Observations
Based on a review of a client ' s chart, email correspondence, and the Pyramid Healthcare, Inc. Ethical Code of Conduct, and the Compliance Handbook, the facility failed to follow its Core Values and Rules of Conduct.
The Pyramid Healthcare, Inc. Ethical Code of Conduct, and the Compliance Handbook indicate that employees shall align with Pyramid Healthcare ' s Core Values of Integrity, striving to be honest, transparent and ethical when dealing with clients, staff and the community. Additionally, they indicate that employees shall not falsify agency records, persons ' served records, and/or other documents associated with their employment with Pyramid Healthcare, Inc.
Chart documentation and email correspondence showed that a Counselor informed the client ' s Probation Officer that family counseling sessions had occurred during treatment. However, there were no counseling notes or documentation of the sessions in the client chart. Additionally, the Probation Officer reported that the client and her father stated that family counseling sessions had not occurred.
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Plan of Correction
Following notification of the concerns identified during the complaint investigation, Pyramid Healthcare initiated an internal investigation into the allegations. The investigation substantiated conduct that was inconsistent with Pyramid Healthcare's Ethical Code of Conduct, Compliance Handbook, Core Value of Integrity, and Rules of Conduct regarding truthful communication and accurate documentation. The employee involved is no longer employed by Pyramid Healthcare.
The client record identified during the investigation was reviewed by facility leadership to ensure documentation accurately reflected services provided and to verify the integrity of the record.
Completion Date: October 15, 2026
Systemic Corrective Actions to Prevent Recurrence
All clinical staff, including counselors, supervisors, and clinical leadership, will receive re-education on:
Pyramid Healthcare Ethical Code of Conduct
Compliance Handbook requirements
Documentation standards
Accurate reporting of services to external stakeholders, including probation/parole officers, referral sources, courts, and other community partners
Prohibition against falsification, misrepresentation, or documentation of services not provided
Clinical leadership will implement a documentation verification process requiring supervisory review of counseling documentation to confirm services represented as completed are supported by corresponding clinical documentation within the electronic health record.
Implementation Date: November 1, 2026
The facility will include documentation integrity and ethical communication requirements as a standing topic during new employee orientation and annual compliance training.
Implementation Date: November 15, 2026
Monitoring and Quality Assurance
The Clinical Director will conduct monthly audits of clinical records to evaluate documentation integrity and compliance with ethical conduct expectations.
The audit process will include:
Review of a minimum of 10 randomly selected client records per month
Verification that services documented in progress notes, treatment plans, discharge summaries, and external communications are supported by corresponding clinical documentation
Review of any documented family counseling sessions to ensure required documentation is present
Verification that services reported to referral sources or criminal justice stakeholders are supported within the clinical record
Performance Benchmark:
100% of audited services will have supporting documentation in the client record.
100% of audited external communications regarding client services will be supported by documentation contained within the clinical record.
Any audit finding below the 100% threshold will result in immediate supervisory review, staff retraining, corrective counseling, and increased audit frequency until compliance is re-established.
Monthly audit results will be maintained and reviewed through the facility's Quality Improvement process.
Monitoring Period: November 2026 through January 2027 (minimum of three consecutive months)
Responsible Persons
Executive Director
Clinical Director
Date of Full Compliance: November 15, 2026 |