Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
Part 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
Part 2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on July 16, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-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. The following deficiencies were identified during this inspection:
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Plan of Correction
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Observations
Based on a review of seven fire drill logs on July 16, 2020, the facility failed to conduct unannounced fire drills at least once a month.
The facility had no documentation of fire drills for the months of March 2020, April 2020 and May 2020 at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drills will be conducted once a month by the Executive Director for this location. Executive Director will place a monthly reminder on his calendar to guarantee completion of a fire drill will take place. Dates and times of fire drill reminder will be during business hours and at random to ensure fire drills are never the same day and time each month.
All fire drills will be properly documented on the fire drill log and all records of Fire Drills completed will be stored with the Executive Director.
Regional Director will conduct a Quarterly audit on the Fire Drill Logs to ensure proper completion and compliance with corrective action plan. |