INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted December 28-29, 2022, by staff from the Bureau of Program Licensure. 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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704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of the detoxification unit staffing schedule between November 27, 2022 through December 10, 2022, the facility failed to have one full-time equivalent primary care staff person available for every seven clients. On December 1, 2022 there were 18 clients in the detoxification unit. The schedule showed two primary care staff persons worked from 3pm-11pm. On December 2, 2022 there were 18 clients in the detoxification unit. The schedule showed two primary care staff persons worked from 7pm-11pm.On December 4, 2022 there were 15 clients in the detoxification unit. The schedule showed two primary care staff persons worked from 3pm-7pm.
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Plan of Correction
In response to nursing staffing shortage during the first week in December 2022, PPIP placed an immediate hold on WM admissions beginning December 6th. PPIP remained on hold and maintained at a capacity of 7 WM clients to allow for appropriate staffing while recruitment efforts were refocused and new nurses were hired/trained. Wage increase was implemented and made retroactive for current nursing staff to improve recruitment efforts. ED has also increased agency nursing contracts to allow consistent agency nursing support, when needed. ED will continue to monitor census daily and adjust nursing staffing accordingly. WM beds will open in increments of 7 as nursing staff are hired and oriented until we are at full capacity (28). |
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 conducted during a complaint investigation on December 28-29, 2022, the facility failed to keep the grounds clean, safe, sanitary and in good repair. The facility also failed to keep the exterior grounds or yard free of hazards.On December 28, 2022, the following was observed:First floor-The intake room (where we worked) was missing a vent cover on the wall near the ceiling and a missing outlet cover on the wall near the door. The bathroom in the intake room had loose tiles on the wall.-Cafeteria had a black substance and dirt and broken floor tile around the entire room and doorway. Chipped paint and cracked cover base were also observed along the lower walls.-The hallway leading to the cafeteria had water damaged ceiling tiles and an outlet with a loose cover exposing wires.-The medical assistant intake office had a black substance on the floor.-The nurse practitioner office had cracked paint and caulking where the radiator connects to the wall.-The doorway leading into the kitchen had trash, including a cigarette butt on the floor, and food stains on floor.First Floor Male unit-In the hallway between resident rooms 115 and 116 there was broken floor tile and broken cove base. -In resident room 115 a section of cove base was broken off of the wall.-In the hallway outside of the laundry room a dirty/dusty floor fan and damaged ceiling tiles were observed.Second floor Male A - detoxification unit-The hallway outside of the lounge had a torn chair.-Resident bedroom 203 was missing a vent cover in the bathroom and the bathroom door had chipped paint.-Resident bedroom 238 had stains on wall and peeling paint.-The laundry room had stains on the floor.-Resident bedroom 239 had a broken outlet cover.-The nurse office room 208 was missing a ceiling tile and had a torn chair.-The case coordinator office room 245 had a missing section of cove base.-The floor fan was dusty.Male Rehabilitation Unit B wing-The lounge had two missing ceiling tiles which exposed a large spider web.-The nurse station had a filthy windowsill, a torn chair and chipped paint around the door frame.-The utility closet was missing floor tiles.Third floor - Female Rehabilitation Unit A wing-Resident bedroom 302 was missing a thermostat cover.-Chipped paint and wood along wall in hallway.Third floor B wing female-The lounge had a paper towel holder that was partially affixed to the wall and appeared to be falling off of the wall; the thermostat cover was missing; and there were water-stained ceiling tiles.-The laundry room had broken and missing tiles.-Resident bedroom 336 was missing a thermostat cover and had water-stained ceiling tiles.Basement -The radiator heater pipes across from the elevator had torn coverings, exposing the insulation.On December 29, 2022 broken pavers were observed in the outside client recreational area.
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Plan of Correction
Pyramid Pittsburgh's Safety Committee will conduct weekly rounds of the facility to note any building/grounds needs on a checklist. These rounds will identify any items in need of repair, cleanliness and/or any safety concerns in the building. This checklist will get reviewed at the weekly leadership staff meeting and addressed by appropriate staff. Any emergent items will be brought to the attention of the Executive Director/Maintenance Manager immediately to be attended to.
All items listed during the physical plant inspection on Dec 28-29, 2022, will be corrected by February 15, 2023.
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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on December 28-29, 2022, the facility failed to maintain lounge furnishings in a state of good repair. The second floor, Male A Detoxification unit had a torn chair and the Male 2A Rehabilitation Unit had a torn chair and loveseat . The Male Rehabilitation Unit B had two torn chairs and a torn loveseat.The third floor, Female B Unit had seven torn chairs and one torn loveseat.
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Plan of Correction
Pyramid Pittsburgh's Safety Committee will conduct weekly rounds of the facility. During these rounds, the team will note any furnishings that are in need of repair. This list will be reviewed at the weekly leadership staff meeting and addressed by appropriate staff. Any emergent items will be brought to the attention of the Executive Director/Maintenance Manager immediately to be attended to.
All furnishings needed repaired/replaced as noted on the physical plant inspection dated Dec 28-29, 2022, will be corrected by March 1, 2023.
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705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on December 28-29, 2022, the facility failed to maintain counseling areas with furnishings in good repair.The intake office had a torn/worn chair.
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Plan of Correction
Pyramid Pittsburgh's Safety Committee will conduct weekly rounds of the facility. During these rounds, the team will note any furnishings that are in need of repair. This list will be reviewed at the weekly leadership staff meeting and addressed by appropriate staff. Any emergent items will be brought to the attention of the Executive Director/Maintenance Manager immediately to be attended to.
All furnishings needed repaired/replaced as noted on the physical plant inspection dated Dec 28-29, 2022, will be corrected by March 1, 2023.
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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
Based on a physical plant inspection conducted during a complaint investigation on December 28-29, 2022, the facility failed to maintain each bathroom in a clean and sanitary manner at all times.The second floor, Male A detoxification unit had filthy showers and chipped floor tile in the doorway to the shower room. There were also wet towels and trash observed all of the bathroom floor.The Male Rehabilitation Unit B had broken shower tile and broken ceiling tile outside the shower room. The group shower room had rusted/corroded shower head and temperature/on-off handle. There were also broken floor and wall tiles.The third floor B Female Unit had a single shower room with peeling caulk and a black substance around the shower pan. The showers across from bedroom 321 had peeling caulk and a black substance around the shower pans.
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Plan of Correction
Pyramid Pittsburgh's Safety Committee will conduct weekly rounds of the facility to note any building/grounds needs on a checklist. These rounds will identify any items in need of repair, cleanliness and/or any safety concerns in the building. This checklist will get reviewed at the weekly leadership staff meeting and addressed by appropriate staff. Any emergent items will be brought to the attention of the Executive Director/Maintenance Manager immediately to be attended to.
All items listed during the physical plant inspection on Dec 28-29, 2022, will be corrected by February 15, 2023.
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on December 28-29, 2022, the facility failed to ensure that all exits are unobstructed.The Male unit on the first floor had an emergency exit that was blocked by a chair and the exterior steps were covered with snow and ice.
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Plan of Correction
Pyramid Pittsburgh's Safety Committee will conduct weekly rounds of the facility to note any building/grounds needs on a checklist. These rounds will identify any items in need of repair, cleanliness and/or any safety concerns in the building. This checklist will get reviewed at the weekly leadership staff meeting and addressed by appropriate staff. Any emergent items will be brought to the attention of the Executive Director/Maintenance Manager immediately to be attended to.
This was corrected immediately on 12/29/2022.
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709.63(a)(4) LICENSURE Medication records
709.63. 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:
(4) Medication records.
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Observations
Based on a review of client records, the facility failed to provide a complete client record. According to QuickMAR medical records, CIWA and RASS assessments are to be completed every four hours. Documentation regarding assessments were missing from three out of five applicable charts reviewed. Client # 2 was admitted 12/11/2022 and was a current client at the time of the investigation. Documentation was missing for both CIWA and RASS assessments on 12/11/2022 at 4 p.m.Client # 5 was admitted 12/11/2022 and was a current client at the time of the investigation. Documentation was missing for both the CIWA and RASS assessments on 12/11/2022 at 4 p.m.Client # 7 was admitted 12/24/2022 and was a current client at the time of the investigation. Documentation was missing for the CIWA assessment on 12/28/2022 at 4 a.m.
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Plan of Correction
Nursing will be reeducated on detox protocols with specific attention to the vital signs and assessment tools (CIWA, RASS) within appropriate time frames to ensure thorough documentation. Reeducation to occur on 2/1/2023, on the next scheduled nursing meeting. This will be monitored through monthly chart monitors conducted by RQM team. |