INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on July 17-18, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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.
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Plan of Correction
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709.34 (c) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
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Observations
Based on a review of administrative documentation and staff interviews, the facility failed to report a significant disruption of services to DDAP within 3 business days.
A storm came through the area of the facility on March 17, 2025, resulting in a downed tree and a loss of power. The clients housed in the effected building were offered and moved to hotel lodging for the evening. Generators were obtained and power restored; however, services were disrupted as some clients were relocated offsite. There was no documentation that an unusual incident report was filed with DDAP within 3 business days.
These findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
Executive Director met with Clinical Supervisor's/Nurse on 8/1/25 to re-review requirements for unusual event reporting to DDAP. We reviewed online submission as well. Moving forward, ED will monitor all incident reports and ensure completion in required time frames. |