This report is a result of an on-site licensure renewal inspection conducted on June 24, 2026 through June 25, 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 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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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure that the intake procedures included the documentation of a psychosocial evaluation in four of twelve applicable records reviewed.
Client #1 was admitted on December 22, 2025, and was discharged December 24, 2025. The projects policies and procedures indicated that a psychosocial evaluation was not completed during the detoxification level of care; therefore, a psychosocial evaluation was not completed on this client.
Client #2 was admitted on March 27, 2026, and was discharged March 31, 2026. The projects policies and procedures indicated that a psychosocial evaluation was not completed during the detoxification level of care; therefore, a psychosocial evaluation was not completed on this client.
Client #3 was admitted on January 21, 2026, and was discharged January 29, 2026. The projects policies and procedures indicated that a psychosocial evaluation was not completed during the detoxification level of care; therefore, a psychosocial evaluation was not completed on this client.
Client #6 was admitted to the detox level of care on May 21, 2026, and discharged on May 24, 2026. The projects policies and procedures indicated that a psychosocial evaluation was not completed during the detoxification level of care; therefore, a psychosocial evaluation was not completed on this client.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
By August 30, 2026, the Director of Clinical Services will conduct a training meeting with all Clinical Supervisors regarding the requirement that a psychosocial evaluation be completed and documented for all admissions, including admissions to detoxification services. Attendance will be documented through a sign-in sheet maintained by the facility.
Pyramid Healthcare has implemented a Centralized Assessment Team model that is being deployed across the organization. The Centralized Assessment Team completes a comprehensive Level of Care Assessment which includes a psychosocial evaluation and other required admission documentation. Duncansville will participate in implementation of this process upon organizational rollout.
Until implementation of the Centralized Assessment Team at the Duncansville facility, Clinical Supervisors will monitor admissions to ensure psychosocial evaluations are completed and documented in the client record in accordance with regulatory requirements.
Beginning on or before
September 1, 2026, the Director of Clinical Services will facilitate weekly audits of at least 50% of all detox admissions completed during the previous week to verify the presence of a completed psychosocial evaluation and required admission documentation.
Audit results will be reviewed monthly for a minimum of 6 months. Compliance will be expected at 100%. Any identified deficiencies will result in immediate corrective action, supervisory review, and additional staff training as indicated.
Responsible Persons:
- Executive Director
- Clinical Director
- Clinical Supervisors
Method of Monitoring:
- Training completed by August 30, 2026, with attendance verified by sign-in sheet.
- Weekly audit of 50% of admissions to verify completion of psychosocial evaluations.
- Monthly review of audit findings during Clinical meetings.
- Monitoring maintained for a minimum of six months. |