INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 6, 2025 through August 7, 2025, 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, Inc. 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records, the project failed to document a written initial individual training plan for each employee within thirty days, appropriate to that employee's skill level with input from both the employee and the supervisor in three out of eleven records reviewed.
Employee #7 was hired on October 7, 2024, and was to have an initial individual training plan documented by November 7, 2024; however, the initial individual training plan was not documented in the personnel record until November 20, 2024.
Employee #9 was hired on September 2, 2024, and was to have an initial individual training plan documented by October 2, 2024; however, the initial individual training plan was not documented in the personnel record until November 20, 2024.
Employee #10 was hired on January 27, 2025, and was to have an initial individual training plan documented by February 27, 2024; however, an initial individual training plan was not documented in the personnel record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The facility has created a universal tracking system for all job titles that will track, starting from the date of hire, completion of all individual training plans to ensure completion within 30 days of hire. This has gone into effect as of 8/11/2025. This universal tracking system will be overseen by the facility Executive Director, and will be monitored on a routine recurring weekly basis to ensure individuals hired within the previous week are completed. This will ensure completion well within the 30 day allotted time-frame. |
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 applicable record reviewed.
Client #14 was admitted to the inpatient non-hospital level of care on November 12, 2024 and was discharged Against Medical Advice (AMA) on December 7, 2024. 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.
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Plan of Correction
At the time of audit, the facility has a tracking system in use for all non-routine discharges, including AMA type discharges, that tracks certain processes related to non-routine discharges to ensure timely and consistent completion of those tasks for those cases. That tracking system is overseen by the facility Executive Director and is monitored daily, 365 days a year, to ensure those tasks are done timely. To remedy this deficiency, the facility had added "Emergency Contact Notification" to the tracking system, to be completed within 12 hours of discharge, and to be documented in the client's ECR. This update to the tracking system has gone into effect as of 8/15/2025. In the event there is no Emergency Contact, a note will be added to the chart indicating contact for 12-hour AMA notification to the emergency contact could not be made due to a lack of active emergency contact assigned by the client. In the event that there is an emergency contact but they do not answer the phone, a note will be added to indicate that the emergency contact was called to notify of the AMA discharge but did not answer. All efforts to reach an emergency contact to notify them of an AMA within 12 hours of discharge will be documented in the ECR.
Additionally, case management, BHT leadership, and all clinical staff will be retrained on these requirements prior to 9/12/2025. Retraining will be documented in a Group Supervision format.
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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 the review of client records, the project failed to offer a copy of release of information forms for the funding source in eleven of fourteen client records reviewed.
Client #4 was admitted to the inpatient non-hospital detox level of care on September 5, 2024 and was discharged on September 11, 2024. A release of information for the funding source, signed by the client on September 6, 2024, did not document whether the client was offered a copy of the form.
Client #5 was admitted to the inpatient non-hospital detox level of care on November 7, 2024 and was discharged on November 12, 2024. A release of information for the funding source, signed by the client on November 7, 2024, did not document whether the client was offered a copy of the form.
Client #6 was admitted to the inpatient non-hospital detox level of care on May 12, 2025 and was discharged on May 18, 2025. A release of information for the funding source, signed by the client on May 12, 2025, did not document whether the client was offered a copy of the form.
Client #7 was admitted to the inpatient non-hospital detox level of care on February 3, 2025 and was discharged on February 7, 2025. A release of information for the funding source, signed by the client on February 3, 2025, did not document whether the client was offered a copy of the form.
Client #8 was admitted to the inpatient non-hospital level of care on June 29, 2025 and was active at the time of the inspection. A release of information for the funding source, signed by the client on June 30, 2025, did not document whether the client was offered a copy of the form.
Client #9 was admitted to the inpatient non-hospital level of care on June 17, 2025 and was active at the time of the inspection. A release of information for the funding source, signed by the client on June 18, 2025, did not document whether the client was offered a copy of the form.
Client #10 was admitted to the inpatient non-hospital level of care on June 9, 2025 and was active at the time of the inspection. A release of information for the funding source, signed by the client on June 9, 2025, did not document whether the client was offered a copy of the form.
Client #11 was admitted to the inpatient non-hospital level of care on November 9, 2024 and was discharged on December 13, 204. A release of information for the funding source, signed by the client on November 8, 2024, did not document whether the client was offered a copy of the form.
Client #12 was admitted to the inpatient non-hospital level of care on October 23, 2024 and was discharged on November 25, 2024. A release of information for the funding source, signed by the client on October 23, 2024, did not document whether the client was offered a copy of the form.
Client #13 was admitted to the inpatient non-hospital level of care on February 28, 2025 and was discharged on March 27, 2025. A release of information for the funding source, signed by the client on February 28, 2025, did not document whether the client was offered a copy of the form.
Client #14 was admitted to the inpatient non-hospital level of care on November 12, 2024 and was discharged on December 7, 2024. A release of information for the funding source, signed by the client on November 12, 2024, did not document whether the client was offered a copy of the form.
These findings were reviewed with project 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.
The Executive Director 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 Group Supervision format before 9/15/2025. This re-education will be recorded in the meeting minutes/notes.
In order to monitor compliance with our plan of correction, the Intake Supervisor will be responsible for monthly supervision with direct care staff to ensure compliance. Executive Director will supervise the Intake Supervisor monthly to monitor the plan of correction. The Executive Director will provide updates to the Regional Director monthly to ensure compliance with plan of correction.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two applicable client record reviewed.
Client #7 was admitted to the inpatient non-hospital detox level of care on February 3, 2025 and was involuntarily discharged on February 7, 2025. There was no documentation in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.
Client #13 was admitted to the inpatient non-hospital level of care on February 28, 2025 and was involuntarily discharged on March 27, 2025. There was no documentation in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
At the time of audit, the facility has a tracking system in use for all non-routine discharges, including involuntary termination types of discharges, that tracks certain processes related to non-routine discharges to ensure timely and consistent completion of those tasks for those cases. That tracking system is overseen by the facility Executive Director and is monitored daily, 365 days a year, to ensure those tasks are done timely. To remedy this deficiency, the facility had added "Discharge Paperwork Fully Signed" to the tracking system. This change has gone into effect as of 8/15/2025 and the ED will monitor this specific measurement daily to ensure that all discharge paperwork related to any non-routine discharge type, including administrative discharges, are signed fully by the staff member within 7 days of discharge, in accordance with the organizations written policy. In both documented cases, the discharge paperwork that informed the client of the decision to involuntarily terminate the clients treatment and their right to appeal the decision was drafted, completed by the staff member but left unsigned by the client. Retraining will take place with all clinical and case management staff before 9/12/2025. Retraining will be documented in Group Supervision format. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records and the project ' s policies and procedures, the project failed to document a psychosocial within 24-hours of the admission date, per the projects policy, in
Client #9 was admitted to the inpatient non-hospital level of care on June 17, 2025 and was active at the time of the inspection. Per the projects policy, a psychosocial was due by June 18, 2025; however, a psychosocial was not documented until June 20, 2025.
Client #12 was admitted to the inpatient non-hospital level of care on October 23, 2024 and was discharged on November 25, 2024. Per the projects policy, a psychosocial was due by October 24. 2024 however, a psychosocial was not documented until November 1, 2024.
Client #14 was admitted to the inpatient non-hospital level of care on November 12, 2024 and was discharged on December 7, 2024. Per the projects policy, a psychosocial was due by November 13, 2024, however, a psychosocial was not documented until November 15, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The facility has created a new tracking system that monitors completion of psychosocial evaluations and level of care assessments for all new intakes to provide an overview of their completion. The tracking system will be monitored daily by both the Intake Supervisor and the Clinical Director to ensure daily assignments of psychosocial evaluations and level of care assessments is completed within the organizations established time-frame. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include progress notes entered within 24-hours of the date of service, per the facility's policy, in four of seven records reviewed.
Client #10 was admitted to the inpatient non-hospital level of care on June 9, 2025 and was active at the time of the inspection. The record contained progress notes for group counseling sessions occurring on June 24, 2025, that were not documented until June 27, 2025; session occurring on July 11, 2025 that was not documented until July 14, 2025; and a session occurring on July 23, 2025 that was not documented until July 27, 2025.
Client #12 was admitted to the inpatient non-hospital level of care on October 23, 2024 and was discharged on November 25, 2024. The record contained progress notes for group counseling sessions occurring on October 28, 2024 that were not documented until November 2, 2024; session occurring on October 29, 2024 that was not documented until November 2, 2024; session occurring on October 30, 2024 that was not documented until November 2, 2024; session occurring on November 5, 2024 that was not documented until November 9, 2024; session occurring on November 6, 2024 that was not documented until November 9, 2024; and a session occurring on November 19, 2024 that was not documented until November 26, 2024.
Client #13 was admitted to the inpatient non-hospital level of care on February 28, 2025 and was discharged on March 27, 2025. The record contained two progress notes for group counseling sessions occurring on March 13, 2025 that were not documented until March 16, 2025 and March 21, 2025.
Client #14 was admitted to the inpatient non-hospital level of care on November 12, 2024 and was discharged on December 7, 2024. The record contained progress notes for group counseling sessions occurring on November 25, 2024 that were not documented until November 28, 2024; session occurring on December 4, 2024 that was not documented until December 6, 2024; and a session occurring on December 3, 2024 that was not documented until December 6, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
At the time of audit, the facility Clinical Director audited, daily, several forms of clinical documentation for all clients. In response to this deficiency, the facility has now added Group Counseling Sessions, Individual Counseling Sessions, and Family Counseling Sessions to the daily audit. This change has taken place as of 8/15/2025. Retraining will take place by 8/31/2025 with all clinical staff that provide direct client care services which reviews the facilities policy for completion of documentation (indicated in the documents signature time-stamp) to be completed within 24 hours of the date that the service was rendered. Retraining will be documented in a Group Supervision format. |