INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted June 3-5, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pyramid Healthcare Inc. York Inpatient 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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705.6 (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.
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Observations
Based on observation during a complaint investigation, the facility failed to provide a wall mirror in each bathroom.
The client bathroom across the hall from the two staff bathrooms and the two intake offices was observed to be without a wall mirror.
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Plan of Correction
A maintenance ticket was placed on 6/16/2025 and the facility supervisor ordered a mirror. The maintenance supervisor secures the mirror to the wall on 6/26/25. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on observation during a complaint investigation, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
A torn black chair was observed in the client bathroom across the hall from the two staff bathrooms and the two intake offices.
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Plan of Correction
On 6/5/2025, the chair with a tear on the seat was removed from the bathroom and the maintenance supervisor disposed of it. The maintenance supervisor will include identification of/action steps to address damaged chairs/other furniture in monthly safety inspections of the building. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on June 3, 2025, conducted during a complaint investigation, the facility failed to prohibit the use of portable space heaters which are not permanently mounted or installed.
An unmounted heater was observed on the floor of the inpatient residential nursing office in the older building.
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Plan of Correction
On 6/3/2025, the unmounted heater was removed from the location and disposed of. The maintenance supervisor will ensure improperly installed/portable heaters are not present in the facility as part of their monthly safety inspection of the building. This regulation was reviewed with all staff on 6/4/2025. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility's Client Detox Observation policy and the Client Observation Forms from the week of April 6, 2025, the facility failed to follow their policy.
The policy indicates that the designated direct care staff will conduct direct observation rounds at intervals of no less than 30 minute increments 24/7. Each client's whereabouts are to documented on the observation form.
The observation forms where not completed for the following:
- 4/7/25 at 0630 for Clients 1, 2, 3, 4, 5
- 4/8/25 at 0130 for Clients 2, 3, 4, 5
- 4/10/25 at 1230 for Client 1
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Plan of Correction
Proper client observations were reviewed with Behavioral Health Tech staff on 6/18/2025. Since all observations listed on the POC were for third shift, the third shift supervisor held a meeting with staff on 6/24/2025, outlining the policy and reviewing the expectations. Behavioral Health Tech supervisor will complete check-ins on each unit daily ensuring compliance with client observations in occurring in real time at least 2 times per shift then once consistently is demonstrated will move to periodic check ins to ensure client observations are being completed. The Behavioral Health Tech supervisor will notify the Behavioral Health Tech manager should any staff not be completing the client observations properly and further action will be taken; retraining and or disciplinary action. |
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 and other administrative documentation, the facility failed to report the following incidents involving physical assault by staff or a client.
On March 24, 2025, a client was hit by another client on the left side of her face resulting in a red left eye and a 3 inch long scratch between her eye and ear. This incident was not reported as required.
On March 24, 2025, a client had her nose ring pulled out during a fight with another client. The skin around her left nostril was red and bleeding. This incident was not reported as required.
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Plan of Correction
Clinical and administrative staff involved in the incidents were re-educated on immediate reporting procedures. The facility's Unusual Incident Reporting Policy has been reviewed to clarify the criteria for reportable incidents, including all physical assaults resulting in injury. This training was completed on June 20, 2025. As of June 21, 2025, the Clinical Supervisor and Behavioral Health Tech manager will review all incident reports daily in morning meetings to ensure that any reportable events are identified promptly and reported to the Department within 3 business days. |
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 and other administrative documentation, along with client and staff interviews, the facility failed to report an event at the facility requiring the presence of police, fire, or ambulance personnel.
On May 29, 2025, an incident occurred at the facility in which six female clients were involved in a physical altercation. The police were called and arrived onsite at the facility. The facility did not report the incident as required.
On May 25, 2025 a client was taken to UPMC Memorial via ambulance. The facility did not report the incident as required.
On April 20, 2025 a client was taken to York Hospital via ambulance. The facility did not report the incident as required.
On April 7, 2025, the Hellam Township Police were at the facility with an individual who refused admission. The police left with the individual on April 8, 2025. The facility did not report the incident as required.
On February 25, 2025, a client was taken to York Hospital via ambulance. The facility did not report the incident as required.
On February 20, 2025, both police and ambulance personnel were at the facility. A client was taken to York Hospital via ambulance. The facility did not report the incident as required.
On February 15, 2025, 911 was called. Police and ambulance were at the facility. The facility did not report the incident as required.
On February 3, 2025 a client was taken to York Hospital via ambulance. The facility did not report the incident as required.
On January 21, 2025 a client was taken to the hospital via ambulance. The facility did not report the incident as required.
On January 3, 2025, a client was taken to the hospital via ambulance. The facility did not report the incident as required.
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Plan of Correction
Clinical and administrative staff involved in the incidents were re-educated on immediate reporting procedures. The facility's Unusual Incident Reporting Policy has been reviewed to clarify the criteria for reportable incidents, including all physical assaults resulting in injury. This training was completed on June 20, 2025. As of June 21, 2025, the Clinical Supervisor and Behavioral Health tech manager will review all incident reports daily in morning meetings to ensure that any reportable events are identified promptly and reported to the Department within 3 business days. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of client charts and the facility's policies, the facility failed to follow their policy for completing the comprehensive (initial) treatment plan in two out of the four reviewed charts.
The facility's policy indicates that the initial treatment plan is to be completed within 72 hours of admission.
Client #3 was admitted on May 9, 2025 and was currently a client at the time of the investigation. The initial treatment plan was due on May 12, 2025. It was completed on May 14, 2025.
Client #4 was admitted on May 13, 2025 and was a current client at the time of the investigation. The initial treatment plan was due on May 16, 2025. It was completed on May 28, 2025.
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Plan of Correction
The Clinical Director will complete a 2-part group training on treatment plan completion, including timeframes for completion/signatures, documenting progress in treatment, and completing treatment plan reviews. Part 2 of the training was completed on 6/20/2025. The Clinical Director will pull daily treatment plan reports to capture any missing or late signatures on treatment plans. In the daily morning meeting , the Clinical director will plan with the team to ensure all signatures are on the treatment plan within required timelines. Once consistency is established then the clinical director will monitor compliance on a weekly then biweekly basis . |
709.53(a)(5) LICENSURE Progress Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record to include progress notes in two out of four applicable charts.
Client #2 was admitted on April 29, 2025 and was a current client at the time of the investigation. The treatment plan update dated May 17, 2025 indicates that the client is to receive individual counseling once a week. The client chart did not contain any individual session notes for the weeks of May 11-17, 2025 and May 25-31, 2025.
Client #4 was admitted on May 13, 2025 and was a current client at the time of the investigation. The comprehensive treatment plan dated May 28, 2025 indicates that the client is to receive individual counseling once a week. The client chart did not contain any individual session notes for the week of May 25-31, 2025.
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Plan of Correction
The clinical director re-educated clinical staff on the importance of timely and accurate documentation of all services rendered; on 6/24/2025 . Each week the clinical director will do a check of current clients and if sessions are not in the chart then the clinical director will require counselors to complete by the end of week to ensure compliance. |