INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 24, 2025 and June 25, 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. - Pyramid Pittsburgh 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that three of fifteen employees received a minimum of four hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee # 13 has been in the medical assistant since March 17, 2021 and was due to have the communicable disease trainings no later than March 17, 2023. There was no documentation that the employee received four training hours of TB/STD at the time of the inspection.
Employee # 14 has been in the position of housekeeping since May 23, 2023 and was due to have the communicable disease trainings no later than May 23, 2025. There was no documentation that the employee received four training hours of TB/STD at the time of the inspection.
Employee #15 has been in the position of medical records since June 26, 2017 and was due to have the communicable disease trainings no later than June 26, 2019. There was no documentation that the employee received four training hours of TB/STD at the time of the inspection.
This is a repeat citation from the July 31, 2024 and July 19, 2023 annual licensing renewal inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Employee 13, 14 and 15 all have completed trainings on 7/9/25 and 8/2/24. Training certificates are available upon request.
2. Site leadership have developed a training tracker for each department to ensure compliance with the training timeframes outlines in this regulation.
3. Training trackers will be reviewed during biweekly supervisions with department managers and Executive Director or Associate Director.
4. All leadership will be trained in the use of the tracker by 8/1/25.
5. All leadership have been trained by ED as of 8/2/25. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on June 25, 2025, the facility failed to provide a wall mirror and an operable soap dispenser in each bathroom.
The bathrooms in rooms 343 and 352 were not equipped with wall mirrors.
The bathroom in room 342 was equipped was not equipped with an operable soap dispenser.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. Maintenance tickets were submitted for all identified issues. Progress on each is as follows
-Mirrors were located in the facility and hung in the room on 7/18/25.
-Extra soap dispensers are present on site and was installed on 7/18/25.
2. Facility walk-throughs take place monthly.
3. Housekeeping will also report any missing or broken items when completing cleaning of client rooms. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on June 25, 2025, the facility failed to ensure that hot water temperature may not exceed 120 degrees Fahrenheit.
When tested, the hot water in a first floor bathroom was 128 degrees Fahrenheit; in a second floor bathroom was 130 degrees Fahrenheit; and in room 310 was 129 degrees Fahrenheit.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. Maintenance tickets were submitted to turn down the water temperatures. This was complete on 7/1/25.
2. Monthly water temperature checks will be conducted by the facility safety champion and document on an internal log. If water temperatures exceed 120F, Associate Executive Director will submit a maintenance ticket and verbally notify maintenance manger of the issue immediately. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection on June 25, 2025, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
Standing water was observed on the male detox bathroom floors, as well as a chair full of water and soap.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. Shower room inspections will take place twice daily by BHT staff.
2. BHT will notify housekeeping if water is identified to ensure timely clean up.
3. All BHT staff will be re-educated at the August BHT all staff meeting by 8/25/25. |
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 the management of treatment/rehabilitation services for clients in five of eight applicable records reviewed.
Client #1 was admitted to the inpatient non-hospital detox level of care on April 28, 2025 and was discharged Against Staff Advice (AMA) on May 2, 2025. The facility failed to follow their policy related to AMA discharges of calling the emergency contact within twelve hours.
Client #5 was admitted to the inpatient non-hospital detox level of care on October 24, 2024 and was discharged Against Staff Advice (AMA) on October 27, 2024. The facility failed to follow their policy related to AMA discharges of calling the emergency contact within twelve hours.
Client #7 was admitted to the inpatient non-hospital detox level of care on March 24, 2025 and was discharged Against Staff Advice (AMA) on March 28, 2025. The facility failed to follow their policy related to AMA discharges of calling the emergency contact within twelve hours.
Client #11 was admitted to the inpatient non-hospital rehabilitation level of care on February 22, 2025 and was discharged Against Staff Advice (AMA) on March 7, 2025. The facility failed to follow their policy related to AMA discharges of calling the emergency contact within twelve hours.
Client #14 was admitted to the inpatient non-hospital rehabilitation level of care on August 9, 2024 and was discharged Against Staff Advice (AMA) on September 3, 2025. The facility failed to follow their policy related to AMA discharges of calling the emergency contact within twelve hours.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
1. All nurses will be retrained on the expectation that they are responsible for contacting client emergency contacts for all non-routine discharges at the nursing department staff meeting on 7/23/25.
2. This expectation will also be included in the training process for all new RN and LPNs.
3. Executive Director and RN Manager will review all non-routine discharges daily for 90 days. Following the 90 day review, a sample of non-routine discharge chars will be reviewed every month. |
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 fourteen of fourteen client records reviewed.
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 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 in active 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.
Director of Admissions and Client Care and Clinical Director will re-educate admission and clinical 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 their staff meeting by 8/15/25.This re-education will be recorded in the meeting minutes/notes.
Clinical staff will offer any current clients who admitted before the updated Treatment, Payment and Healthcare Operations consent a copy of their current consent during the next treatment plan review and document the offering in their case note.
In order to monitor compliance with our plan of correction, the Clinical Director and Director of Intake and Client Care will be responsible for weekly review of documentation to ensure compliance. Executive Director will supervise Clinical Director and Director of Intake and Client Care weekly to monitor the plan of correction. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of corrections that were approved by the Department.
A plan of correction for employees receiving a minimum of four hours of TB/STD training was submitted and approved by the Department for the July 31, 2024, and July 19, 2023, annual licensing inspections. Employees receiving a minimum of four hours of TB/STD training was again found to be a deficiency in the June 25, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. ED created a tracker including all open POCs, action steps, target dates and status. This document is accessible by all facility leadership who have responsibilities for POCs.
2.Department leadership is responsible for the direct monitoring on their plan of correction. AED and ED are responsible for the oversite and accountability for each department.
3. ED will review with all managers and directors who have open POCs in weekly or biweekly supervision. Status of each action step will be assessed as well as any changes that need to be made. |