INITIAL COMMENTS
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This report is a result of an on-site initial licensure inspection conducted on July 3, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. As this was the initial inspection conducted, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all trash, garbage and rubbish was stored in noncombustible, covered containers that prevent the penetration of insects and rodents. The findings include:An initial physical plant inspection was conducted on July 3, 2014 at approximately 9:45 AM.Three full 13oz bags of trash were observed on the ground and resting against the rear exterior wall of the facility by the stair tower exit door. The assistant vice president of operations confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen outside the counseling room.The findings include:An initial physical plant inspection was conducted on July 3, 2014 at approximately 9:45 AM.The windows located in the counselor office across from the group room and the counselor office at the end of the hallway in the rear of the building were not equipped with blinds or window covers for privacy. The assistant vice president of operations confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on observation during a physical plant inspection, the facility failed to provide an operable soap dispenser in each bathroom.The findings include:An initial physical plant inspection was conducted on July 3, 2014 at approximately 9:45 AM.All three of the bathrooms within the facility each had an inoperable soap dispenser. The assistant vice president of operations confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that interior exits and stairs were lighted at all times. The findings include:An initial physical plant inspection was conducted on July 3, 2014 at approximately 9:45 AM.The light source within the stair tower exit was not operational at the time of inspection. The assistant vice president of operations confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all fire extinguishers were inspected and approved annually. The findings include:An initial physical plant inspection was conducted on July 3, 2014 at approximately 9:45 AM.The facility failed to ensure that the fire extinguishers located in the waiting area, the group room, and the hallway by the stair tower were inspected by either the local fire department or a fire extinguisher company within the past year. All three of the fire extinguishers were last inspected in October 2012. The assistant vice president of operations confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |