INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 12-13, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pyramid Healthcare, Inc., was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to not permit in the facility heaters that are not permanently mounted or installed. A portable space heater was observed by DDAP staff in the Executive Directors office. This finding was reviewed with the facility staff during the complaint investigation.
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Plan of Correction
The regional director is conducting reorientation with the Dallas Inpatient facility on the organizations policy as it relates to compliance with DDAP Regulation 705.8. Reorientation will be completed prior to 6/12/2026. Ongoing monitoring will take place monthly through Facility Safety Walk-Throughs, conduced by the Facilities Supervisor (i.e. maintenance manager), on a monthly basis. The Facilities Safety Walk-Throughs will be updated to include Space Heaters starting in June 2026. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of detox and residential client records, the facility failed to adhere to timeframes designated in its grievance and appeal procedure. The facility ' s " Conflict Resolution/Grievance Procedure (3.10) " notes " the Grievance Form is collected and reviewed by the Executive Director or Leadership Designee. Within 48 hours, a written response to the individual issuing the complaint is completed by the Executive Director or their designee in Facility Section of the Grievance Form and approved by the Executive Director. "Client #1 was admitted to detox on March 27, 2026, and discharged on April 1, 2026. This client filed a written grievance with the facility on March 31, 2026. As per the facility ' s policy a response was to be given to the client no later than April 2, 2026; The facility documented on the grievance form that it responded to the grievance on April 8, 2026. Client #2 was admitted on December 22, 2025, and was discharged on January 27, 2026. This client filed a written grievance with the facility on January 19, 2026. As per the facility ' s policy, a response was to be given to the client no later than January 21, 2026; The facility documented on the grievance form that it responded to the grievancet on January 22, 2026. These findings were reviewed with the facility staff during the complaint investigation.
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Plan of Correction
The facilities "Conflict Resolution/Grievance Procedure (3.10)" will be reviewed with all designated designees at the facility to ensure that all designees understand the time-frame outlined within the policy. These supervisions will be conducted on an individual one-on-one basis, documented, and completed prior to 6/12/2026. This will include retraining on the Grievance Procedure with all department managers who take on the role of Leadership Designee in the context of this policy. Ongoing monitoring for compliance to the time-line will be conducted on a monthly basis by the facilities Executive Director. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on the review of medication administration records, the facility failed to document the administration, or the reason a medication was not administered. Client #1 was prescribed Suboxone 2-8mgs, to be administered daily from April 2, 2026, through May 1, 2026. There was no documentation of this medication being administered or the reason it was not administered on April 5, 2026.This finding was reviewed with facility staff during the complaint investigation process.
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Plan of Correction
The facilities Nursing Manager and Assistant Nursing Manager will conduct retraining in the form of individualized one-on-one supervision sessions with all LPN/RN staff. During these individualized one-on-one supervisions, a review of all area's that require documentation of medication administration will be reviewed. Additionally, the process for documenting medication refusals will be reviewed. These individual supervision sessions will be documented as they're conducted and the staff members will sign off on understanding of our internal processes for documenting medication administration or documentation refusals. All supervisions will take place and be documented by 6/25/2026.
Ongoing monitoring will take place during 8:45am morning clinical meeting. Medication refusals are reviewed for the prior day during this meeting. For all noted medication refusals, the Nurse Manager and/or Assistant Nurse Manager will verify that there is a documented reason for the med refusal in the MAR. Any errors identified will be adjusted within 24 hours of the error taking place through this form of ongoing daily monitoring. |