INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on April 12, 2022 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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705.7 (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.
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Observations
Based on a physical plant inspection, the facility failed to store all cooking utensils in a clean enclosed area. It was observed that the cooking utensils were kept in an open plastic bin that contained dirt and crumbs inside the bin.
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Plan of Correction
A new utensil holder, with a cover, is on order. Utensil holder will be cleaned after every meal. Dietary Supervisor is responsible for the ordering of dietary supplies. Executive Director will have oversight of ordering and arrival of product. Dietary Supervisor is responsible for the oversight of cleanliness of the dining room and items, specifically the utensil holder. Target date, May 1, 2022. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, the facility failed to store all food items off the floor. In the pantry area, an open box of potato chips was observed to be on the floor.
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Plan of Correction
Dietary Supervisor will ensure that all food items are stored appropriately, on shelves, and off the floor. Potato chips, along with other snacks, will be stored on the top shelves. A sign will be posted in the dry goods storage room to inform all staff to place all boxes back on shelves when done utilizing and to keep all food items off the floor. Dietary Supervisor to have oversight. Target date 5/1/2022. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of unusual incident reports, the facility failed to inform the Department of an unusual incident involving a physical assault of a client within the required three days. It was discovered that the facility was informed on February 28, 2022 that a physical assault occurred on the premises. The facility filled out the unusual incident report documentation, however, the facility neglected to submit it to the Department.
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Plan of Correction
Current incident reporting process breakdown, which was discovered upon facility on site investigation. Target date of correction was the date of investigation, 4/13/2022. Medical Assistant, JS, is responsible for the submission of all incident reporting completion and submission. It was identified that a process breakdown was occurring. Since 4/13/2022, Jazmin has the correct link for DDAP incident reporting submissions. Executive Director monitors timely and efficient completion of incident reports. Executive Director to have daily oversight and is notified, via email and smartsheet, when an unusual incident report is completed and submitted. Staff responsible: Jazmin S. Staff to have oversight: Kelly Salloum, ED. Target Date: 4/13/2022. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of unusual incident reports, the facility failed to inform the Department of an unusual incident involving the presence of ambulance personnel within the required three business days. A report dated November 28, 2021 was found involving EMS on the premises to transport a client to the hospital. The facility filled out the unusual incident report documentation, however, the facility neglected to submit the documentation to the Department.
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Plan of Correction
Current incident reporting process breakdown, which was discovered upon facility on site investigation. Target date of correction was the date of investigation, 4/13/2022. Medical Assistant, JS, is responsible for the submission of all incident reporting completion and submission. It was identified that a process breakdown was occurring. Since 4/13/2022, Jazmin has the correct link for DDAP incident reporting submissions. Executive Director monitors timely and efficient completion of incident reports. Executive Director to have daily oversight and is notified, via email and smartsheet, when an unusual incident report is completed and submitted. Staff responsible: Jazmin S. Staff to have oversight: Kelly Salloum, ED. Target Date: 4/13/2022. |