D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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PYRAMID HEALTHCARE INC. PINE RIDGE
13505 SOUTH EAGLE VALLEY ROAD
TYRONE, PA 16686

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Survey conducted on 07/30/2026

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on July 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. Pine Ridge 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
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.
Observations Based on a review of client records, the facility failed to follow their written procedures for notifying emergency contacts within twelve hours if a client leaves against staff advice in two of two applicable records reviewed. Client #5 was admitted to the inpatient non-hospital residential level of care on January 16, 2026, and was discharged Against Staff Advice (ASA) on March 17, 2026. The facility failed to notify the emergency contact within twelve hours. Client #6 was admitted to the inpatient non-hospital residential level of care on January 12, 2026, and was discharged Against Staff Advice (ASA) on March 16, 2026. The facility failed to notify the emergency contact within twelve hours. These findings were reviewed with project staff during the licensing process.	Plan of Correction The clinical department will be re-educated on the procedure of contacting emergency contacts within 12 hours of AFA discharges during clinical team meeting on 8/10/26. Clinical Supervisor will review this monthly via chart audits to ensure ongoing compliance.
709.28 (c) (1) 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: (1) Name of the person, agency or organization to whom disclosure is made.
Observations Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosures will be made to in one of seven records reviewed. Client #1 was admitted on May 15, 2026, and was active at the time of the inspection. A release of information form signed by the client on June 10, 2026, did not specify the name of the person, agency or organization to whom disclosure is to be made. . These findings were reviewed with project staff during the licensing process.	Plan of Correction ED and Clinical Supervisor will re-educate clinical staff on ROI completion, addressing completion of full name/address of individual agency or organization during clinical team meeting on 8/10/2026. Clinical supervisor will review ROIs for accuracy during monthly chart audits and address any ongoing concerns or issues. An ROI was updated for Client #1 for his employer on 8/11/26.
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.
Observations Based on the review of administrative documents, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident requiring the presence of police, fire or ambulance personnel. The facility did not file an unusual incident report with the Department for an event at the facility that required the presence of emergency medical services on January 13, 2026. This finding was reviewed with project staff during the licensing process.	Plan of Correction ED and Clinical Supervisor will review protocol and criteria for submission of unusual incident reports during supervision on 8/13/26. ED will monitor for ongoing compliance and meeting timelines during monthly audits. This unusual incident report was submitted by the Clinical Supervisor on 8/12/26.
709.52(c) LICENSURE Provision of Counseling Services 709.52. 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 client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in six of seven records reviewed. Client #2 was admitted on March 2, 2026, and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on March 4, 2026, indicated that the client was to receive five group counseling sessions per week; however, the client only received two group counseling sessions per week for the months of March 2026, April 2026, May 2026, June 2026 and July 2026. Client #3 was admitted on April 16, 2026, and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on April 20, 2026, indicated that the client was to receive one individual counseling session and two group counseling sessions per week; however, there were no individual counseling sessions documented in the record for the weeks of May 31, 2026 through June 6, 2026, June 7, 2026 through June 13, 2026, and June 21, 2026 through June 27, 2026. Additionally, the client only received one group counseling sessions for the weeks of May 17, 2026 through May 23, 2026, and May 31, 2026 through June 6, 2026. Client #4 was admitted on April 21, 2026, and was discharged on June 22, 2026. A comprehensive treatment and rehabilitation plan, documented in the client record on April 27, 2026, indicated that the client was to receive one individual counseling session and two group counseling sessions per week; however, the client only received one group counseling session for the weeks of May 3, 2026 through May 9, 2026, May 17, 2026 through May 23, 2026 and May 31, 2026 through June 6, 2026. Client #5 was admitted on January 16, 2026, and was discharged on March 17, 2026. A comprehensive treatment and rehabilitation plan, documented in the client record on January 21, 2026, indicated that the client was to receive one individual counseling session and two group counseling sessions per week; however, the client only received one group counseling session for the weeks of February 8, 2026 through February 14, 2026, and February 22, 2026 through February 28, 2026. Client #6 was admitted on January 12, 2026, and was discharged on March 16, 2026. A comprehensive treatment and rehabilitation plan, documented in the client record on January 16, 2026, indicated that the client was to receive one individual counseling session and two group counseling sessions per week; however, the client only received one group counseling session for the weeks of February 8, 2026 through February 14, 2026, and March 1, 2026 through March 7, 2026. Client #7 was admitted on October 10, 2025, and was discharged on January 9, 2026. A comprehensive treatment and rehabilitation plan, documented in the client record on October 13, 2025, indicated that the client was to receive one individual counseling session and two group counseling sessions per week; however, the client only received one group counseling session for the weeks of October 26, 2025 through November 1, 2025, November 19, 2025 through November 15, 2025, and December 7, 2025 through December 13, 2025. These findings were reviewed with project staff during the licensing process.	Plan of Correction Clinical Supervisor will address the clinical team on ensuring completion of required group and individual counseling sessions during clinical team meeting on 8/10/2026. Clinical supervisor will complete weekly reports to ensure compliance with maintaining required clinical therapy hours. Clinical Supervisor will also monitor compliance through monthly chart audit reviews. Any ongoing issues will be addressed by the clinical supervisor during monthly supervision with clinicians.