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 July 7 & 8, 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 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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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 April 13-18, 202, the patient census was 415. The facility was required to provide at least 41.5 physician hours. There were 39.75 physician hours documented.
During the week of May 17-23, 2026, the patient census was 414. The facility was required to provide at least 41.4 physician hours. There were 36.25 physician hours documented.
This is a repeat citation from the August 27 & 28, 2025 licensing inspection.
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 7/16/2026.
Completion Date: 7/16/2026
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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 thirty days of admission, per facility policy, in two out of six records reviewed.
Client #1 was admitted on January 20, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 19, 2026; however, it was not completed until April 17, 2026.
Client #11 was admitted on September 10, 2025, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than November 8, 2025; however, it was not completed until November 18, 2025.
This is a repeat citation from the August 27 & 28, 2025 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 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 7/16/2026.
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 7/16/2026.
Completion Date: 7/16/2026
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to follow their approved exception to update treatment and rehabilitation plans for clients in treatment more than twice a month, every 60 days, and for clients who are stable and receiving counseling less than twice a month, every 120 days, in four out of eleven records reviewed.
Client #1 was admitted on January 20, 2026, and was still active at the time of the inspection. A treatment plan was completed on April 17, 2026, and the next update was due no later than June 15, 2026; however, there is no documentation that one was completed.
Client #3 was admitted on September 30, 2025, and was still active at the time of the inspection. A treatment plan was completed on April 10, 2026, and the next update was due no later than June 9, 2026; however, there is no documentation that one was completed.
Client #8 was admitted on September 15, 2025, and was still active at the time of the inspection. A treatment plan was completed on September 26, 2025, and the next update was due no later than November 25, 2025; however, it was not completed until January 28, 2026. The next update was due no later than March 29, 2026; however, it was not completed until April 9, 2026.
Client #11 was admitted on September 10, 2025, and was still active at the time of the inspection. A treatment plan was completed on November 18, 2025, and the next update was due no later than January 17, 2026; however, it was not completed until February 11, 2026.
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 and treatment plan updates due for clients. All counselors will ensure that treatment and rehabilitation plans are developed for clients in treatment more than twice a month, every 60 days and for clients who are stable and receiving counseling less than twice a month, every 120 days. All counselors will ensure that all treatment plans are completed with the client and signed by the client during individual counseling sessions. Executive director and clinical supervisor will review procedures with all counselors during treatment team staff meeting on 7/16/2026.
Clinical supervisor will audit 10% of client charts prior to conducting individual supervision with counselors. Executive director and clinical supervisor will monitor to ensure that treatment and rehabilitation plans are completed are developed for clients in treatment more than twice a month, every 60 days and for clients who are stable and receiving counseling less than twice a month, every 120 days. Executive director and clinical supervisor will monitor to ensure that all treatment plans are completed with the client and signed by the client during individual counseling sessions.
Executive director and clinical supervisor will review procedures and protocols with the clinical team at the treatment team meeting on 7/16/2026.
Completion Date: 7/16/2026
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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 five out of eleven records reviewed.
Client #2 was admitted on January 28, 2026, and was still active at the time of the inspection. The treatment plan dated February 3, 2026, indicated one individual session a month. There was no documentation of the client receiving individual therapy in the month of May 2026.
Client #3 was admitted on September 30, 2025, and was still active at the time of the inspection. The treatment plan dated December 18, 2025, indicated one individual session a month. There was no documentation that the client received an individual session in the month of February 2026. The treatment plan dated April 10, 2026, indicated individual sessions twice a month. There was only one documented individual session in the month of May 2026.
Client #7 was admitted on September 27, 2017, and discharged on December 4, 2025. The treatment plan dated August 18, 2025, indicated one individual session a month. There was no documentation that the client received individual therapy in the months of October or November 2025.
Client #9 was admitted on March 9, 2022, and discharged on April 29, 2026. The treatment plan dated December 4, 2025, indicated one individual session a month. There was no documentation that the client received individual therapy in the months of February or March 2026.
Client #11 was admitted on September 10, 2025, and was still active at the time of the inspection. The treatment plans dated November 18, 2025, and February 11, 2026, indicated one individual session a month. There is no documentation that the client received individual therapy in the months of January, April, May and June 2026.
This is a repeat citation from the August 27 & 28, 2025 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 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 7/16/2026.
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 7/15/2026. 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 procedure will be reviewed with all clinical staff at the upcoming treatment team meeting that will be conducted on 7/16/2026.
Completion Date: 7/16/2026
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709.93(a)(8) LICENSURE Client records
709.93. 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 within ninety days of admission and yearly thereafter, per facility policy, in nine out of eleven records reviewed.
Client #1 was admitted on January 20, 2026, and was still active at the time of the inspection. A case consultation was due no later than April 20, 2026; however, there is no documentation that one was completed.
Client #3 was admitted on September 30, 2025, and was still active at the time of the inspection. Case consultations were due no later than December 28, 2025, March 28, 2026, and June 26, 2026; however, there was no documentation that case consultations occurred.
Client #4 was admitted on December 27, 2018, and was still active at the time of the inspection. A case consultation was due no later than December 27, 2025; however, there was no documentation that one was completed.
Client #5 was admitted on April 3, 2018, and was still active at the time of the inspection. A case consultation was due no later than April 3, 2026; however, there was no documentation that one was completed.
Client #6 was admitted on December 24, 2025, and was still active at the time of the inspection. A case consultation was due no later than March 23, 2026; however, there was no documentation that one was completed.
Client #7 was admitted on September 27, 2017, and discharged on December 4, 2025. A case consultation was due no later than September 27, 2025; however, there was no documentation that one was completed.
Client #8 was admitted on September 15, 2025, and was still active at the time of the inspection. Case consultations were due no later than December 14, 2025, March 14 and June 12, 2026; however, there was no documentation that they occurred.
Client #9 was admitted on March 9, 2022, and discharged on April 29, 2026. A case consultation was due no later than March 9, 2026; however, there was no documentation that one occurred.
Client #11 was admitted on September 10, 2025, and was still active at the time of the inspection. A case consultation was due no later than December 9, 2025; however, there was no documentation that one occurred.
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 case consultations are completed within ninety days of admission and yearly thereafter, per facility policy. All counselors will update case trackers on a monthly basis to reflect that case consultations are provided within ninety days of admission and yearly thereafter, per facility policy. Executive director and clinical supervisor will review procedures with all counselors during treatment team staff meeting on 7/16/2026.
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 7/15/2026. This audit will be done by reviewing any new admissions to ensure that case consultations are completed within ninety days of admission and yearly thereafter, per facility policy. This procedure will be reviewed with all clinical staff at the upcoming treatment team meeting that will be conducted on 7/16/2026.
Completion Date: 7/16/2026
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