INITIAL COMMENTS
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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 10, 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of seven fire drill logs on July 10, 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 October 2019, 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 drill in October was a result of Administrative Assistant in charge of drills being out of office on leave - to correct this, the Administrative Assistant supervisor will conduct the drill any time the Administrative Assistant is unavailable to do it.
Fire drills in March, April and May were not completed because most staff were working from home and all clients were being served through telehealth. We have now returned to office based services and regular monthly drills have resumed, however should this situation occur again (where staff and clients are not at the facility), the Facility Director will conduct a drill monthly or will request a waiver. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of six fire drill logs on July 10, 2020, the facility failed to utilize an alternate means of notifying a fire drill was being conducted. The facility was granted an exception to not use a smoke detector or fire alarm but is required with the exception to utilize an alternate means of notification. The fire drill record did not include this information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Quality Management Director has created a new form to record the fire drills that includes a question and space to record how the fire drill notification was made. This form and instructions on completing were given on 7/14/2020 to the Administrative Assistant responsible for conducting drills and their supervisor by the Facility Director. The new form has been placed in the fire drill binder and will be utilized for all future drills beginning this month. The facility director will monitor quarterly that the new form is being utilized properly. |