INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17, 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, 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) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the June 2024 through June 2025 fire drill logs, the facility failed to document the time that the fire drill took place.
The October 17, 2024, February 28, 2025, and June 7, 2025, fire drills logs did not have a specific time that the drill was conducted.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On July 18, 2025, fire drill log requirements and regulation 705.10(d)(4) were reviewed with the maintenance team. The Maintenance Supervisor will report the date, time, and shift of each monthly fire drill during leadership meetings, and this will be documented in the meeting minutes to ensure compliance On July 17, 2025, the Director requested that the PI team make all fields on the fire drill log submission sheet mandatory for submission. |
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 the June 2024 through June 2025 fire drill logs, the facility failed to document that a fire drill was conducted during sleeping hours at least every 6 months.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
On July 18, 2025, fire drill log requirements and Regulation 705.10(d)(5) were reviewed with the maintenance team. Each month, the Maintenance Facility Supervisor is required to conduct a fire drill. To ensure all shifts are covered within the required timeframes, the supervisor will rotate between first, second, and third shifts on a monthly basis. The Maintenance Supervisor will report the date, time, and shift of each monthly fire drill to the director during leadership meetings, and this information will be documented in the meeting minutes to ensure compliance. |
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 fifteen out of fifteen client records reviewed.
Client #1 was admitted on July 11, 2025 to the detoxification level of care and discharged on July 16, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated July 11, 2025 was offered to the client.
Client #2 was admitted on July 14, 2025 to the detoxification level of care 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 14, 2025 was offered to the client.
Client #3 was admitted on July 13, 2025 to the detoxification level of care 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 13, 2025 was offered to the client.
Client #4 was admitted on July 14, 2025 to the detoxification level of care 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 15, 2025 was offered to the client.
Client #5 was admitted on November 19, 2024 to the detoxification level of care and discharged on November 24, 2024. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated November 19, 2024 was offered to the client.
Client #6 was admitted on February 27, 2025 to the detoxification level of care and discharged on March 5, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated February 27, 2025 was offered to the client.
Client #7 was admitted on January 17, 2025 to the detoxification level of care and discharged on January 23, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for the funding source dated January 18, 2025 was offered to the client.
Client #8 was admitted on May 15, 2025 to the to the inpatient non-hospital level of care 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 16, 2025 was offered to the client.
Client #9 was admitted on June 23, 2025 to the inpatient non-hospital level of care 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 June 25, 2025 to the inpatient non-hospital level of care 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 29, 2025 was offered to the client.
Client #11 was admitted on January 16, 2025 to the inpatient non-hospital level of care and discharged on January 22, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated January 17, 2025 was offered to the client.
Client #12 was admitted on April 30, 2025 to the inpatient non-hospital level of care and discharged on May 20, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated April 30, 2025 was offered to the client.
Client #13 was admitted on October 7, 2024 to the inpatient non-hospital level of care and discharged on November 5, 2024. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated October 8, 2025 was offered to the client.
Client #14 was admitted on November 13, 2024 to the inpatient non-hospital level of care and discharged on December 6, 2024. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated November 13, 2024, was offered to the client.
Client #15 was admitted on February 19, 2025 to the inpatient non-hospital level of care and discharged on March 27, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated February 19, 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, Assessment supervisor and clinical supervisor will be responsible for ensuring completion of the Consent for Treatment, Payment and Healthcare Operations consent with those clients and offering a copy.
Assessment supervisor and clinical supervisor 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 clinical supervision by August 6,2025. 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 supervision with direct care staff to ensure compliance. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical plant inspection on July 17, 2025, the facility failed to ensure that drugs for external use were stored separately from oral drugs as there was cooling gel stored with the oral medication in the medication cart located in the female wing.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On July 17, 2025, medical staff ensured that drugs for external use were stored separately from oral medications. Regulation 709.32(c)(3)(i) will be reviewed with the medical department during nursing meetings on August 7 and 8, 2025. Compliance will be monitored by nurse manager through monthly cart audits conducted by medical and pharmacy staff, with records maintained in the pharmacy cart audit binder. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) 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 per the facility ' s policy and procedures manual in two out of four discharged records reviewed. The facility ' s policy and procedures manual states that within seven days of a discharge a follow up occurs.
Client #5 was admitted on November 19, 2024 to the detoxification level of care and discharged on November 24, 2024. A follow up contact was due no later than December 1, 2024; however, there is no documentation that one occurred.
Client #6 was admitted on February 27, 2025 to the detoxification level of care and discharged on March 5, 2025. A follow up contact was due no later than March 12, 2025; however, has occurred on March 18, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The follow-up policy will be reviewed on August 7, 2025 with clinical staff and case coordinators, to clarify workflows, timelines, and documentation requirements. With a focus on completing and documenting follow-up calls within the required seven-day timeframe. To ensure compliance, the Clinical and Case Coordinator Supervisors will conduct weekly audits of recent discharges.
A Smartsheet will be created by August 11, 2025, to track these audits. It will be updated weekly by the Clinical and case coordinator Supervisor and overseen by the Executive Director.
Additionally, the compliance team will perform monthly chart audits. The Quality Specialist Department will review 10 charts each month and report findings to the Executive and Clinical Directors.
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709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations per the facility ' s policy and procedures in three out of eight client records. The facility's policy and procedures manual states that case consultation occurs within seven days.
Client #8 was admitted on May 15, 2025 to the to the inpatient non-hospital level of care and was still active at the time of the inspection. A case consultation was due no later than May 22, 2025; however, it wasn ' t completed until June 18, 2025.
Client #9 was admitted on June 23, 2025 to the inpatient non-hospital level of care and was still active at the time of the inspection. A case consultation was due no later than June 30, 2025; however, there was no documentation that one was completed.
Client #11 was admitted on January 16, 2025 to the inpatient non-hospital level of care and discharged on January 22, 2025. A case consultation was due no later than January 29, 2025; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The case consultation notes policy will be reviewed with all clinical staff on August 7, 2025, to define timelines and clarify documentation requirements. To support timely completion, the Clinical Supervisor will conduct weekly audits of admissions to monitor compliance and address any issues.
A Smartsheet will be created by August 11, 2025, to track these audits. It will be updated weekly by the Clinical Supervisor and overseen by the Executive Director.
Additionally, the compliance team will perform monthly internal chart audits. The Quality Specialist Department will review 10 charts each month and report findings to the Executive and Clinical Directors.
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709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including a discharge summary in three out of five discharge records. The facility's policy and procedure manual states that a discharge summary is completed within seven days of discharge.
Client #11 was admitted on January 16, 2025 to the inpatient non-hospital level of care and discharged on January 22, 2025. A discharge summary was due no later than January 29, 2025; however, there was no documentation that one was completed.
Client #12 was admitted on April 30, 2025 to the inpatient non-hospital level of care and discharged on May 20, 2025. A discharge summary was due no later than May 27, 2025; however, there was no documentation that one was completed.
Client #13 was admitted on October 7, 2024 to the inpatient non-hospital level of care and discharged on November 5, 2024. A discharge summary was due no later than November 12, 2024; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The discharge summary policy will be reviewed with all clinical staff on August 7, 2025, to define timelines and clarify documentation requirements. To support timely completion, the Clinical Supervisor will conduct weekly audits of upcoming discharges to monitor compliance and identify any issues.
A Smartsheet will be created by August 11, 2025, to track these audits. It will be updated weekly by the Clinical Supervisor and overseen by the Executive Director.
Additionally, to ensure regulatory compliance, the compliance team will conduct monthly internal chart audits. The Quality Specialist Department will review 10 charts each month and share findings with the Executive and Clinical Directors.
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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 per the facility ' s policy and procedures manual in two out of five discharged records reviewed. The facility ' s policy and procedures manual states that within seven days of a discharge a follow up occurs.
Client #12 was admitted on April 30, 2025 to the inpatient non-hospital level of care and discharged on May 20, 2025. A follow up contact was due no later than May 27, 2025; however, there was no documentation that one was completed.
Client #13 was admitted on October 7, 2024 to the inpatient non-hospital level of care and discharged on November 5, 2024. A follow up contact was due no later than November 12, 2024; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The discharge and follow-up policy will be reviewed on August 7, 2025 with clinical staff and case coordinators, to clarify workflows, timelines, and documentation requirements. With a focus on completing and documenting follow-up calls within the required seven-day timeframe. To ensure compliance, the Clinical and Case Coordinator Supervisors will conduct weekly audits of recent discharges.
A Smartsheet will be created by August 11, 2025, to track these audits. It will be updated weekly by the Clinical and case coordinator Supervisor and overseen by the Executive Director.
Additionally, the compliance team will perform monthly chart audits. The Quality Specialist Department will review 10 charts each month and report findings to the Executive and Clinical Directors.
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