INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29-30, 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-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(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 a review of personnel records, the facility failed to ensure a written individual training plan was developed annually for each employee in four of thirteen records.
The facility policy and procedures state that an individual training plan is to be developed annually by December.
Staff #3 was promoted to clinical supervisor on June 26, 2022, and still employed at the time of inspection. The training plan was completed on February 25, 2026.
Staff #6 was hired as a counselor on July 30, 2024, and still employed at the time of inspection. The training plan was completed on February 12, 2026.
Staff #8 was hired as a counselor on September 15, 2025, and still employed at the time of inspection. The training plan was completed on June 23, 2026.
Staff #13 was hired as a counselor on May 1, 2023, and still employed at the time of inspection. The training plan was completed on June 25, 2026.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All new hire staff will have their training and development plan complete with their supervisor in their first 10 days of working on site.
All existing clinical staff will complete their training and development plan for the upcoming calendar year during their individual supervision in November.
All other department managers will schedule and meet with their direct reports during the month of November to complete each staff's training and development plan.
Facility Leadership will send ED all scheduled supervision dates to ensure all are scheduled. ED will meet with all members of facility leadership, Associate Director, Clinical Director, Director of Intake and Client Care, BHT Manager and RN Manager by December of each year to review that all of their departments have completed their training and development plans. |
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 fourteen of twenty-five employees received a minimum of six hours of HIV/AIDS and at least four hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Staff #6 was hired as a counselor on July 30, 2024, and still employed at the time of inspection. The communicable disease trainings were due no later than July 30, 2025; however, the HIV/AIDS training was completed July 29, 2026, and the TB/STD training was completed January 22, 2026.
Staff #7 was hired as a counselor on November 4, 2024, and still employed at the time of inspection. The communicable disease trainings were due no later than November 4, 2025; however, the HIV/AIDS training was completed January 4, 2026, and the TB/STD training was not completed as of the date of the inspection.
Staff #14 was hired as a behavior technician on April 5, 2016, and still employed at the time of inspection. The communicable disease trainings were due no later than April 5, 2018; however, the TB/STD training was not completed as of the date of the inspection.
Staff #15 was hired as a behavior technician on December 20, 2018, and still employed at the time of inspection. The communicable disease trainings were due no later than December 20, 2020; however, the HIV/AIDS training was completed June 24, 2025, and the TB/STD training was not completed as of the date of the inspection.
Staff #16 was hired as a behavior technician on July 18, 2024, and still employed at the time of inspection. The communicable disease trainings were due no later than July 18, 2026; however, the TB/STD training was not completed as of the date of the inspection.
Staff #17 was hired as a behavior technician on February 1, 2024, and still employed at the time of inspection. The communicable disease trainings were due no later than February 1, 2026; however, the HIV/AIDS training was completed July 1, 2026, and the TB/STD training was not completed as of the date of the inspection.
Staff #18 was hired as a lead behavior technician on August 1, 2023, and still employed at the time of inspection. The communicable disease trainings were due no later than August 1, 2025; however, the HIV/AIDS training was completed June 26, 2026, and the TB/STD training was not completed as of the date of the inspection.
Staff #19 was hired as a behavior technician supervisor on April 28, 2021, and still employed at the time of inspection. The communicable disease trainings were due no later than April 28, 2023; however, the TB/STD training was not completed as of the date of the inspection.
Staff #20 was hired as a behavior technician supervisor on August 16, 2022, and still employed at the time of inspection. The communicable disease trainings were due no later than August 16, 2024; however, the HIV/AIDS training was completed June 26, 2026, and the TB/STD training was not completed as of the date of the inspection.
Staff #21 was hired as a behavior technician supervisor on February 15, 2024, and still employed at the time of inspection. The communicable disease trainings were due no later than February 15, 2026; however, the HIV/AIDS training was completed July 1, 2026, and the TB/STD training was not completed as of the date of the inspection.
Staff #22 was hired as a case coordinator on July 17, 2023, and still employed at the time of inspection. The communicable disease trainings were due no later than July 17, 2025; however, the TB/STD training was completed October 14, 2025.
Staff #23 was hired as a behavior technician manager on January 9, 2023, and still employed at the time of inspection. The communicable disease trainings were due no later than January 9, 2025; however, the TB/STD training was completed May 12, 2026.
Staff #24 was hired as housekeeper on May 23, 2022, and still employed at the time of inspection. The communicable disease trainings were due no later than May 23, 2024; however, the TB/STD training was completed July 9, 2025.
Staff #25 was hired as lead medical technician on March 17, 2021, and still employed at the time of inspection. The communicable disease trainings were due no later than March 17, 2023; however, the HIV/AIDS training was completed June 24, 2026, and the TB/STD training was completed on November 28, 2025.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the June 24-25, 2025, July 31, 2024, and July 19, 2023 licensing inspections.
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Plan of Correction
All new hires with direct care positions will have the on demand training complete prior to working directly with clients.
Non-direct care positions will compete the on demand trainings before beginning their schedules.
All staff regardless of position will have their live training scheduled before the end of their first week on site to guarantee completion by the due date. Department managers are responsible to ensure this happens and that the staff is aware and attends their scheduled training |
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 two of two applicable records reviewed.
The facility policy and procedures state that the emergency contact is to be notified of AMA discharges no later than twelve hours from departure.
Client #3 was admitted to the detox level of care on May 13, 2026, and discharged on May 14, 2026. There was no documentation of the emergency contact notification.
Client #4 was admitted to the detox level of care on May 20, 2026, and discharged on May 22, 2026. There was no documentation of the emergency contact notification.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the June 24-25, 2025 licensing inspection.
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Plan of Correction
Clients reviewed did not have an emergency contact on file which was noted in the nursing discharge note.
To reflect when a client declines providing an emergency contact, the Clinical Assessment Team (CAT) will document in a memo to chart when a client declines providing an emergency contact.
Any client who declines providing an emergency contact during their assessment will be asked again during their intake for 3.5 and during their first case coordination check in for 3.7. This will be documented in the client's chart.
Weekly chart monitoring is completed by either CD or AED. Evidence of clients declining an EC, if applicable, will be added to the chart monitoring tool. This tool is provided to ED, who will follow up is it noted as not present. |
709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to ensure intake procedures included documentation of personal history in four of seven records.
The facility policy and procedures state that the psychosocial evaluation and histories for withdrawal management clients is done on the day prior to step-down. Clients #4-7 did not step down and were admitted and discharged to the detox level of care; therefore, there was no documentation of personal history in the records.
Client #4 was admitted to the detox level of care on May 20, 2026, and discharged on May 22, 2026. There was no documentation of personal history in the record.
Client #5 was admitted to the detox level of care on May 24, 2026, and discharged on May 29, 2026. There was no documentation of personal history in the record.
Client #6 was admitted to the detox level of care on November 16, 2025, and discharged on November 22, 2025. There was no documentation of personal history in the record.
Client #7 was admitted to the detox level of care on November 24, 2025, and discharged on November 29, 2025. There was no documentation of personal history in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 7/13/26, all clients admitting to treatment receive a level of care assessment, which includes a psychosocial evaluation.
There is a daily scheduled created between the Clinical Assessment Team (CAT) and the site with client arrival and assessment times. The completion of the assessment is communicated through a Teams Channel with leadership and staff from both departments.
CAT Team Assessor notifies ED, AED, CD, Director of Intake/Client Care and CAT leadership with the LOCA is complete. The LOCA cannot be finalized without the personal history section being complete |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to ensure intake procedures included documentation of a psychosocial evaluation in four of seven records.
The facility policy and procedures state that the psychosocial evaluation and histories for withdrawal management clients is done on the day prior to step-down. Clients #4-7 did not step down and were admitted and discharged to the detox level of care; therefore, there was no documentation of a psychosocial evaluation in the records.
Client #4 was admitted to the detox level of care on May 20, 2026, and discharged on May 22, 2026. There was no documentation of a psychosocial evaluation in the record.
Client #5 was admitted to the detox level of care on May 24, 2026, and discharged on May 29, 2026. There was no documentation of a psychosocial evaluation in the record.
Client #6 was admitted to the detox level of care on November 16, 2025, and discharged on November 22, 2025. There was no documentation of a psychosocial evaluation in the record.
Client #7 was admitted to the detox level of care on November 24, 2025, and discharged on November 29, 2025. There was no documentation of a psychosocial evaluation in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 7/13/26, all clients admitting to treatment receive a level of care assessment that includes a psychosocial evaluation and history.
There is a daily schedule created between the Clinical Assessment Team (CAT) and the facility with client arrival and assessment times. The completion of the assessment is communicated though a Team Channel with leadership and staff from both departments.
CAT Team Assessor notifies ED, AED, CD, Director of Intake/Client Care and CAT leadership with the LOCA is complete. The LOCA cannot be finalized without the psychosocial section being complete |
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
A plan of correction for employees receiving a minimum of six hours of HIV/AIDS and at least four hours of TB/STD training using a Department approved curriculum within the regulatory timeframe was submitted and approved by the Department for the June 24-25, 2025, July 31, 2024, and July 19, 2023 annual licensing inspections. The communicable disease trainings were again found to be a deficiency in the July 29-30, 2026 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to monitor the completion with our plan of correction, department management will be responsible for weekly monitoring that trainings are scheduled and complete as assigned. Executive director will supervise department managers and will provide monthly status updates to Regional Director. |