INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on July 29 & 30, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Foundations Medical 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 records reviewed. Client #1 was admitted on September 13, 2024 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 September 13, 2024, 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 13, 2025, was offered to the client. Client #3 was admitted on July 20, 2023 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 September 25, 2024, was offered to the client. Client #4 was admitted on June 9, 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 9, 2025, was offered to the client. Client #5 was admitted on January 30, 2025 and discharged on February 18, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated January 29, 2025, was offered to the client. Client #7 was admitted on March 18, 2016 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 2, 2025, was offered to the client. Client #8 was admitted on June 26, 2024 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 the funding source dated January 24, 2025, was offered to the client. Client #10 was admitted on January 16, 2025 and discharged on April 29, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated January 16, 2025, was offered to the client. Client #11 was admitted on May 27, 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 28, 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.
Facility leadership 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 weekly team meeting by 8/26/2025. This re-education will be recorded in the meeting minutes/notes.
In order to monitor compliance with our plan of correction, the Lead Counselor will be responsible for monthly supervision with direct care staff to ensure compliance. Executive Director will supervise the Lead Counselor monthly to monitor the plan of correction. Executive Director will provide updates to the Regional Director monthly to ensure compliance with plan of correction.
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715.17(c)(3)(i-v) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(3) Inspection of storage areas. A narcotic treatment program shall inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State and local laws and regulations. A narcotic treatment program shall develop and implement written policies and procedures regarding who performs the inspections, how often, and in what manner the inspections are to be documented. The policies and procedures shall include the following:
(i) Disinfectants and drugs for external use shall be stored separately from oral and injectable drugs.
(ii) Drugs requiring special conditions for storage to insure stability shall be properly stored.
(iii) Outdated and contaminated drugs shall be removed and destroyed according to Federal and State regulations.
(iv) Administration of controlled substances shall be documented.
(v) Controlled substances and other abusable drugs shall be stored in accordance with Federal and State regulations.
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Observations
Based on a physical plant inspection and a review of administrative documentation the facility failed to inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State, and local laws and regulations. The facility did not have documentation that the inspections were conducted. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Pyramid Healthcare will review and amend the existing policy to include inspection of storage areas as outline in this regulatory requirement. Compliance Department is currently working on policy amendment and will be forwarded upon completion.
Executive Director reviewed storage inspection process with nursing staff on 8/21/2025 and will continue to complete monthly storage checks using current documentation. Executive Director will review these checks at monthly nursing supervision.
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715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of patient records, the facility failed to document the results of an initial intake physical examination within the facility ' s policy and procedures timeframe during the intake appointment in one out of six applicable records reviewed.Patient #11 was admitted on May 27, 2025 and was still active at the time of the inspection. There was no documentation in the patient record that the initial physical examination was completed at the time of the inspection. Ther was a document that was not fully completed or signed by the doctor. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed this instance and provided retraining of full completion of initial physical examinations with the Medical Director on 8/18/2025 .
Executive Director will check medical's alerts on Carelogic at least weekly to ensure completion of necessary documentation beginning 8/22/2025. This will be an ongoing process to ensure compliance.
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