INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted June 25-26, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pyramid Healthcare Inc., was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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 charts and the facility's policies, the facility failed to follow their policy for completing the combined initial and comprehensive treatment plan in one out of six reviewed charts.
The facility's policy indicates that the combined initial and comprehensive treatment plan is to be completed within 72 hours of admission.
Client #4 was admitted on April 24, 2025 and discharged on June 13, 2025. The combined initial and comprehensive treatment plan dated April 25, 2025 was blank/incomplete. The combined initial and comprehensive treatment plan dated May 14, 2025 was completed late.
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Plan of Correction
The plan of correction for comprehensive treatment plan being late is as followed:
1. All counselors will be re-trained all all guidelines for documentation due dates. This meeting will occur on 7/7/20205.
2. Clinical Director will complete weekly audits of selected counselor charts to ensure documentation is occurring in at timely manner.
3 Clinical Director will review the alerts in the electronic chart that will inform her and the counselor of when treatment plan are due to ensure completion. Completed daily during the morning clinical meeting. |
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.
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Observations
Based on a review of client charts, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in two out of six reviewed charts.
Client #2 was admitted on April 5, 2025 and discharged on May 1, 2025. The Comprehensive Treatment plan dated April 7, 2025 indicates group therapy 5 times per week and individual therapy weekly. The client should have had an individual counseling session during the week of April 21, 2025.
Client #6 was admitted on May 12, 2025 and discharged on June 19, 2025. The Comprehensive Treatment plan dated May 14, 2025 indicates group therapy 5 times per week and individual therapy weekly. The client should have had an individual counseling session during the week of May 26, 2025.
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Plan of Correction
The plan of correction for documentation not being in the chart in a timely manner will be:
1. All counselors will be re-trained all all guidelines for documentation due dates. This meeting will occur on 7/7/20205.
2. Clinical Director will complete weekly audits of selected charts at least 3 charts a week, to ensure documentation is occurring in at timely manner. Executive director will oversee. Audits will start immediate. ly
3 Clinical Director will review the alerts in the electronic chart that will inform her when documentation is not in the chart or late. Any counselor that are late with documentation, will continue to meet with Leadership daily until documentation is in compliance.
Audits will be completed weekly and reviewed during the morning clinical meeting. |