INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted February 16-17, 2023, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pyramid Healthcare Inc. 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 conducted during a complaint investigation on February 16, 2023, the facility failed to maintain the building in good repair at all times.
The cover base was observed to be missing on the wall closest to the door in lounge B16.
The wall was observed to have chipped paint and peeling wallpaper in the short hallway of the West Village.
This was discussed with facility staff at the time of the complaint investigation.
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Plan of Correction
The cover base was replaced closest to the door in the lounge B16 on 2/22/2023. Regular monitoring of cover bases will occur during monthly physical plant reviews completed by the Facility Manager to ensure that cover bases are appropriately secured.
Facility Manager has developed a strategic plan which include deep cleaning and repainting of the facility. This plan is outlined to be completed by 8/1/2023. Monitoring of facility maintenance and needs will occur monthly by Facility Manager.
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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 February 16, 2023, the facility failed to maintain the lounge furnishing in a state of good repairs.
In the B16 lounge, two torn chairs were observed.
This was discussed with facility staff at the time of the complaint investigation.
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Plan of Correction
The two torn chairs in lounge B16 were replaced on 2/16/2023 by Facility Manager. Monitoring of appropriate furniture maintenance will occur during monthly physical plant review completed by the Facility Manager. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on February 16, 2023, the facility failed to store all food items off the floor.
A large bag containing juice was observed laying on floor next to its containment box with a tube connected to the juice machine in the client lounge B16.
This was discussed with facility staff at the time of the complaint investigation.
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Plan of Correction
Kitchen Manager will educate dietary staff on proper food storage in the lounges during a departmental meeting on 3/6/2023. This education will include monitoring of the lounges before, during, and after each shift. Additionally, the juice bags will be changed to juice cartridges on 3/3/2023 which will be stored inside of the juice machines. The daily monitoring of the lounges will begin on 3/3/2023 and be conducted by Kitchen Manager, Kitchen Supervisor, or by a delegated employee in the absence of Kitchen Leadership. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client charts during a complaint investigation conducted on February 16-17, 2023, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in two of the five reviewed charts.
Client # 1 was admitted on October 2, 2022 and discharged on October 27, 2022. The treatment plan dated October 3, 2022 indicates that the client will have weekly individual therapy and group therapy five times per week. The chart documentation indicates that the client only had one individual session on October 20, 2022.
Client # 4 was admitted on September 25, 2022 and discharged on November 19, 2022. The treatment plan dated September 27, 2022 and updated on October 26, 2022 both indicated that the client was to receive weekly individual therapy and daily group therapy. The chart documentation indicates that the client only had one individual session on October 12, 2022.
This was discussed with facility staff at the time of the complaint investigation.
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Plan of Correction
Weekly monitoring of client records are completed by Clinical Supervisors and provided to Clinical Director for review each Monday by 4:00 PM. Monthly comprehensive monitors of client records are completed by Clinical Supervisors and Clinical Director. Additional comprehensive monitoring is completed by Regional Quality Manager and reviewed monthly with Clinical Supervisors and Clinical Director. Performance Improvement plans and/or disciplinary action will be provided to clinicians with delinquent documentation. These monitors include frequency of services provided. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on a review of client charts during a complaint investigation conducted on February 16-17, 2023, the facility failed maintain a complete client record. Progress notes were missing in two of the five reviewed charts.
Client # 1 was admitted on October 2, 2022 and discharged on October 27, 2022. The treatment plan dated October 3, 2022 indicates that the client will have weekly individual therapy and group therapy five times per week. The client chart only contains one individual progress note dated October 20, 2022.
Client # 4 was admitted on September 25, 2022 and discharged on November 19, 2022. The treatment plan dated September 27, 2022 and updated on October 26, 2022 both indicated that the client was to receive weekly individual therapy and daily group therapy. The client chart only contained one individual progress note dated October 12, 2022. In addition, the group notes were missing the individual client's data/participation information on the following dates: 9/26/22, 10/3/22, 10/4/22, 10/7/22, 10/10/22, 10/11/22, 10/12/22, 10/13/22, 10/17/22, 10/18/22, 10/19/22, 10/21/22, 10/24/22, and 11/1/22.
This was discussed with facility staff at the time of the complaint investigation.
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Plan of Correction
Weekly monitoring of client records are completed by Clinical Supervisors and provided to Clinical Director for review each Monday by 4:00 PM. Monthly comprehensive monitors of client records are completed by Clinical Supervisors and Clinical Director. Additional comprehensive monitoring is completed by Regional Quality Manager and reviewed monthly with Clinical Supervisors and Clinical Director. Performance Improvement plans and/or disciplinary action will be provided to clinicians with delinquent documentation. These monitors include presence of completed progress notes. |