INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 11, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, 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. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on the review of August 2021 through July 2022 fire drill logs, the facility failed to conduct unannounced fire drills from October 2021 through January 2022.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
A training was held for the maintenance department on 8/25/22 to review protocal and procedures for conduting fire drills. Reviewed protocal for unannounced drills. Executive Director and risk leader will montior monthly for ongoing compliance. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
Based on a review of fire drill logs from August 2021 through July 2022, the facility failed to document the exit route used in drill conduct August 2021 through February 2022, May 2022 and June 2022.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Maintenance team was addressed and retrained on fire drill protocal and proper documentation on 8/24/22. Reviewed process for documenting and alternating exit routes for each drill. Executive Director and risk leader will monitor monthly fire drills for complaince and will address any ongoing areas of concern. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of fire drill logs from August 2021 through July 2022, the facility failed to conduct any drills during sleeping hours.
The finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Maintenance team was addressed and retrained on fire drill protocal and proper documentation on 8/24/22. Reviewed policy on documenting drills every 6 months during sleep hours. Executive Director and risk leader will monitor monthly fire drills for complaince and will address any ongoing areas of concern. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a review of fire drill logs from August 2021 through July 2022, the facility failed to document that a fire alarm or smoke detector was set off during the May 2022 fire drill.
The finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Maintenance team was addressed and retrained on fire drill protocal and proper documentation on 8/24/22. Reviewed policy on setting off alarm or smoke detector during each monthly drill. Executive Director and risk leader will monitor monthly fire drills for complaince and will address any ongoing areas of concern. |