INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 22, 2010 through November 24, 2010 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. The following deficiencies were identified during this inspection and a plan of correction is due on December 28, 2010.
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Plan of Correction
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on observations on November 23, 2010 and an interview with the Facility Director, the facility failed to ensure that the water temperature did not exceed 120 F in 3 of 4 bathrooms where temperatures were taken.The findings include:A physical plant inspection was conducted on November 23, 2010. On November 23, 2010 temperatures for sinks in the unisex public restroom on the ground level, the female residential restroom on the basement level, and 2 female residential bathrooms on the second floor were taken.1) The female residential restroom on the basement level water temperature was 137 F.2) Female residential client room # 20 bathroom on the second floor water temperature was 135 F.3) The female residential hall bathroom on the second floor water temperature was 140 F. An interview with the maintenance director conducted on November 23, 2010 confirmed that the water temperatures for the female residential restroom on the basement level, female residential room #20 and the female residential hall bathroom on the second floor, exceeded 120 F.
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Plan of Correction
On 12/6/2010, Program Director spoke with on site maintenance staff who oversees the water temperatures regarding the temperature being too high. Maintenance staff on site understands the importance of this regulation and adherence to it. The settings will be adjusted to ensure the temperature does not exceed 120 F. Program Director will monitor compliance of this regulation via monthly water temerpature logs. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on the physical plant inspection on November 23, 2010 the facility failed to keep cold food being stored at or below 40F and frozen food being stored at or below 0 F.The findings include:A physical plant inspection was conducted on November 23, 2010 from 12:30 P.M. to approximately 1:00 P.M. Four refrigerators/freezers and three freezers are provided for client food storage.1) The refrigerator/freezer in the kitchen on the ground level temperature for refrigerator section was 39 F; however, the thermometer for the freezer was broken. The Licensing Specialist used his own thermometer and received temperature reading of 15 F. The Licensing Specialist left the thermometer in the refrigerator/freezer for approximately 6 minutes.2) Refrigerator/Freezer # 1 on the basement level lacked a thermometer in both the refrigerator and freezer. The Licensing Specialist used his own thermometer and received a temperature reading of 46 F for the refrigerator and the temperature for the freezer section was 4 F. The Licensing Specialist left the thermometer in the refrigerator /freezer for approximately 6 minutes. 3) Refrigerator/Freezer # 3 on the basement level temperature for refrigerator section was 11 F but the temperature for the freezer section was 28 F. The Licensing Specialist obtained the temperature from the thermometer in the refrigerator section and the thermometer in the freezer section.4) Freezer # 4 on the basement level temperature was 15 F. The Licensing Specialist obtained the temperature from the thermometer in the freezer.5) Chest Freezer # 2 on the basement level did not have a thermometer. The Licensing Specialist used his own thermometer and received a temperature reading of 46 F for the freezer. The Licensing Specialist left the thermometer in the freezer for approximately 6 minutes.An interview with the maintenance director on November 23, 2010 confirmed that food was not stored at the appropriate temperatures in those refrigerator/freezers and freezers. Also, the maintenance director confirmed that those refrigerator/freezers and freezers did not have thermometers. However, during the course of the inspection, the maintenance director did provide thermometers for all of the refrigerators and freezers.
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Plan of Correction
On 11/29/2010, maintenance staff bought new thermometers and placed them in the refrigerators/freezers in which there were none. Maintenance staff on site will ensure that there are always thermometers in all refrigerators and freezers via weekly checks. Maintenance staff on site will oversee the recording of temperatures daily to ensure they are falling within range. Program Director will monitor the temperatures and thermometer placement monthly via monthly facility walk through and temperature logs. |
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 the fire drill record log and an interview with the Facility Director, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.The findings include:The fire drill record log was reviewed on November 24, 2010. The log was reviewed from November 30, 2009 to October 25, 2010. Drills during sleeping hours had been conducted on October 29, 2009 at 6:00 A.M. The next sleeping hour drill should have been conducted on or before April 29, 2010; however, the next sleeping hour drill was not conducted until June 30, 210 at 6:10 A.M. An interview with the facility director conducted on November 24, 2010 confirmed that no fire drill was conducted during sleeping hours during the month of April.
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Plan of Correction
Program Director spoke to on site Maintenance staff who currently conducts all fire drills on 12/6/2010. He was informed and educated on the fact that one sleeping fire drill needs completed every 6 months. On site Maintenance staff will conduct a sleeping fire drill once every 6 months, with the first one being completed by 12/31/2010. The documentation of these drills will be inspected by Program Director and on site Risk Committee monthly to ensure compliance of all fire drills. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records and an interview with the Facility Director, the facility failed to document the type and frequency of services in the individual treatment and rehabilitation plan in six of six inpatient client records.The findings include:Six inpatient client records were reviewed on November 22 through 24, 2010. The type and frequency of services were required in the individual treatment and rehabilitation plan in six client records. The facility did not document the type and frequency of services in the individual treatment and rehabilitation plan in client records #1, 2, 3, 4, 5, and 6.Client # 1 was admitted on October 4, 2010. The treatment plan was completed on October 5, 2010 and did not include documentation of the type and frequency of treatment and rehabilitation services. Client # 2 was admitted on October 5, 2010. The treatment plan was completed on October 6, 2010 and did not include documentation of the type and frequency of treatment and rehabilitation services. Client # 3 was admitted on October 12, 2010. The treatment plan was completed on October 12, 2010 and did not include documentation of the type and frequency of treatment and rehabilitation services. Client # 4 was admitted on September 27, 2010. The treatment plan was completed on September 28, 2010 and did not include documentation of the type and frequency of treatment and rehabilitation services. Client # 5 was admitted on September 3, 2010. The treatment plan was completed on September 3, 2010 and did not include documentation of the type and frequency of treatment and rehabilitation services. Client # 6 was admitted on August 16, 2010. The treatment plan was completed on August 17, 2010 and did not include documentation of the type and frequency of treatment and rehabilitation services. An interview with the facility director on November 24, 2010 confirmed that those client records did not include documentation of the type and frequency of treatment and rehabilitation services.
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Plan of Correction
Program Director will hold in-service for all counselors to review the inclusion of type and frequency of treatment and rehabilitation services in the individual treatment plan. This in-service will be conducted by 12/31/2010. Compliance will be ensured by Program Director via open and closed chart monitors monthly |
709.52(a)(3) LICENSURE Support service type
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on the review of client record an interview with the Facility Director, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in six of six inpatient client records.The findings include:Six inpatient client records were reviewed on November 22 through 24, 2010. The proposed type of support services were required in the individual treatment and rehabilitation plan in six client records. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in client records # 1, 2, 3, 4, 5, and 6.Client # 1 was admitted on October 4, 2010. The treatment plan was completed on October 5 , 2010 and did not include documentation of the proposed type of support services.Client # 2 was admitted on October 5, 2010. The treatment plan was completed on October 6, 2010 and did not include documentation of the proposed type of support services.Client # 3 was admitted on October 12, 2010. The treatment plan was completed on October 12, 2010 and did not include documentation of the proposed type of support services.Client # 4 was admitted on September 27, 2010. The treatment plan was completed on September 28, 2010 and did not include documentation of the proposed type of support services.Client # 5 was admitted on September 3, 2010. The treatment plan was completed on September 3, 2010 and did not include documentation of the proposed type of support services.Client # 6 was admitted on August 16, 2010. The treatment plan was completed on August 17, 2010 and did not include documentation of the proposed type of support services.An interview with the facility director on November 24, 2010 confirmed that those client records did not include documentation of the proposed type of support services.
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Plan of Correction
By 12/31/2010, Program Director will conduct in-service with all counselors to educate them on ensuring that all individual treatment and rehabilitations plans include support services for all clients. Program Director will ensure compliance via open and closed chart monitors monthly. |