INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 30, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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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 fire drill logs from July 2025 to May 2026, the facility failed to document that a fire drill was conducted during sleeping hours at least every six months. The fire drill logs documented an overnight fire drill occurring in the month of September 2025 and not again until April 2026.
This is a repeat citation from the July 17, 2025, licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrator, Maintenance Director, and other staff responsible for life safety compliance were re-educated on 7/6/2026 on the regulatory requirements on for fire drill frequency, documentation, and scheduling, with emphasis on conducting and documenting overnight fire drills at least every six months.
The maintenance supervisor will review the fire drill tracking log monthly in leadership meeting to verify that all required fire drills are completed and documented according utilizing the already established smartsheet submission. Any identified deficiencies will be addressed immediately through corrective action and additional staff education as needed to ensure ongoing compliance. |
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 client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in three out of four applicable records reviewed.
Client #12 was admitted to the detoxification level of care on May 4, 2026, and stepped down to the residential level of care on May 10, 2026, and discharged against facility advice on May 12, 2026. The facility failed to follow their policy for against facility advice discharges of calling the emergency contact within twelve hours.
Client #13 was admitted to residential rehabilitation level of care on November 20, 2025, and discharged against facility advice on December 22, 2025. The facility failed to follow their policy for against facility advice discharges of calling the emergency contact within twelve hours.
Client #14 was admitted to the detoxification level of care on October 22, 2025, and stepped down to the residential rehabilitation level of care on October 27, 2025, and discharged against facility advice on November 13, 2025. The facility failed to follow their policy for against facility advice discharges of calling the emergency contact within twelve hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On August 6, 2026, all applicable staff will be re-educated on the facility policy regarding emergency calls for clients who leave the facility against facility advice or against medical advice. The education will emphasize staff responsibilities, required documentation, and the procedures for completing emergency notifications in accordance with facility policy.
As a systemic corrective action, the facility's Non-Routine Discharge Communication will be revised to include a required documentation for staff to record contact with the client's emergency contact. This required field will ensure that emergency contact notification is documented before the non-routine discharge process can be considered complete.
Following the re-education and implementation of the revised Non-Routine Discharge Communication, the Clinical Director will monitor compliance by reviewing all non-routine discharges, including AFA and AMA discharges, to verify that emergency calls were completed, emergency contact notification was documented in the client record, and all documentation requirements were met.
Clinical director will have oversight to ensure all calls are made and documented when appropriate. Clinical director will complete chart checks on a case by case basis after discharge for any client who has left AMA/AFA to ensure this documentation is completed.
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information within seven days of discharge, per facility policy, in two out of four applicable records reviewed.
Client #12 was admitted to the detoxification level of care on May 4, 2026, and stepped down to the residential rehabilitation level of care on May 10, 2026, and discharged on May 12, 2026. A follow up was due no later than May 19, 2026; however, there was no documentation that a follow up contact was completed.
Client #13 was admitted to the residential rehabilitation level of care on November 20, 2025, and discharged on December 12, 2025. A follow up was due no later than December 29, 2025; however, the follow up contact was not completed until January 22, 2026.
This is a repeat citation from the July 17, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will review regulation 709.53(a)(11) with the clinical team during group supervision on July 30th, 2026. To ensure compliance with this regulation monthly internal chart audits will be conducted by clinical director. Clinical Director will pull 10 charts randomly monthly and review findings with Executive Director and Clinical team monthly. |