INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on August 27 & 28, 2025, 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 York Pharmacotherapy Services 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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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in nine out of eleven client records reviewed.
Client #1 was admitted on July 8, 2025 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated July 9, 2025 was offered to the client.
Client #2 was admitted on March 12, 2025 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated March 10, 2025 was offered to the client.
Client #3 was admitted on December 9, 2024 and discharged on March 7, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated December 5, 2024 was offered to the client.
Client #4 was admitted on June 27, 2022 and discharged on July 10, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated February 3, 2025 was offered to the client.
Client #5 was admitted on May 15, 2025 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated May 15, 2025 was offered to the client.
Client #6 was admitted on March 2, 2021 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated March 6, 2025 was offered to the client.
Client #8 was admitted on July 15, 2024 and discharged on July 23, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for the funding source dated August 9, 2025 was offered to the client.
Client #9 was admitted on June 25, 2025 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated June 24, 2025 was offered to the client.
Client #10 was admitted on March 11, 2025 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated March 7, 2025 was offered to the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Pyramid Healthcare has submitted a ticket into its health records system to add an enhancement. This enhancement will denote that a copy of the Consent for Treatment, Payment and Healthcare Operations consent is offered to the client and will be memorialized and maintained in the client record. This denote will be a required field at the bottom of the document. As a result, staff will be unable to move forward to complete the document without the review and acknowledgement of whether a copy was offered to the client or not. Compliance monitors on a monthly basis the completion of the Consent for Treatment, Payment and Healthcare Operations consent for all clients active in treatment. The monitoring information is shared with the facilities operations and clinical leadership team through a scorecard to review and identify if any client receiving care may be missing one. If clients are determined to be missing a document, facility leadership and/or designee will be responsible for ensuring completion of the Consent for Treatment, Payment and Healthcare Operations consent with those clients and offering a copy.
Executive director will re-educate staff on the expectation to offer a copy of the Treatment, Payment and Healthcare Operations consent to each client and document that offering on the updated consent form in treatment team meeting conducted on 9/11/25. This re-education will be recorded in the meeting minutes/notes.
In order to monitor compliance with our plan of correction, the clinical supervisor will be responsible for monthly supervision with direct care staff to ensure compliance. Executive director will supervise the clinical supervisor and review on a monthly basis to monitor the plan of correction. Executive director will provide updates to the regional director bi-weekly to ensure compliance with plan of correction.
Completion Date: 9/11/2025
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients.
During the week of May 25-31, 2025, the patient census was 452. The facility was required to provide at least 45.2 physician hours. There were 42.5 physician hours documented.
During the week of June 15-21, 2025, the patient census was 449. The facility was required to provide at least 44.9 physician hours. There were 34.5 physician hours documented.
During the week of June 22-28, 2025, the patient census was 452. The facility was required to provide at least 45.2 physician hours. There were 22.25 physician hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director will review schedule with medical director prior to the start of each week to ensure that the physician is scheduled to provide one-third of all required physician time. Executive director will also track to ensure that the remaining time provided by a certified registered nurse practitioner or physician assistant will not exceed two-thirds of the required narcotic treatment physician time. This will ensure that the required narcotic treatment physician time is scheduled for each week.
Executive director will utilize a tracker to maintain a weekly record of physician hours scheduled for each week that calculates physician hours needed in relation to weekly census totals. This tracker will calculate the narcotic treatment physician time required for each week and ensure that the medical director provides at least one-third of all required hours. Executive director will also maintain a weekly census report to ensure that the medical director is scheduled for at least one-third of all required narcotic treatment physician time as it pertains to weekly census numbers. This will be implemented on 9/15/2025.
Completion Date: 9/15/2025
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to ensure that verification of the individual's identity was obtained during the intake process in one out of six applicable records reviewed.
Patient #3 was admitted on December 9, 2024 and discharged on March 7, 2025. The record did not contain documentation that the individual's identity was verified during intake.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative assistant will support with uploading appropriate client identification to verify client's identity into chart on the same day that level of care assessment is completed. The counselor assigned to complete the level of care assessment with potential clients will verify client's identity, including name, address, date of birth, emergency contact and other identifying data and ensure that all information is in the client's ECR.
Executive director and clinical supervisor will check new admits prior to induction into treatment program and ensure that appropriate client identification to verify client's identity, including name, address, date of birth, emergency contact and other identifying data is uploaded in ECR. Executive director and clinical supervisor will re-educate the team on the importance of ensuring that we verify client's identity, including name, address, date of birth, emergency contact and other identifying data prior to admission into this treatment program. This will be implemented and reviewed with team during treatment team meeting conducted on 9/11/25.
Completion Date: 9/11/2025
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to document an annual physical examination by the narcotic treatment physician within the regulatory timeframe in one out of four applicable records reviewed.
Patient #11 was admitted on November 9, 2018 and was still active at the time of the inspection. An annual physical was completed on November 8, 2023; and the next one was due no later than November 8, 2024; however, it was completed on November 26, 2024.
This is a repeat citation from the July 11, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing staff will run annual reports in Methasoft system at least 60 days prior to client's annual due date to ensure that annual examination is scheduled and completed by within the regulatory time frame. Nursing staff will track upcoming annuals due and the dates of the previous annual examination and this list will be reviewed with executive director every 2 weeks. This will be implemented and procedures will be reviewed with nursing staff on 9/16/2025.
Executive director will review annual tracker with nursing staff, medical director, and certified registered nurse practitioner to ensure that annual evaluations are being scheduled and completed within the regulatory timeframe. This will be implemented and reviewed with medical team on 9/16/2025.
Executive director will meet every 3 weeks with medical director to monitor that annual evaluation by the narcotic treatment physician is completed within the regulatory timeframe. The first meeting will occur on 9/16/2025 and continue every 3 weeks to help ensure compliance in relation to annual evaluations being scheduled and completed in the regulatory timeframe.
Completion Date: 9/16/2025
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document an annual evaluation of the client's status completed by the patient 's counselor and reviewed, dated and signed by the medical director within the regulatory time frame in three out of four appliable records reviewed.
Patient #4 was admitted on June 27, 2022 and discharged on July 10, 2025. An annual evaluation was completed on June 18, 2024 and the next one was due no later than June 18, 2025; however, there is no documentation that one was completed.
Patient #6 was admitted on March 2, 2021 and was still active at the time of the inspection. An annual evaluation was completed on April 30, 2024 and the next one was due no later than April 30, 2025; however, it was completed on June 18, 2025.
Patient #7 was admitted on August 7, 2023 and discharged on February 3, 2025. An annual evaluation was due no later than August 7, 2024; however, there was no documentation that one was completed.
This is a repeat citation from the July 11, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors will be required to keep a case tracker of clients on their caseload that specifically tracks the intake date for each client. Counselors will ensure that annual evaluations are completed prior to the client's anniversary of initial intake date. The case tracker will be updated on a weekly basis by each counselor. Case trackers will be reviewed by clinical supervisor and/or executive director on a monthly basis to ensure that case trackers are being utilized. This will be implemented and reviewed with clinical team during treatment team staff meeting on 9/11/2025.
Clinical supervisor will audit 10% of client charts prior to monthly supervision with counselors. In conducting this audit leadership staff will specifically be looking to see that annual evaluations are being completed prior to client's anniversary of intake date. Executive director will ensure that medical director has signed off on the annual review by checking alerts in the EMR. These audits will begin on 9/11/2025.
Executive director will meet with medical director and clinical supervisor on 9/11/2025 to discuss the importance of reviewing and signing annual evaluations within 5 days of a counselor completing an annual evaluation. Executive director will also monitor medical director alerts in the electronic clinical record to ensure that annuals are signed within 5 days of a counselor completing an annual evaluation. This will begin on 9/11/2025.
Completion Date: 9/11/2025
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 records, the facility failed to document that a comprehensive treatment plan was developed with the client within the facility ' s policy and procedures manual in two out of six records reviewed. The facility ' s policy and procedures manual states that a comprehensive treatment plan is developed with the client within thirty days of admission.
Client #3 was admitted on December 9, 2024 and discharged on March 7, 2025. A comprehensive treatment plan was completed on December 26, 2024; however, there was no documentation it was developed with the client. The client did not sign the document until February 20, 2025.
Client #9 was admitted on June 25, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than July 25, 2025; however, it was completed on August 22, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors will be required to keep a case tracker of clients on their caseload that specifically tracks the intake date of clients. All counselors will then ensure that a comprehensive treatment plan is developed within 30 days of admission. All counselors will also be required to meet with new admits within 30 days of admission into the methadone program and ensure that the comprehensive treatment plan is completed with the client and signed by the client during the initial individual counseling session conducted with client. Executive director and clinical supervisor will review procedures with all counselors during treatment team staff meeting on 9/11/2025.
Clinical supervisor will audit 10% of client charts prior to conducting individual supervision with counselors. Executive director and clinical supervisor will monitor new admissions to ensure that the comprehensive treatment plan is completed with the client and signed by the client during the initial individual counseling session conducted by counselor.
Executive director and clinical supervisor will review procedures and protocols with the clinical team at the treatment team meeting on 9/11/25.
Completion Date: 9/11/2025
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in four out of eleven applicable records reviewed.
Client #2 was admitted on March 12, 2025 and was still active at the time of the inspection. The treatment plans dated March 25, 2025, and May 28, 2025 indicated individual session bi weekly. There was no documentation of the client receiving individual therapy the weeks of April 21,2025, June 23, 2025 and August 4, 2025.
Client #4 was admitted on June 27, 2022 and discharged on July 10, 2025. The treatment plan dated March 31, 2025, indicated monthly individual sessions. There was no documentation that the client received individual session in the month of April 2025.
Client #6 was admitted on March 2, 2021 and was still active at the time of the inspection. The treatment plans dated March 6, 2025, and August 5, 2025, indicated individual and group sessions monthly. There was no documentation that the client received group therapy in the months of April, May, June, and July 2025.
Client #10 was admitted on March 11, 2025 and was still active at the time of the inspection. The treatment plans dated March 21, 2025, May 15, 2025, and July 11, 2025, indicated one group and one individual session a month. There is no documentation that the client received group therapy in the months of May, June, and July 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors will be required to keep a case tracker of clients on their caseload that specifically tracks that counseling services are provided according to the individual treatment and rehabilitation plan. All counselors will update case trackers on a monthly basis to reflect counseling services are provided in accordance with the individual treatment and rehabilitation plan. Executive director and clinical supervisor will review procedures with all counselors during treatment team staff meeting on 9/11/2025.
Clinical supervisor and executive director will audit 10% of client charts on a monthly basis and review findings with counselors. Executive director and clinical supervisor will meet bi-monthly to review their findings and this will begin on 9/9/2025. This audit will be done by reviewing psychotherapy hours to ensure that counseling services are provided according to the individual treatment and rehabilitation plan for each month the client is in treatment. This will be reviewed with all clinical staff at the upcoming treatment team meeting that will be conducted on 9/11/2025.
Completion Date: 9/11/2025
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