INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 2025 through July 10, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Dolminis 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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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 the review of client records, the project failed to offer a copy of release of information forms for the funding source in seventeen of seventeen client records reviewed.
These findings were reviewed with project 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, facility leadership and/or designee 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/Lead counselor 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 treatment team on 8/7/25. 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.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
The facility failed to document an annual evaluation of each patient's status that was completed by the patient's counselor and was reviewed, dated and signed by the medical director in one of twelve applicable patient records reviewed.
Patient #17 was admitted on September 26, 2023 and was discharged on June 17, 2025. An annual evaluation was due in September 2024, per the program's policy and procedure of completion within their anniversary month; however, there was no documentation in the patient record of an annual evaluation at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure timely completion of Annual Evaluations, clinicians will utilize centralized tracking system through the Electronic Medical Record that records each client's upcoming due dates based on the admission date to the facility. Clinical staff will utilize biannual reporting, with reports generated on July 1 and December 1 to identify upcoming Annual Evaluations to be completed. Clinical staff will be responsible to review and complete Annual Evaluation during individual therapy sessions on or before due date and route to medical director for review and signature on or before due date. During treatment team on 7/24/25, lead counselor reviewed the updated process for reviewing and tracking annual evaluation due dates. The importance of adhering to documentation timelines to ensure consistent accountability and compliance was also discussed. Clinical supervisor/lead counselors will monitor for timely completion of Annual Evaluations during monthly supervision. |
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.
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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 four of ten applicable client records reviewed.
Client #11 was admitted on December 3, 2024, and was active at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on December 17, 2024, indicated that the client was to receive one individual session per week and one group counseling session per month; however, there were no individual counseling sessions documented in the client record for the month of March 2025 and no group counseling sessions documented in the client record for the months of January 2025, February 2025 or March 2025.
Client #12 was admitted on October 6, 2021, and was discharged on September 30, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on July 2, 2024, indicated that the client was to receive one individual counseling session per month; however, there were no individual counseling sessions documented in the client record for the months of August 2024 and September 2024.
Client #13 was admitted on November 3, 2017, and was discharged on March 6, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on August 7, 2024, indicated that the client was to receive one individual counseling session per month; however, there were no individual counseling sessions documented in the client record for the months of September 2024 and February 2025.
Client #15 was admitted on April 4, 2024, and was active at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on November 25, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of December 1, 2024 through December 7, 2024, December 15, 2024 through December 21, 2024, December 29, 2024 through January 4, 2025, and January 19, 2025 through January 25, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During treatment team on July 24, 2025, lead counselor addressed scheduling needs with clinical team, emphasizing the importance of adhering to each client's treatment plan and ensuring that all therapy sessions are scheduled in accordance with the mutually agreed upon treatment schedule. Clinical staff will continue proactive outreach efforts to clients who have missed appointments or have not yet scheduled their sessions. This will include contacting clients through available communication methods and offering assistance in rescheduling or setting up future appointments. Additionally, the clinical team was instructed to utilize the Electronic Medical Record (EMR) system to schedule recurring appointments, ensuring clients are placed on a consistent and timely therapy schedule, minimizing the risk of missed sessions in the future. These corrective actions are aimed at ensuring full compliance with treatment plans and enhancing client engagement with their recovery process. Clinical supervisor/lead counselors will monitor for therapy sessions consistent with frequency of client's treatment plan during monthly supervision. |