INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 21, 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 Ridgeview Behavioral Health Center 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(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 project failed to ensure that staff persons and volunteers received 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 in one out of six records reviewed.
Employee # 6 was hired as a behavioral health technician on May 14, 2024, and was currently in that position at the time of the inspection. Employee #6 was due to have the communicable disease training no later than May14, 2026. There was no documentation that the employee received the six hours of HIV/AIDS training and the four hours of TB/STD training as of the date of the inspection.
This is a repeat citation from the August 1, 2024, and July 31, 2025 licensing inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Employee #6 has been taken off the schedule until his trainings are received. We are waiting to hear if he has a spot in the August training. If he does not, he will be in the September training.
The Executive Director has implemented a Smartsheet tracking system for each department to monitor staff compliance with all DDAP-required trainings, including first-year counselor training requirements. Each departmental Smartsheet contains a list of all staff members, required trainings, due dates, completion dates, and current compliance status. This information was manually entered by staff and checked by all the supervisors for accuracy. In the old system, the reports run were inaccurate, and weren't tracking all of the trainings, so the report has been amended.
The Smartsheets are shared with the applicable department supervisor and the Executive Director to ensure ongoing oversight and accountability. Automated reports are generated and distributed to the supervisor and Executive Director every Monday and Thursday. In addition, automated notifications are sent when a training is due within 30 days to allow sufficient time for completion.
Supervisors and ED will review smartsheet during Monthly Supervisor meetings and assist staff in signing up if they need a training. Employees who fail to maintain required training compliance will be removed from the work schedule until all training requirements have been completed and compliance has been restored.
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on July 21, 2026, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit.
When tested, the hot water in the staff bathroom was 149.8 degrees Fahrenheit. Additionally, the hot water in the Faith Unit shower room was 124.2 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A tracking form has been created in a word document for monitoring water temperatures monthly. This tracker will be placed in the maintenance/housekeeping binder that is located in the front office. This binder is already used daily by maintenance to complete their facility duty checklist. They will now use this tracker monthly to temp the different water sources within the facility. ED will review this monthly to ensure compliance is completed monthly. In Maintenance absence, ED or Housekeeping will fill out the temp log to ensure completion. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of client records, the facility failed to ensure that verbal orders were authenticated in writing by a physician or other medical professional within three business days from the time the order was given in two applicable records reviewed.
Client # 4 was admitted on October 8, 2025, and was discharged on November 11, 2025. Verbal orders were given on November 4, 2025, that were not authenticated in writing by an authorized provider until November 13, 2025.
Client # 7 was admitted on October 6, 2025, and was discharged on November 17, 2025. Verbal orders were given on November 14, 2025, that were not authenticated in writing by an authorized provider until December 11, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Current Verbal order policy was reviewed with all providers and nursing staff on 8-5-26. During this time we reviewed that if the provider is unable to come on site within 24 hours, then nursing will send the document via docusign to ensure compliance. Executive Director is working to ensure all nurses employed at RV have access to Docusign, and will ensure all nurses have this by 8-20-26. All providers currently have access to docusign. Executive Director will meet with all providers and nursing staff again when all nurses have docusign and re review the process, and this will take place by 8-27-26. Nurses will complete weekly audits each Saturday to ensure compliance is being kept. If there is not a nurse scheduled for Saturdays, they will communicate that and complete it Fridays. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two of two applicable client records reviewed.
Client #5 was admitted on April 1, 2026, and was involuntarily discharged on May 8, 2026. There was no documentation in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.
Client #6 was admitted on April 9, 2026, and was involuntarily discharged on June 4, 2026. There was no documentation in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Executive Director will review the involuntary discharge process with all supervisors by 8-14-26 to ensure they are signing the paper with the client if an involuntary discharges occur on their shift. Executive Director will review the involuntary discharge process with all Clinical Staff and Case Managers on 8-4-26, during our Treatment team meeting. Clinical Supervisor will ensure these are being completed, and review during weekly chart monitors. If any staff are not following the process, it will be addressed in individual supervision. |
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
Based on a review of client records and administrative information, the facility failed to comply with a plan of correction that was approved by the Department.
A plan of correction for staff members receiving 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 was submitted and approved by the Department for the August 1, 2024, and July 31, 2025, annual licensing inspections. Staff members receiving the minimum number of communicable diseases training hours, was again found to be a deficiency in the July 21, 2026, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has implemented a Smartsheet tracking system for each department to monitor staff compliance with all DDAP-required trainings, including first-year counselor training requirements. Each departmental Smartsheet contains a list of all staff members, required trainings, due dates, completion dates, and current compliance status.
The Smartsheets are shared with the applicable department supervisor and the Executive Director to ensure ongoing oversight and accountability. Automated reports are generated and distributed to the supervisor and Executive Director every Monday and Thursday. In addition, automated notifications are sent when a training is due within 30 days to allow sufficient time for completion. Supervisors and Executive Directors are manually checking the report and comparing it against the training transcripts to confirm the accuracy of the report. This will be monitored by the supervisors and executive director, to put more eyes on this process and ensure nothing is getting missed, instead of relying only on the reports. Executive Director and all supervisors review this monthly to ensure all trainings are being focused on, and discuss if any staff need to come off the schedule due to non compliance.
All current training requirements have been added to the tracking system, and any new training requirements will be entered immediately upon notification. Staff identified as non-compliant will be required to register for and complete the outstanding training for the next scheduled training available. Employees who fail to maintain required training compliance will be removed from the work schedule until all training requirements have been completed and compliance has been restored. The tracker we used the previous plans of correction was inaccurate and reporting inaccurate data, which is why it continued to be deficient. The new tracker, combined with checking against the completed transcripts will assist in compliance.
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