INITIAL COMMENTS
|
This report is a result of an initial on-site inspection of a new physical plant for an existing facility. The inspection was conducted on June 22, 2009 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 Manor 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 July 24, 2009.
|
Plan of Correction
|
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.
|
Observations
Based on a physical plant inspection, the facility failed to provide furnishings in counseling areas in Building A and Building C.
The findings include:
A physical plant inspection was conducted on June 22, 2009 at 10:00 AM. Administrative and counseling areas in Building A and Building C do not have furnishings.
|
Plan of Correction
Due to the fact that we are moving our location from an existing facility, these furnishings are presently at our current location. These items are to be moved by the maintenance crew prior to the arrival of the clients at the new facility. The furnishings include approximately 50 chairs that will be placed in the counselors' offices for group as well as a desk and several filing cabinets. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential 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.
|
Observations
Based on a physical plant inspection, the facility failed to provide privacy in counseling areas in Building A.
The findings include:
A physical plant inspection was conducted on June 22, 2009 at 10:00 AM. Counseling areas in Building A did not have a covering over the window to ensure privacy.
|
Plan of Correction
There are interior windows in the two counselors' offices in building A. Maintenance has installed blinds on both windows. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
|
Observations
Based on a physical plant inspection, the facility failed to provide assembled beds in Building E.
The findings include:
A physical plant inspection was conducted on June 22, 2009 at 10:00 AM. Building E does not have all of the beds assembled. The two bedrooms on the first floor do not have assembled beds. Two bedrooms on the second floor are to have two single beds in each room, but only have one single bed assembled in each room.
|
Plan of Correction
We currently have 25 existing beds at our present facility. Upon moving, beds from our existing facility will be set up in building E to complete the two bedrooms that only have one bed at this time. |
705.5 (f) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(f) A bedroom may not be used as a means of egress from or access to another part of the facility.
|
Observations
Based on a physical plant inspection, the facility failed to provide a second means of egress from the second floor that is not from a bedroom.
The findings include:
A physical plant inspection was conducted on June 22, 2009 at 10:00 AM. The second floor of Building E has a second egress from within a bedroom.
|
Plan of Correction
Blueprints are currently being submitted in construct a fire escape from the second floor hallway. Program director will notify Dept of Health as soon as this is completed. We will not be considering any of the beds in this building for licensure until the fire escape is completed. |
705.5 (h) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(h) Each bedroom shall be ventilated by operable windows or have mechanical ventilation.
|
Observations
Based on a physical plant inspection, the facility failed to provide maintenance on a bedroom window.
The findings include:
A physical plant inspection was conducted on June 22, 2009 at 10:00 AM. A window in bedroom #8 in Building D is cracked.
|
Plan of Correction
Window has been removed and sent away to be repaired. Window will be picked up on July 7, 2009 and will be installed by maintenance on july 7, 2009. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential 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.
|
Observations
Based on a physical plant inspection, the facility failed to provide all of the requirements for the bathroom.
The findings include:
A physical plant inspection was conducted on June 22, 2009 at 10:00 AM. The facility failed to provide a mirror, a soap dispenser, a trash can, and paper towels in the bathrooms in Building B and Building D.
|
Plan of Correction
Mirrors, soap dispensers, and paper towel holders have been purchased and maintenance has installed them. We currently have over 30 trash cans in bathrooms at the existing facility. Upon moving, these trash cans will be placed in designated areas in bathrooms as well as client bedrooms. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
|
Observations
Based on a physical plant inspection, the facility failed to provide privacy in the bathroom.
The findings include:
A physical plant inspection was conducted on June 22, 2009 at 10:00 AM. The facility failed to provide privacy in bathrooms in Building B, Building C, and Building D. The second floor bathroom in Building B did not have a curtain, door or partition to provide for privacy. The bathroom in Building C did not have a curtain, door or partition to provide for privacy. The half bathroom in Building D, bedroom #11 did not have a curtain, door or partition separating it from the bedroom, failing to provide for privacy.
|
Plan of Correction
Curtain rods and shower curtains have been installed by maintenance in building B and building C. A door was installed by maintenance in the half bath in room #11 in building D.All other bathrooms in every building are equipped with doors to ensure privacy. |
705.7 (b) (1) 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:
(1) Have a food preparation area with a refrigerator, a sink, a stove, an oven and cabinet space for storage.
|
Observations
Based on a physical plant inspection, the facility failed to provide a fully equipped kitchen in Building B, Building D, and Building E.
The findings include:
A physical plant inspection was conducted on June 22, 2009 at 10:00 AM. There were no appliances in the kitchens in Building B, Building D, and Building E at the time of the inspection.
|
Plan of Correction
Due to the new facility being one location with multiple buildings, one fully equipped kitchen is centrally located in building B. All meals will be prepared and served in this kitchen and attached dining hall, which is set up to serve 38 individuals at once. The kitchen in building B currently has two industrial refrigerators and one commerial upright freezer. There is a 6 burner stove with two ovens as well as a 2' by 2' flat grill attachment. This room is also equipped with 3 sinks, a steam table for serving, and a food preparation table. Building E is equipped with appliances in a fully functional kitchen in order to allow for possible life skills groups. Building D has a snack counter where individuals may keep snack foods. A refrigerator from the current facility will be relocated to building D's snack area in order to allow individuals to store drinks and snacks that require refrigeration. This will be relocated upon moving. |
705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
|
Observations
Based on a physical plant inspection, the facility failed to provide a means to clean the eating, drinking, and cooking utensils in the kitchens in Building B, Building D, and Building E.
The findings include:
A physical plant inspection was conducted on June 22, 2009 at 10:00 AM. The facility does not have a dishwasher in the kitchens in Building B, Building D, and Building E.
|
Plan of Correction
Building B is the only building where eating, drinking, and cooking utensils will be used. We possess an industrial dishwasher at our current facility which will be relocated to our new facility's kitchen on the date we relocate. |
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.
|
Observations
Based on a physical plant inspection, the facility failed to provide a refrigerator/freezer in the kitchens in Building B and Building D.
The findings include:
A physical plant inspection was conducted on June 22, 2009 at 10:00 AM. The facility does not have a refrigerator/freezer in the kitchens in Building B and Building D.
|
Plan of Correction
two industrial refrigerators and one industrial freezer are located in the room directly next to the kitchen in building D. Building B does not have a kitchen due to the fact that all meals will be prepared in the main kitchen in building D. Building B will have a refrigerator in the snack area upon completion of our move in order to allow clients to store snack foods and drinks. |
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.
|
Observations
Based on a physical plant inspection, the facility failed to provide an unobstructed means of egress from the second floor in Building D.
The findings include:
A physical plant inspection was conducted on June 22, 2009 at 10:00 AM. The second exit from the second floor in Building D has a door that is difficult to open.
|
Plan of Correction
Maintenance removed and repaired fire exit door in building D. Door has been replaced and is in good working condition. |
705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
|
Observations
Based on a physical plant inspection, the facility failed to provide a second means of egress from the second floor in Building E and Building B.
The findings include:
A physical plant inspection was conducted on June 22, 2009 at 10:00 AM. The facility did not provide a second means of egress from the second floor in Building E. In building B, the second egress from the second floor is located within a bedroom (bedroom #7).
|
Plan of Correction
We have submitted plans for a fire escape to be builtin building E and are awaiting approval. We are not at this time requesting that these beds be licensed in building E. Upon completion of the frie escape, we will contact your agency regarding these beds.
In building B, the 4 bed bedroom (#7)that contained the fire escape has been remodeled. A hallway has been built allowing a second form of egress through the center of the existing bedroom. The areas on either side of this hallway have been converted to single bedrooms. Each bedroom measuring approximately 100 square feet. This will decrease the number of beds in this building from 21 to 19.
The bedrooms created in building B as a result of creating a hallway will hold a single bed in each room. The first bedroom measures 78 square feet and the other measures 110 square feet. At this time, we will not be seeking approval for this bedrooms. Program director will notify the DOH when these rooms are completed and we would like to seek an increase in beds. |
705.10 (b) (1) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(1) Maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
|
Observations
Based on a physical plant inspection, the facility failed to provide a smoke detector in Building A.
The findings include:
A physical plant inspection was conducted on June 22, 2009 at 10:00 AM. The facility did not provide a smoke detector in Building A.
|
Plan of Correction
Smoke detectors were purchased and installed by maintenance in building A. |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
|
Observations
Based on a physical plant inspection, the facility failed to provide a designated hearing-impaired resident bedroom with an alarm device for the hearing impaired.
The findings include:
A physical plant inspection was conducted on June 22, 2009 at 10:00 AM. The facility did not equip a designated hearing-impaired resident bedroom with an alarm device for the hearing impaired in any of the buildings on the campus that house bedrooms; Building B, Building D, and Building E.
|
Plan of Correction
A strobe-horn fire alarm has been installed in bedroom #2 which is located in building B. |