INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 21 - 22, 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., Monroe Outpatient 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one out of one applicable employee received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe.
Employee #10 was hired as a client support on July 8, 2024, and was due to have the communicable disease trainings completed no later than July 8, 2026. There was no documentation in the personnel file for the completion of the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The identified employee has been registered for the next available Department-approved TB/STD and other health-related topics training and is scheduled to complete the training in September 2026. The Executive Director will verify and document completion of the training.
To prevent recurrence, the Executive Director will maintain and review a staff training tracking system on a monthly basis to monitor required trainings and applicable completion deadlines for all staff. The Executive Director will be responsible for implementing and maintaining this monitoring process and ensuring staff remain compliant with regulatory training requirements. |
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.
|
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 two out of fourteen records reviewed.
Client #2 was admitted to the partial hospitalization level of care on July 7, 2026, 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 forms for an emergency contact, a physician, a probation officer, and a consent for treating providers, health plans, third-party payers and people helping to operate the program, all signed and dated July 7, 2026, were offered to the client.
Client #3 was admitted to the partial hospitalization level of care on June 10, 2026, 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 physician, signed and dated July 16, 2026, was offered to the client.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor will re-educate all clinical staff on the requirement to document that clients are offered a copy of all signed consent forms at the time the consent is executed. For active clients identified as having deficient documentation, the assigned clinical staff member will review the consent with the client at the next scheduled contact, offer the client a copy, and document that the copy was offered.
To prevent recurrence, the Clinical Supervisor will conduct weekly chart audits to verify that documentation reflects that clients were offered a copy of all signed consent forms. Any deficiencies identified during these audits will be communicated to the assigned clinical staff member and corrected with the client at the next scheduled contact. The Clinical Supervisor will document and track audit findings and corrective actions to ensure identified deficiencies are resolved. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of partial hospitalization client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of seven records reviewed.
Client #3 was admitted to the partial hospitalization level of care on June 10, 2026, and was active at the time of inspection. The treatment plan dated June 15, 2026, and updated June 30, July 15, and July 20, 2026, indicated group sessions five times per week and individual sessions two times per week. Only one individual session was documented for the week of July 12-18, 2026.
Client #4 was admitted to the partial hospitalization level of care on January 9, 2026, and was discharged to the outpatient level of care on February 13, 2026. The treatment plans dated January 9, 2026, and January 12, 2026, indicated group sessions five times per week and individual sessions twice per week. Only four group sessions were documented for the week of January 11-17, 2026, and three group sessions were documented for the week of February 1-7, 2026.
Client #5 was admitted to the partial hospitalization level of care on March 4, 2026, and was discharged on April 2, 2026. The treatment plan dated March 5, 2026, indicated group sessions five times per week and individual sessions two times per week. Only four group sessions were documented for the weeks of March 8-14, 2026, and March 22-28, 2026. No individual sessions were documented for the week of March 8-14, 2026.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor will re-educate all clinical staff on their responsibility to document outreach for all missed PHP services, including Did Not Show (DNS) and Canceled By Client (CBC) appointments. Re-education will include expectations for completing and documenting outreach following missed services to demonstrate continued efforts to engage clients in treatment and provide services in accordance with the individualized treatment plan.
The Clinical Supervisor will conduct weekly chart audits to verify attendance documentation, outreach efforts, and compliance with individualized treatment plans. Audit findings will be documented and tracked. Any deficiencies identified during the audit will be reviewed with the responsible clinical staff member during supervision, and the staff member will be required to correct the identified deficiency when applicable. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in four out of seven applicable records reviewed.
Client #8 was admitted to the partial hospitalization program on January 9, 2026, transferred to the outpatient level of care on February 13, 2026, and was discharged on May 20, 2026. The treatment plan dated February 13, 2026, and updated on March 17, 2026 and April 14, 2026, indicated group sessions three times per week. The record did not contain documentation of any group sessions for the week of April 12-18, 2026. The record only contained documentation of two group sessions the week of March 29 - April 4, 2026, and one group session the week of April 19-25, 2026. The treatment plan updated April 28, 2026, indicated weekly group sessions. There was no documentation in the record of any group sessions the weeks of May 3-9, 2026 and May 10-16, 2026.
Client #10 was admitted to the outpatient level of care on April 17, 2026, and was discharged on June 10, 2026. The treatment plan dated May 7, 2026, indicated weekly group sessions. There was no documentation in the record of any group sessions between May 31 - June 6, 2026.
Client #12 was admitted to the outpatient level of care on April 17, 2026 and was still active at the time of the inspection. The treatment plan dated May 1, 2026, indicated group sessions weekly. There was no documentation in the record of any group sessions during the weeks of May 3- 9, 2026 and May 10-16, 2026.
Client #13 was admitted to the outpatient level of care on February 26, 2026, and was still active at the time of the inspection. The treatment plan dated March 31, 2026, indicated group sessions three times per week. There was no documentation in the record of any group sessions during the week of April 26 - May 2, 2026. The record only documented one group session the weeks of April 19-25, 2026, and May 3-9, 2026.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 17, 2025, July 12, 2024, August 29, 2023, and August 22, 2022, licensing inspections.
|
Plan of Correction
The Clinical Supervisor will re-educate all clinical staff on their responsibility to document outreach for all missed outpatient services, including Did Not Show (DNS) and Canceled By Client (CBC) appointments. Re-education will include expectations for documenting outreach following missed services to demonstrate efforts to engage clients in treatment and ensure services are provided in accordance with the individualized treatment plan.
The Clinical Supervisor will conduct weekly chart audits to verify attendance documentation, outreach following DNS and CBC appointments, and compliance with individualized treatment plans. Audit findings will be documented on a tracking tool maintained by the Clinical Supervisor to identify deficiencies, corrective actions taken, and resolution of identified deficiencies. Any deficiency identified during an audit will be reviewed with the responsible clinical staff member and corrected when applicable.
The Clinical Supervisor will review audit findings with clinical staff during individual supervision and provide additional education or corrective action as needed. Audit findings and compliance trends will be reviewed monthly by the Clinical Supervisor and Executive Director to evaluate ongoing compliance and determine whether additional corrective measures are necessary. |
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.
|
Observations
Based on a review of client records, the facility failed to comply with a plans of correction that was approved by the Department.
A plan of correction for assuring that counseling services are provided according to the individual treatment and rehabilitation plan was submitted and approved by the Department for the July 17, 2025, July 12, 2024, August 29, 2023, and August 22, 2022, annual licensing inspections. Following treatment according to treatment plan was again found to be a deficiency in the July 21-22, 2026 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director will review all approved Plans of Correction with the staff responsible for carrying out the identified corrective actions to ensure expectations, responsibilities, and required monitoring are clearly understood. The Executive Director will be responsible for ensuring that each approved Plan of Correction is implemented as written and that required follow-up activities are completed.
Compliance with approved Plans of Correction will be reviewed monthly by the Executive Director. This review will include verification that required audits, staff education, supervision, or other corrective actions identified in the Plan of Correction have been completed and documented. If an identified corrective action has not been completed as required, the Executive Director will follow up with the responsible staff member to ensure the action is completed and provide additional education or corrective feedback as necessary. |