INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9, 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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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 seven out of eight client records reviewed.
Client #1 was admitted on January 30, 2025 and discharged on March 11, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated January 30, 2025, was offered to the client.
Client #2 was admitted on September 4, 2024 and discharged on December 30, 2024. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated September 4, 2024, was offered to the client.
Client #3 was admitted on September 17, 2024 and discharged on November 22, 2024. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated September 17, 2024, was offered to the client.
Client #5 was admitted on March 19, 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 19, 2025, was offered to the client.
Client #6 was admitted on March 19, 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 19, 2025, was offered to the client.
Client #7 was admitted on February 5, 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 February 5, 2025, was offered to the client.
Client #8 was admitted on February 17, 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 February 17, 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
The Executive Director reviewed on 8/4/2025 with the clinical team by providing re-education 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. This re-education will be recorded in the meeting minutes/notes. Staff retraining will occur as needed based on performance. Retraining will be documented in supervision logs.
In order to monitor compliance with our plan of correction, the Executive Director will be responsible for bi-weekly supervision with direct care staff to ensure compliance. Executive Director will provide updates to the Regional Director bi-weekly to ensure compliance with plan of correction. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to follow their written plan for intake and admission to complete a medical history within twenty-four hours of admission, per facility policy, in three out of eight records reviewed.
Client #4 was admitted on September 24, 2024 and discharged on November 18, 2024. A medical history was completed prior to the admission by the Single County Authority on July 3, 2024; however, there was no documentation that the receiving facility reviewed the medical history for completeness and accuracy with the client and documented such review by dated signature of both the facility staff conducting the review and the client within 24 hours of admission.
Client # 6 was admitted on March 19, 2025 and was still active at the time of the inspection. A medical history was completed prior to the admission by the Single County Authority on December 16, 2024; there was no documentation that the receiving facility reviewed the medical history for completeness and accuracy with the client and documented such review by dated signature of both the facility staff conducting the review and the client within 24 hours of admission.
Client #8 was admitted on February 17, 2025 and was still active at the time of the inspection. A medical history was completed by a prior drug and alcohol facility on November 18, 2024; there was no documentation that the receiving facility reviewed the medical history for completeness and accuracy with the client and documented such review by dated signature of both the facility staff conducting the review and the client within 24 hours of admission.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director reviewed on 7/14/2025 with the clinical team that all sections of the bio-psychosocial must be reviewed and verified as completed during the intake session. The clinician will note the review of these sections in their individual DAP note and the bio-psychosocial completed upon admission.
In an effort to monitor continued compliance Executive Director will complete the following:
-Executive Director will create an admission checklist to ensure this information is documented at intake.
-Clinicians will be provided with the admission checklist and receipt of the checklist will be documented in clinical supervision note.
-Executive Director will complete monthly chart audits on any new intake clients to ensure continued compliance.
This clinical education has been documented in the Staff Meeting minutes from 7/14/2025. Executive Director reviewed all active client charts on 7/14/2025 for compliance of the fore mentioned deficiency and all active charts have been brought into compliance. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility failed to follow their written plan for intake and admission to complete a drug and alcohol history within twenty-four hours of admission, per facility policy, in three out of eight records reviewed.
Client #4 was admitted on September 24, 2024 and discharged on November 18, 2024. A drug and alcohol history was completed prior to the admission by the Single County Authority on July 3, 2024; there was no documentation that the receiving facility reviewed the drug and alcohol history for completeness and accuracy with the client and documented such review by dated signature of both the facility staff conducting the review and the client within 24 hours of admission.
Client # 6 was admitted on March 19, 2025 and was still active at the time of the inspection. A drug and alcohol history was completed prior to the admission by the Single County Authority on December 16, 2024; there was no documentation that the receiving facility reviewed the drug and alcohol history for completeness and accuracy with the client and documented such review by dated signature of both the facility staff conducting the review and the client within 24 hours of admission.
Client #8 was admitted on February 17, 2025 and was still active at the time of the inspection. A drug and alcohol history was completed by a prior drug and alcohol facility on November 18, 2024; there was no documentation that the receiving facility reviewed the drug and alcohol history for completeness and accuracy with the client and documented such review by dated signature of both the facility staff conducting the review and the client within 24 hours of admission.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director reviewed on 7/14/2025 with the clinical team that all sections of the bio-psychosocial must be reviewed and verified as completed during the intake session. The clinician will note the review of these sections in their individual DAP note and the bio-psychosocial completed upon admission.
In an effort to monitor continued compliance Executive Director will complete the following:
-Executive Director will create an admission checklist to ensure this information is documented at intake.
-Clinicians will be provided with the admission checklist and receipt of the checklist will be documented in clinical supervision note.
-Executive Director will complete monthly chart audits on any new intake clients to ensure continued compliance.
This clinical education has been documented in the Staff Meeting minutes from 7/14/2025. Executive Director reviewed all active client charts on 7/14/2025 for compliance of the fore mentioned deficiency and all active charts have been brought into compliance. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to follow their written plan for intake and admission to complete a personal history within twenty-four hours of admission, per facility policy, in three out of eight records reviewed.
Client #4 was admitted on September 24, 2024 and discharged on November 18, 2024. A personal history was completed prior to the admission by the Single County Authority on July 3, 2024; there was no documentation that the receiving facility reviewed the personal history for completeness and accuracy with the client and documented such review by dated signature of both the facility staff conducting the review and the client within 24 hours of admission.
Client # 6 was admitted on March 19, 2025 and was still active at the time of the inspection. A personal history was completed prior to the admission by the Single County Authority on December 16, 2024; there was no documentation that the receiving facility reviewed the personal history for completeness and accuracy with the client and documented such review by dated signature of both the facility staff conducting the review and the client within 24 hours of
Client #8 was admitted on February 17, 2025 and was still active at the time of the inspection. A personal history was completed by a prior drug and alcohol facility on November 18, 2024, however; there was no documentation that the receiving facility reviewed the personal history for completeness and accuracy with the client and documented such review by dated signature of both the facility staff conducting the review and the client within 24 hours of admission.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director reviewed on 7/14/2025 with the clinical team that all sections of the bio-psychosocial must be reviewed and verified as completed during the intake session. The clinician will note the review of these sections in their individual DAP note and the bio-psychosocial completed upon admission.
In an effort to monitor continued compliance Executive Director will complete the following:
-Executive Director will create an admission checklist to ensure this information is documented at intake.
-Clinicians will be provided with the admission checklist and receipt of the checklist will be documented in clinical supervision note.
-Executive Director will complete monthly chart audits on any new intake clients to ensure continued compliance.
This clinical education has been documented in the Staff Meeting minutes from 7/14/2025. Executive Director reviewed all active client charts on 7/14/2025 for compliance of the fore mentioned deficiency and all active charts have been brought into compliance. |