INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted January 16, 2025, 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 January 16, 2025, the facility failed to maintain a clean, safe building in good repair at all times.
The following was observed:
Main building:
Bedroom 103 - had missing trim on the wall corner
Bedroom 215 had a missing light cover and torn/peeling wallpaper on all of the bedroom walls
Bedrooms 203 and 207 had broken window blinds
Bedroom 204 a hole in the far wall beside bed
Annex: 2nd floor, bedroom 2 had a hole in the wall
Detoxification unit, room D-3 had broken blinds
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Plan of Correction
The objective of this Plan of Correction for Building Exterior and Grounds is to ensure that the residential facility adheres to licensure requirement 705.2. This involves maintaining a building exterior and grounds that are consistently clean, safe, and sanitary, as well as in good repair for the safety and well-being of residents, employees, and visitors. For immediate repairs, the plan involves the following actions: Replace the missing trim in Bedroom 103 by February 20, 2025. In Bedroom 215, install a new light cover and repair the torn or peeling wallpaper on all walls by February 20, 2025. For Bedrooms 203 and 207, repair or replace the broken window blinds by February 21, 2025. In Bedroom 204, patch and repair the hole in the far wall beside the bed by February 20, 2025. Repair the hole in the wall in Annex, 2nd Floor, Bedroom 2 by February 20, 2025, and replace the broken blinds in Detoxification Unit, Room D-3 by February 20, 2025. To ensure ongoing compliance, a regular inspection and maintenance routine will be implemented. Starting February 2, 2025, a weekly inspection schedule for all facility areas will be introduced to promptly identify potential safety and repair issues, with a designated maintenance team member overseeing this task. Each inspection will be documented, and a log of identified issues with corresponding actions will be maintained. Additionally, preventive measures will include developing a maintenance checklist for each room and common area, covering inspections of walls, lights, blinds, and overall cleanliness. This checklist will be reviewed monthly by the maintenance supervisor. Monthly supervision sessions for housekeeping and maintenance staff will also be conducted, focusing on best practices for maintaining a safe and sanitary environment, with the first session scheduled for February 20, 2025. Communication and feedback are essential components of this plan. A communication protocol will be established to allow staff to report maintenance issues promptly, utilizing the Maintenance Ticket SOP by February 2, 2025. Feedback from complaint investigations will be reviewed and addressed to continually improve processes. By systematically addressing these issues, our facility aims to maintain compliance with the required standards while enhancing the safety and well-being of all residents, employees, and visitors. |
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 January 16, 2025, the facility failed to maintain lounge area furniture in good repair.
In the basement residential area, the Sunshine Room, had four torn/damaged black chairs, one with torn fabric falling off the bottom of the chair. The green sofa was torn and the inside stuffing was coming out.
In the detoxification unit, the Lounge across from room DH-5 had a broken light switch cover with sharp edges and a damaged end-table with missing laminate.
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Plan of Correction
The Plan of Correction for Living Rooms and Lounges Compliance aims to ensure adherence to licensure requirement 705.3 by maintaining living room and lounge areas with safe, well-maintained furnishings for clients, their families, and invited guests. The correction plan begins with an immediate assessment and inventory of all lounge and living room areas by February 20, 2025, identifying furniture and fixtures that need repair or replacement, encompassing all common areas accessible to clients and guests. In terms of furniture repair and replacement, the Sunshine Room in the basement residential area will have four torn or damaged black chairs replaced with new, durable chairs by March 13, 2025, along with a new sofa that meets durability and safety standards by the same date. In the Detoxification Unit Lounge, the broken light switch cover will be replaced to eliminate sharp edges and comply with safety regulations by February 20 2025, and a damaged end-table will be repaired or replaced to ensure safety and intact laminate by February 20, 2025. The plan establishes a regular cleaning and maintenance protocol, initiated on February 20 2025, focusing on monthly inspections of furnishings for wear or damage, with specific staff members assigned to conduct routine checks and report issues to the maintenance team immediately. Ongoing staff training will emphasize the importance of promptly reporting furniture and facility maintenance issues, by reviewing the Maintenance Ticket SOP by February 2, 2025. |
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 January 16, 2025, the facility failed to maintain counseling area furniture in good repair.
The Annex Building, 1st floor, Counselor Office had one severely torn chair.
The Serenity Building, Motivational Room had four damaged/torn chairs.
The Serenity Building, Intake Office had one torn chair.
The Census Room had two torn chairs.
The Detox Office 1 had a torn chair.
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Plan of Correction
The Plan of Correction for Counseling Areas Compliance aims to ensure adherence to licensure requirement 705.4 (2) by maintaining all counseling areas within the residential facility with furnishings in good repair, thus providing a safe and welcoming environment for clients. The correction plan begins with an immediate assessment and inventory, involving a thorough inspection of all counseling areas by February 2, 2025. This assessment will identify furniture needing repair or replacement in areas such as the Counselor Office, Motivational Room, Intake Office, Census Room, and Detox Office. The repair and replacement strategy involves immediate actions to be completed by March 13, 2025. These include replacing the severely torn chair in the Annex Building's Counselor Office with a new, durable chair and replacing the four damaged or torn chairs in the Serenity Building's Motivational Room with high-quality seating that meets safety standards. Additionally, the torn chair in the Serenity Building's Intake Office will be replaced with a comfortable, supportive option. Similarly, the two torn chairs in the Census Room will be replaced to maintain a professional environment, and a suitable chair will replace the torn chair in Detox Office 1. To support this, furniture standards and maintenance protocols will be developed, including a maintenance monthly inspections of all counseling area furnishings starting March 13, 2025. Specific staff members will be assigned the responsibility of overseeing the maintenance of these furnishings, with this role incorporated into their job descriptions. Moreover, ongoing staff training will emphasize promptly reporting furniture and facility maintenance issues, with a review of the Maintenance Ticket SOP by February 2, 2025. |
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 January 16, 2025, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The following was observed in the Main Building:
Bedroom 103 - had cracked/peeling paint on the bathroom ceiling
Bedrooms 108 and 210 - had a black mold-like substance around the shower spicket in the bathrooms
Bedroom 111 - has a black mold-like spots on the bathroom ceiling
Bedrooms 107 and 216 - were missing bathroom light covers
Bedroom 202 - had a moldy shower floor mat in the shower
The following was observed in the Serenity Building:
Staff bathroom - had black mold-like spots around the ceiling vent
Client bathroom - had an extremely thick layer of dust/dirt and black mold-like spots around the ceiling vent
The following was observed in the Detoxification Unit:
D-2 - had a loose drain cover on the floor of the shower and the paint on the ceiling of the shower was chipping off and falling into the shower pan.
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Plan of Correction
The Plan of Correction for Bathroom Compliance aims to ensure adherence to licensure requirement 705.6 (7) by maintaining all bathrooms within the residential facility in a functional, clean, and sanitary manner at all times. To begin, a comprehensive inspection of all bathrooms throughout the Main Building, Serenity Building, and Detoxification Unit will be conducted by February 2, 2025. This assessment will identify areas needing immediate attention for cleaning and repairs. Housekeeping staff will be assigned to perform an initial deep cleaning of all bathrooms to address any surface-level cleanliness issues prior to the detailed inspection. The repair and remediation strategy involves several key actions. In the Main Building, the cracked and peeling paint on the bathroom ceiling in Bedroom 103 will be repaired by March 27, 2025, ensuring proper surface preparation and repainting to prevent future issues. For Bedrooms 108 and 210, the residual growth around the shower spigot will be removed by March 27, 2025, along with any necessary repairs to underlying condensation issues contributing to the problem. In Bedroom 111, the environmental stain on the bathroom ceiling will be addressed following safe remediation protocols by March 27, 2025. Additionally, missing bathroom light covers in Bedrooms 107 and 216 will be installed to ensure that all fixtures are secure and functional by the same deadline. In Bedroom 202, the shower floor mat will be replaced, and a thorough cleaning will be conducted to eliminate any remaining stain in the shower area by March 13, 2025. In the Serenity Building, the darkened patch around the ceiling vent in the staff bathroom will be addressed by March 27, 2025, with attention to identifying and resolving any moisture sources. For the client bathroom, similar efforts will focus on removing the darkened patches and cleaning the thick layer of dust and dirt around the ceiling vent by the same deadline. In the Detoxification Unit, the loose drain cover on the shower floor in D-2 will be secured, and the shower ceiling will be repainted to eliminate chipping paint by February 20, 2025, ensuring the new paint is appropriate for bathroom environments to prevent future deterioration. Furthermore, a strict cleaning schedule will be implemented for all bathrooms, including daily cleaning, thorough weekly inspections, and monthly deep cleaning to uphold high standards of cleanliness and sanitation. Specific staff members will be designated to conduct routine maintenance checks on bathrooms, ensuring both proper function and cleanliness are consistently maintained. |
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 January 16, 2025, the facility failed to ensure that hallways and exits from the facility are unobstructed.
The exit located in the hallway between the residential and annex buildings was blocked by large water cooler refill bottles, a plastic storage bin, trash, and a cleaning materials.
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Plan of Correction
The Plan of Correction for Fire Safety Compliance aims to ensure adherence to licensure requirement 705.10 (a) (1) (i) by maintaining unobstructed stairways, hallways, and exits throughout the residential facility, thereby ensuring the safety of residents, staff, and visitors in the event of an emergency. To achieve this, an immediate inspection of all hallways, exits, and stairways within the facility will be conducted to identify and remove any existing impediments, with this inspection completed by February 2, 2025. Special attention will be given to areas previously identified as blocked, specifically where large water cooler refill bottles, a plastic storage bin, trash, and cleaning materials were found. All obstructions in these areas will be removed by February 20, 2025.
In addition, protocols will be established to designate all exits, hallways, and stairways as "No Obstruction Zones," ensuring that these areas remain clear at all times. Clear and visible signage reinforcing the need to keep emergency exits unobstructed will be installed near exits and hallways by February 20, 2025. To maintain ongoing compliance, a daily inspection will be implemented to verify that hallways and exits are free from obstructions. Additionally, the maintenance team will conduct weekly facility checks beginning February 20, 2025.
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on January 16, 2025,
the facility failed to prohibit heaters that are not permanently installed.
Unmounted space heaters were observed in three counselor offices.
This was discussed with facility staff at the time of the investigation.
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Plan of Correction
The Plan of Correction for Heating and Cooling Compliance aims to ensure adherence to licensure requirement 705.26 (2) by prohibiting the use of heaters that are not permanently mounted or installed within the facility, thereby safeguarding the well-being of residents, staff, and visitors. To begin, an immediate inspection of the facility will be conducted to identify and remove all unmounted space heaters currently in use, particularly in the three counselor offices noted during the inspection. This removal is to be completed by February 6, 2025, and documented in a maintenance log to ensure accountability. In addition, the current Standard Operating Procedure (SOP), titled "Prohibited Staff Items," will be assessed to confirm it explicitly addresses the prohibition of unmounted space heaters. The SOP will be revised to clarify what constitutes "permanently mounted or installed heaters" and to outline specific consequences for staff who violate this policy. The updated SOP will be distributed to all staff members by February 7, 2025, ensuring that everyone comprehends the changes and the importance of compliance. Furthermore, a mandatory training session will be scheduled for all staff to review heating and cooling safety requirements, emphasizing the dangers associated with unmounted heaters and the necessity of adhering to the policy. This training, set to occur by February 10, 2025, will also include a review of the updated "Prohibited Staff Items" SOP, utilizing examples and scenarios to reinforce compliance. To establish ongoing monitoring, a comprehensive system will be developed that includes regular monthly inspections by maintenance staff to ensure compliance with the heating and cooling policy, with findings documented in a compliance log. Additionally, designated staff will be responsible for verifying adherence to the SOP during weekly checks of counselor offices and other areas where heaters may be utilized. |