INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 8 - 9, 2011 by staff from the Division of Drug and Alcohol 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:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility summary report, the facility failed to provide documentation of HIV/AIDS and TB/STD training for one of five personnel.
The findings include:
Five personnel records were reviewed on October 3, 2011. The facility summary report was reviewed on November 8, 2011. Five personnel were required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required TB/STD training for employee #5.
Employee # 5 is a counselor who was promoted into the counselor position on August 9, 2010. HIV/AIDS and TB/STD training was to be completed within one year of hire, by August 9, 2011. The facility failed to provide documentation of TB/STD training as of the date of the facility inspection on November 8 and 9, 2011.
The facility director confirmed on 11-9-2011 that the general training requirements were not completed for this employee.
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Plan of Correction
A TB/STD training is being offered on Feb 7, 2012 at Pyramid's Corporate office in Lakemont. Program Director will ensure that employee #5 will attend this training via the "request to attend training" form utilized by employees when requesting trainings. Adherence will be assured via the Program Director asking for and receiving documentation from the HR department that this employee does, in fact, attend. |
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 observation and a physical plant inspection, the facility failed to provide an unobstructed exit from a bedroom.
The findings include:
A physical plant inspection was conducted on November 9, 2011. Building C was inspected at approximately 10:45 AM. The door at bedroom #11 could not be opened because it was blocked by the resident's bed.
This was confirmed by the Behavioral Health Technician Supervisor and the Facility Director at the time of the inspection on November 9, 2011.
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Plan of Correction
Program Director will hold an in-service by 12/16/11 for the staff members who sit on the facility risk committee in order to review adherence to the ability to open all bedroom doors without any blockage. This will then be monitored via weekly walk throughs by the risk committee members, to include both the Tech Supervisor and Program Director. |
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.
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Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
Fire drill logs were reviewed on November 9, 2011. The fire drill logs were reviewed for the period of October 2010 to October 2011. There was a fire drill documented during sleeping hours on October 22, 2010 and the next fire drill during sleeping hours was documented on October 15, 2011.
This was discussed with and confirmed by the facility director on 11-9-2011 at 12:00 PM.
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Plan of Correction
Program Director will hold an inservice by 12/16/2011 with the facility risk committee members in order to review the fire drill policy requirements, focusing on the necessity of holding a sleeping hours fire drill at least once every 6 months. Adherence to this policy will be ensured by the Program Director via monthly review of the Fire Drill logs. |