INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28-29, 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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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to provide a ventilated toilet and washrooms by exhaust fan or window.
Neither the client bathroom nor the staff bathroom located in the basement had an operational exhaust fan or window available.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon review, the affected basement bathrooms were equipped with exhaust fan ventilation systems; however, the fan belt serving these units was broken, rendering the fans inoperable at the time of inspection. The broken belt was replaced during the week of 8/2/26. Both the client bathroom and staff bathroom exhaust fans have since been tested and confirmed operational, restoring compliant ventilation to both rooms. Maintenance staff conducted an inspection of all exhaust fan ventilation systems throughout the facility to confirm that no other toilet or wash rooms were affected by a similar mechanical issue. All other units were found to be operational. To prevent recurrence, the facility has implemented a monthly preventive maintenance check of all exhaust fan belts and ventilation systems, starting 8/17/2026. Maintenance staff will inspect each belt for wear and functionality and replace any belt showing signs of deterioration before failure occurs. |
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 #11 was admitted to the non-hospital residential level of care on December 17, 2025, and was discharged Against Medical Advice (AMA) on December 24, 2025. The facility failed to document an 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
The facility is reinforcing a new process that mandates notifying the emergency contact within 12 hours of a non-routine discharge by documenting the notification in EMR, and using a new spreadsheet to track in real time. The BHT Manager will oversee staff training on the updated process. Training is to be completed by September 1, 2026. The BHT Manager will ensure daily use of a specific tracking form and, alongside the BHT Supervisors, will conduct compliance checks beginning September 1, 2026. Weekly audits by the BHT Manager, beginning September 8, 2026, will assess compliance with the notification and documentation requirements. Audit findings will be reviewed in monthly leadership meetings led by the Executive Director, who will address any identified issues promptly. These measures are designed to ensure adherence to client treatment management procedures and enhance coordination in client care and discharge processes.
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