INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 15-16, 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 Dallas 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to have a clinical supervisor participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position in one of one applicable record reviewed.Employee #3 was hired July 6, 2025, as a counselor and was promoted to clinical supervisor on May 25, 2026, and was current in that position at the time of the licensing inspection. Employee #3 ' s personnel record did not include documentation of a monthly meeting with their supervisor for the month of June 2026. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of 07/31/2026, Dallas Inpatient's Clinical Director Supervisions have been assigned to Pyramid Healthcare's VP of Clinical Services. Supervisions between the VP of Clinical Services and Dallas Inpatient's Clinical Director are now scheduled to take place at one-time monthly intervals, minimum. The first supervision took place on 07/31/2026 and will continue at a monthly rate indefinitely. Pyramid Healthcare's VP of Clinical Services assumes responsibility for scheduling monthly supervisions with Dallas Inpatient's Clinical Director. Dallas Inpatient's Clinical Director assumes responsibility for attendance to and participation in monthly supervisions with the Pyramid Healthcare VP of Clinical Services. Dallas Inpatient's Executive Director assumes responsibility for ensuring frequency of supervisions is kept to one-time monthly, minimum, and that proper documentation of these supervisions is archived for ease of future reference while also ensuring that this process remains consistent into the future. |
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 client records, the facility failed to follow their written procedures for contacting the client 's emergency contact within twelve hours of a client leaving against medical advice in one of one applicable record reviewed.Client #13 was admitted to the non-hospital residential level of care on June 19, 2026, and discharged Against Medical Advice (AMA) on June 25, 2026. The facility failed to document the emergency contact was contacted within twelve hours. These findings were reviewed with the project staff during the licensing process.This is a repeat citation from August 7, 2025, licensing inspection.
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Plan of Correction
At Pyramid Healthcare Dallas Inpatient, responsibility for completing Emergency Contact notifications for AMA and AFA discharge types within 12 hours of discharge belongs to staff with Behavioral Health Technician Supervisor or Behavioral Health Technician Lead titles. There is a minimum of 1 of these titles scheduled on all shifts, 24/7, and in the absence of one being scheduled there is a scheduled cover designated on all shifts who assumes responsibility for this task during that shift. In response to this citation, the following is being completed.
Formal written individual supervision is to take place with all staff who carry the title of Behavioral Health Technician Supervisor or Behavioral Health Technician Lead, as well as the Behavioral Health Technician Manager. The formal written individual supervision will cover Pyramid Healthcare's written procedure for contacting the client's emergency contact within twelve hours of a client leaving against medical advice or against facility advice.
The system developed in response to the original citation in August 7, 2025, will continue with the additional oversight being added of an Assistant Program Director, a new title developed and fille following the July 16, 2026 annual licensing inspection. This change serves as a second layer of Director oversight on all AMA or AFA discharge types, monitoring completion of all aspects of the discharge which includes notification attempts to the client's Emergency Contact to be made and documented within twelve hours of discharge. Additionally, 12 hour interval alarms have been set and are to continue 24/7/365 to alert the Behavioral Health Technician Manager, Assistant Program Director, and Executive Director at the hours of 9am and 9pm to act as prompts to check the system developed in response to the original citation in August 7, 2025, to ensure any AMA or AFA discharge types that occurred in the preceding 12 hour interval have Emergency Contact Notifications completed and documented in the clients Electronic Chart Record. This allows for real-time monitoring and a real-time feed-back loop to provide supervision to the Behavioral Health Technicians and Behavioral Health Supervisors responsible for conducting these notifications in the event one is not yet complete, and allows for correction to take place prior to the twelve hour deadline passing. The 12 hours alarm system is set to continue for a minimum of 365 days. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to include the requirement of psychosocial evaluations in their intake procedures for the non-hospital short-term detoxification level of care. Four out of seven records reviewed did not include documentation of a psychosocial evaluation. Client #2 was admitted to the detox program on July 12, 2026, and was active at the time of the licensing process. A psychosocial evaluation was not documented in client chart at time of licensing process.Client #3 was admitted to the detox program on July 10, 2026, and was active at the time of the licensing process. A psychosocial evaluation was not documented in client chart at time of licensing process.Client #4 was admitted to the detox program on July 7, 2026, and was discharged on July 14, 2026. A psychosocial evaluation was not documented in client chart at time of licensing process.Client #6 was admitted to the detox program on April 13, 2026, and was discharged on April 17, 2026. A psychosocial evaluation was not documented in client chart at time of licensing process.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of August 2026, Pyramid Healthcare Dallas Inpatient is utilizing a Pyramid Healthcare centralized Assessment process to allow for consistent access to Assessment Counselors who will conduct Level of Care/Psychosocial Assessments with all new admissions within the time-frames outlined by Pyramid Healthcare in their policy handbook for the 3.5 clinically managed inpatient residential rehabilitation, 3.7 medically monitored inpatient residential rehabilitation, and 3.7 withdrawal management levels of care. This change allows for Assessment Counselors to be available to conduct these assessments with all new admissions, and assessments are scheduled for pending admissions prior to their arrival to Pyramid Healthcare Dallas Inpatient and the scheduled time aligns with their anticipated arrival time to Pyramid Healthcare Dallas Inpatient to ensure timely completion of their Level of Care/Psychosocial Assessment. This is a permanent process change designed to solve this citation type specifically, and provides highly consistent and reliable adherence to regulation 709.62(c)(vi).
Ongoing monitoring of completion is conducted daily by the Executive Director of Pyramid Healthcare's Centralized Assessment Team, which is the team of Assessment Counselors who conduct Level of Care/Psychosocial Assessments with all new admissions. Reviews are done daily to ensure that all admissions who arrived within the preceding 24 hours have completed Level of Care/Psychosocial Assessments in their Electronic Chart Record; and deficiencies are addressed and corrected in real-time to ensure routine and ongoing compliance with completion timeliness. |