INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 21, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gratitude House 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from September 2024 though June 2024, the facility failed to document a fire drill during sleep hours every six months.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Driector reviewed this with the maintenance team and risk team during our monthly meeting on 8/13/25. Staff were retrained on fire drill protocol and proper documentation. Executive Director reviewed policy on documenting drills every 6 months during sleep hours. We reviewed sleep hours, to ensure they are not occurring during MAT med pass times. Executive Director and Safety Leader will monitor monthly fire drills for compliance and will address any ongoing areas of concern. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the specific information to be disclosed in four out seven records reviewed.
Client #1 was admitted on April 11, 2025 and was still active at the time of the inspection. A release of information form for a dentist and eye doctor, was signed and dated April 11, 2025 by the client that did not include the specific information to be disclosed.
Client #3 was admitted on March 3, 2025 and was still active at the time of the inspection. A release of information form for a dentist was signed and dated March 03, 2025 by the client that did not include the specific information to be disclosed.
Client #4 was admitted on March 7, 2025 and was discharged on May 05, 2025. A release of information form for a dentist and eye doctor, was signed and dated March 07, 2025 by the client that did not include the specific information to be disclosed.
Client #6 was admitted on January 16, 2025 and was discharged on May 26, 2025. A release of information form for a dentist and eye doctor, was signed and dated January 16, 2025 by the client that did not include the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will meet with nursing staff, clinical staff, and admission staff on 8/13/25 during staff meeting to review ROI's and appropriate information to be disclosed. Clinical Supervisor will review ROI complaince for all admissions and monitor compliance through monthly chart audits. All active client ROI's will be updated by 8/25/2025. |
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 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 seven out of seven client records reviewed.
Client #1 was admitted on April 11, 2025 and was still active at the time of the inspection. There was no documentation that a copy of the informed and voluntary consent to release information form to a funding source dated April 11, 2025, was offered to the client.
Client #2 was admitted on March 31, 2025 and was still active at the time of inspection. There was no documentation that a copy of the informed and voluntary consent to release information form to a funding source dated March 31, 2025, was offered to the client.
Client #3 was admitted on March 3, 2025 and was still active at the time of the inspection. There was no documentation that a copy of the informed and voluntary consent to release information form to a funding source dated March 3, 2025, was offered to the client.
Client #4 was admitted on March 7, 2025 and was discharged on May 5, 2025. There was no documentation that a copy of the informed and voluntary consent to release information form to a funding source dated March 7, 2025, was offered to the client.
Client #5 was admitted on October 2, 2024 and was discharged on December 31, 2024. There was no documentation that a copy of the informed and voluntary consent to release information form to a funding source dated October 2, 2024, was offered to the client.
Client #6 was admitted on January 16, 2025 and was discharged on May 26, 2025. There was no documentation that a copy of the informed and voluntary consent to release information form to a funding source dated January 16, 2025, was offered to the client.
Client #7 was admitted on November 4, 2024 and was discharged on March 3, 2025. There was no documentation that a copy of the informed and voluntary consent to release information form to a funding source dated November 4, 2024, was offered to the client.
These findings were reviewed with facility 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 and maintained 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 active in 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, Clinical Supervisor will be responsible for ensuring completion of the Consent for Treatment, Payment and Healthcare Operations consent with those clients and offering a copy.
Executive Director and Clinical Sueprvisor will re-educate 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 our clinical meeting on 8/13/25. This re-education will be recorded in the meeting minutes/notes.
In order to monitor compliance with our plan of correction, the Clinical Supervisor will be responsible for weekly supervision with direct care staff to ensure compliance. Executive Director will supervise the Clinical Supervisor weekly to monitor the plan of correction. Executive Director will provide updates to the Regional Director bi-weekly to ensure compliance with plan of correction. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
There was documentation that ambulance personnel were at the facility on June 4, 2025; however, there was no documentation that it had been reported to the Department.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will meet with the Clinical Supervisor's/Nurse on 8/20/25 to re-review requirements for unusual event reporting to DDAP. We will review online submission as well. Moving forward, ED will monitor all incident reports and ensure completion in required time frames. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with the client within the facility ' s policy time frame of 72 hours within admission, in four out of seven records reviewed.
Client #1 was admitted on April 11, 2025, and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due no later than April 14, 2025; however, it was not completed until April 29, 2024.
Client #4 was admitted on March 07, 2025, and was discharged May 05, 2025. The individual treatment and rehabilitation plan was due no later than March 10, 2025; however, it was not completed until March 19, 2024.
Client #5 was admitted on October 02, 2024, and was discharged December 31, 2024. The individual treatment and rehabilitation plan was due no later than October 05, 2024; however, it was not completed until October 07, 2024.
Client #6 was admitted on January 16, 2025, and was discharged on May 26, 2025. individual treatment and rehabilitation plan was due no later than January 19, 2025; however, it was not completed until January 20, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review timelines for treatment plan completion during next clinical meeting on 8/20/25. Clinical Supervisor will monitor treatment plans weekly for the next month, to ensure complaince. Clinical Supervisor will then continue to monitor compliance during monthly chart audits and will address any ongoing issues during individual monthly supervision. |
709.53(a)(5) LICENSURE Progress Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed within 24 hours after therapy sessions, in seven of seven records reviewed.
Client # 1 was admitted on April 11, 2025 and was still active at the time of the inspection. The record contained progress notes for individual sessions occurring on April 11, 2025, and June 27, 2025; that were not completed until April 15, 2025, and July 02, 2025, respectively. Additionally, the record contained a progress notes for group sessions occurring on April 14, 2025, April 16, 2025, April 21, 2025, April 23, 2025, May 12, 2025, June 18, 2025, and June 24, 2025; that were not completed until May 18, 2025, May 18, 2025, May 18, 2025, May 18, 2025, May 14, 2025, June 20, 2025 and June 26, 2025, respectively.
Client # 2 was admitted on March 31, 2025 and was still active at the time of the inspection. The record contained progress notes for group sessions occurring on April 03, 2025, April 17, 2025, April 25, 2025, May 02, 2025, May 12, 2025, May 20, 2025, June 18, 2025, and June 24, 2025. that were not completed until April 08, 2025, April 22, 2025, April 28, 2025. May 05, 2025, May 14, 2025, May 22, 2025, June 20, 2025, and June 26, 2025, respectively. Additionally, the record contained a progress note for a group session occurring on July 17, 2025, that was not completed at the time of the inspection.
Client #3 was admitted on April 03, 2025 and was still active at the time of the inspection. The record contained a progress note for an individual session occurring on July 16, 2025, that was not completed until July 18, 2025. Additionally, the record contained progress notes for group sessions that occurred on March 24, 2025, April 28, 2025, and June 18, 2025, that were not completed until March 26, 2025, May 08, 2025 and June 20, 2025, respectively.
Client #4 was admitted on March 07, 2025 and was discharged on May 05, 2025. The record contained progress notes for individual sessions occurring on March 13, 2025, and April 30, 2025, that were not completed until March 16, 2025 and May 06, 2025, respectively. Additionally, the record contained progress notes for group sessions that occurred on March 17, 2025, March 19, 2025, March 24, 2025, March 26, 2025, March 31, 2025, April 02, 2025, April 14, 2025, April 16, 2025, April 23, 2025, April 28, 2025 and May 05, 2025, that were not completed until March 23, 2025, March 23, 2025, April 08, 2025, April 08, 2025, April 08, 2025, April 08, 2025, May 18, 2025, May 18, 2025, May 18, 2025, April 30, 2025, and May 18, 2025, respectively.
Client #5 was admitted on October 02, 2024 and was discharged on December 31, 2025. The record contained progress notes for group sessions occurring on November 04, 2024, and November 6, 2024, that were not completed until November 11, 2024 and November 10, 2024, respectively.
Client #6 was admitted on January 16, 2025 and was discharged on May 26, 2025. The record contained progress notes for individual sessions occurring on March 28, 2025 and April 11, 2025, that were not completed until March 31, 2025 and April 14, 2025, respectively.
Client #7 was admitted on November 4, 2024 and was discharged on March 3, 2025. The record contained a progress note for a group session occurring on November 06, 2025, that was not completed until November 10, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Clinical Supervisor will review timelines for treatment notes to be completed during next clinical meeting on 8/20/25. Clinical Supervisor will continue to monitor compliance during monthly chart audits and will address any ongoing issues during individual monthly supervision.
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