D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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PYRAMID HEALTHCARE, INC.
ROMA CORPORATE CENTER<br>1605 North Cedar Crest Boulevard, Suite 602
ALLENTOWN, PA 18104

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Survey conducted on 07/15/2026

INITIAL COMMENTS
This report is a result of an off-site licensure renewal inspection conducted July 14-15, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. As this was an off-site inspection, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance. Based on the findings of the off-site inspection, Pyramid Healthcare, Inc. Allentown OP 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(f)(2) LICENSURE Trng Hours Req-Coun 704.11. Staff development program. (f) Training requirements for counselors. (2) Each counselor shall complete at least 25 clock hours of training annually in areas such as: (i) Client recordkeeping. (ii) Confidentiality. (iii) Pharmacology. (iv) Treatment planning. (v) Counseling techniques. (vi) Drug and alcohol assessment. (vii) Codependency. (viii) Adult Children of Alcoholics (ACOA) issues. (ix) Disease of addiction. (x) Aftercare planning. (xi) Principles of Alcoholics Anonymous and Narcotics Anonymous. (xii) Ethics. (xiii) Substance abuse trends. (xiv) Interaction of addiction and mental illness. (xv) Cultural awareness. (xvi) Sexual harassment. (xvii) Developmental psychology. (xviii) Relapse prevention. (3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
Observations Based on a review of the Staffing Requirement Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one out of six applicable records reviewed. Employee #9 was hired as a counselor on July 12, 2021, and was still active in the position at the time of the inspection. The facility's training year that was reviewed was from January 1, 2025, through December 31, 2025. Employee #9 only had 24.25 hours of annual training documented for the training year reviewed. This finding was reviewed with facility staff during the licensing process.	Plan of Correction ED will review staff training hours quarterly 08/01/2026, 10/01/2026, 01/01/2027 and 04/01/2027 and document review of trainings with staff during monthly supervision to ensure staff are completing required trainings and meeting required yearly training hours.
704.12(a)(6) LICENSURE OutPatient Caseload 704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios. (a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client. (6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
Observations Based on the review of the Staffing Requirement Facility Summary Report (SRFSR), it was determined that the project failed to comply with the client/counselor ratios. The project exceeded the maximum caseload permitted for one of nine clinicians reviewed. Employee # 9 was hired as a counselor on July 12, 2021, and was still active in that position at the time of the inspection. Employee #9 was reported to have 11 hours per work week dedicated to their 10 clients on their caseload. The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility's work week. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE. The FTE counselor's caseload calculation is as follows: 11 hours a week devoted to clients/40-hour work week=0.275 (FTE); Employee #9 has 10 clients on their caseload which results in 10/0.275 = 36.36, which equals to a client/counselor ratio of 36/1. This finding was reviewed by facility staff during the licensing process.	Plan of Correction CS will review counselor caseload reports weekly. However, in the absence of the CS the ED will review reports weekly. ED will complete monthly compliance audits to verify adherence to client/counselor ratio requirements. Any identified variances will be corrected immediately and documented, with trends reviewed during leadership meeting with Regional Director.
705.28 (d) (1) LICENSURE Fire safety. 705.28. Fire safety. (d) Fire drills. The nonresidential facility shall: (1) Conduct unannounced fire drills at least once a month.
Observations Based on a review of fire drill logs from July 2025 through June 2026, the facility failed to conduct unannounced fire drills at least once a month in three out of eleven months reviewed. There was no documentation of an unannounced fire drill occurring during the months of July 2025, October 2025, and April 2026. These findings were reviewed with facility staff during the licensing process.	Plan of Correction ED will review all fire safety policies and applicable regulatory requirements with staff on or before 8/30/26 via staff meeting to reinforce expectation for conducting and documenting unannounced fire drills. ED will establish an annual fire drill schedule that ensures drills are conducted on varying days, shifts and times without prior notification to staff. ED will designate Administrative Assistant responsible for coordinating, documenting and tracking all required ire drills to ensure compliance. ED will monitor overall compliance of fire drills schedules, documentation and tracking on a quarterly basis by meeting with the Administrative Assistant to ensure compliance.
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 client records, the facility failed to ensure that counseling services are provided according to the individual treatment plan in five out of seven records reviewed. Client #10 was admitted to the partial hospitalization level of care on February 26, 2026, and transferred to the outpatient level of care on March 6, 2026, and was still active at the time of inspection. The individual treatment plan dated March 6, 2026, indicated group sessions five times per week. The record only contained documentation of three group sessions during the weeks of March 8-14, 2026, and March 22-28, 2026, two group sessions the week of March 15-21, 2026, and one group session March 29-April 4, 2026. The treatment plan update dated April 15, 2026, indicated group sessions three times per week. The record only contained documentation of two group sessions in the week of April 19-25, 2026, and one group session the weeks of May 10-16, 2026, May 17-23, 2026, May 24-30, 2026, May 31-June 6, 2026, June 7-13, 2026, and June 14-20, 2026. Client #11 was admitted to the outpatient level of care on July 30, 2025, and discharged on January 14, 2026. The individual treatment plan dated August 12, 2025, indicated group sessions weekly. There was no documentation of any group sessions for the weeks of August 31 - September 6, 2025, and September 7-13, 2025. The treatment plan update dated September 22, 2025, indicated group sessions three times per week. There was no documentation of any group sessions for the weeks of October 19-25, 2025, November 2-8, 2025, November 9-15, 2025, November 23-29, 2025, December 7-13, 2025, December 14-2025, 2025, December 21-27, 2025, and December 28, 2025 - January 3, 2026. Only two group sessions were documented for the weeks of October 5-11, 2025, October 12-18, 2025, and October 26 - November 1, 2025, and only one group session was documented for the weeks of November 16-22, 2025, and November 30 - December 6, 2025. Client #12 was admitted to the partial hospitalization level of care on October 22, 2025, and transferred to the outpatient level of care on November 21, 2025, and was discharged on March 13, 2026. The individual treatment plan dated October 27, 2025, indicated five group sessions per week, and individual sessions twice per week. There were no documented individual sessions in the week of November 23-29, 2025. Only three group sessions were documented for the week of November 23-29, 2025. The treatment plan updates dated December 2, 2025, and December 31, 2025, indicated group sessions three times per week. Only two group sessions were documented the week of January 11-17, 2026. Client #15 was admitted to the partial hospitalization level of care on November 19, 2025, and transferred to the outpatient level of care on December 9, 2025, and was discharged on January 2, 2026. The individual treatment plan dated December 10, 2025, indicated group sessions three times per week and monthly individual sessions. Only one group session was documented the week of December 21-27, 2025. Client #16 was admitted to the partial hospitalization level of care on December 31, 2025, and transferred to the outpatient level of care on September 24, 2025, and was discharged to a higher level of care on December 31, 2025. The individual treatment plan dated September 29, 2025, and the update dated November 26, 2025, both indicated weekly group sessions. There was no documentation of group sessions during the weeks of November 9-15, 2025, November 16-22, 2025, December 7-13, 2025, and December 14-20, 2025. These findings were reviewed with facility staff during the licensing process.	Plan of Correction CS will educate and support counselors in supervision on the requirements to provide counseling services as outlined in each clients individualized treatment plan and to promptly update treatment plans when clinically indicated. CS will implement a tracking system to monitor requirements and alert staff to missed services/call logs and support counselors in the implementation of this tracking system during supervision with each staff member. ED will reinforce supervisor reviews via weekly audits of treatment plans, clinical documentation and services delivery to ensure consistency between prescribed services and those provided. ED will conduct a monthly compliance review to evaluate adherence to treatment plan requirements and identify any trends requiring corrective action.