroom ceiling ventilation cover appeared to be loose.In client bedroom #214 a large hole was observed in the bathroom ceiling where the air ventilation fan vent was missing.In client bedroom 326 the bathroom was observed to have a loose towel bar.In client bedroom 328 the bathroom was observed to have a loose towel bar and a missing second towel bar.In client bedrooms 324 and 336 the bathrooms were observed to be missing towel bars.
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Plan of Correction
All community showers will be inspected for any black mold-like substance. Immediate attention to this substance and the proper actions necessary to remove the substance will be performed.
In client bedroom #330, the sink will be fixed to stop any leak onto the floor in the bathroom
In client bedroom #222, the large hole in the bathroom door will be repaired.
In client bedroom #219 the bathroom ceiling ventilation cover will be checked and repaired as needed.
In client bedroom #214 the large hole in the bathroom ceiling where the air ventilation fan vent was missing will be repaired.
In client bedroom 326 and room 328 the bathroom the towel bars will be secured properly. Also in room 324, 328 and 336, any additional towel bars will be installed.
All repairs will be completed by 1/15/2021 by maintenance staff.
Workgroup has been created to ensure all plan needs are addressed in a timely fashion.
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