INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on 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, Pyramid Healthcare Lehigh Valley 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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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that counselor assistants documented to the facility director, upon the completion of each calendar year, that they are continuing to work towards counselor status in one of one applicable personnel record reviewed.
Employee # 7 has been in the position of counselor assistant since April 3, 2022. There was no documentation to the facility director that they were working toward counselor status by the end of the 2024 calendar year as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will obtain documentation from Employee #7 (and any CA moving forward) that they are continuing to work towards counselor status upon the completion of each calendar year. This will be tracked via HR Records and correspondence with CD and CAs. |
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 facility failed to ensure that two applicable employees received a minimum of 4 hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee # 8 was hired as a support staff member on December 26, 2022. Employee # 8 was due to have the communicable disease trainings no later than December 26, 2024; however, the TB/STD training was not completed as of the date of the inspection.
Employee # 9 was hired as a support staff member on March 27, 2023. Employee # 9 was due to have the communicable disease trainings no later than March 27, 2025; however, the TB/STD training was not completed as of the date of the inspection.
This is a repeat citation from the August 4, 2021, August 19, 2022, June 26, 2023, and June 13, 2024 annual licensing renewal inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #8 and Employee #9 were scheduled to complete the TB/STD training after the June 13, 2024 annual licensing renewal inspection, but did not follow through with attending the training.
Both employees were aware of the expectation to complete the training, due to already being out of compliance, and will be receiving disciplinary for insubordination. They have since been scheduled for the training and are expected to attend the training on August 18th, 2025.
Continued from last citation, Administrative Assistant will ensure that all new hires register for TB/STD with their respective Department Head within their first 30 days of hire. AA will track completion via Smartsheet, with ED's oversight. ED will monitor this Smartsheet on a quarterly basis, with first audit being completed no later than 8/15/2025.
Current employees' trainings will also be tracked in this Smartsheet.
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on July 10, 2025, the facility failed to provide an operable soap dispenser in each bathroom. The large restroom on the first floor did not have soap.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The morning of July 10, 2025, upon inspection of all bathrooms, the soap dispenser was fully functioning with soap. Unfortunately, Facility Supervisor was not notified immediately when the last of the soap was used. Typically, Maintenance and House Keeping staff are notified immediately when soap is running low.
Facility will ensure there is always an operable soap dispense in each bathroom by daily checks completed by House Keeper and overseen by Facility Supervisor.
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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.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in two of two applicable records reviewed. The facility failed to follow their policy related to AMA discharges of calling the emergency contact within twelve hours.
Client # 3 was admitted to the inpatient non-hospital level of care on February 25, 2025 and discharged Against Medical Advice (AMA) on March 19, 2025.
Client # 4 was admitted to the inpatient non-hospital level of care on October 22, 2024 and discharged Against Medical Advice (AMA) on November 12, 2024.
This is a repeat citation from the June 13, 2024 annual licensing renewal inspection.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Executive Director met with Clinical Director and BHT Manager to review this POC on July 29, 2025. The same POC from last year is being continued: if a client leaves the facility as a non-routine discharge (against facility advice, behaviorally, medically, etc.) during a shift when their Primary Counselor and/or Clinical Director is in the building, they will call the emergency contact and document this attempt in the client's chart immediately.
If a client leaves the facility as a non-routine discharge while the primary counselor and/or CD is not in the building, the BHT Shift Lead or BHT Shift Supervisor will call the emergency contact and document this attempt in the client's chart.
CD will monitor compliance in real-time (by being notified of NRD via notification from staff who are on site) and ensure documentation with weekly audits. After 90 days of consistent compliance, CD will monitor compliance on a monthly basis.
Update: What is being done differently is the notification to Clinical Director in real time of a NRD. Then, CD will ensure communication is had with the emergency contact. This was not done before. Additionally, this is a new Clinical Director - and not the same CD as the previous POC. |
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 seven of seven 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 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 in active 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, Executive Director and/or Clinical Director 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 and Clinical Director will re-educate admission and clinical 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 their staff meeting by 8/15/25.This re-education will be recorded in the meeting minutes/notes.
Clinical staff will offer any current clients who admitted before the updated Treatment, Payment and Healthcare Operations consent a copy of their current consent during the next treatment plan review and document the offering in their case note.
In order to monitor compliance with our plan of correction, the Clinical Director and Executive Director will be responsible for weekly review of documentation to ensure compliance. Executive Director will supervise Clinical Director weekly to monitor the plan of correction.
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in two of four applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed seven days following admission or as needed.
Client # 3 was admitted on February 25, 2025 and was discharged on March 19, 2025. The record did not contain documentation of a case consultation note.
Client # 4 was admitted on October 22, 2024 and was discharged on November 12, 2024. The record did not contain documentation of a case consultation note.
This is a repeat citation from the June 13, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director met with Clinical Director to review this POC on July 29, 2025.
Clinical Director will ensure that Case Consultations are completed within 7 days of a client's admission into treatment by auditing charts on a weekly basis, every Friday. After 90 days of consistent compliance, CD will monitor compliance on a monthly basis. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to complete a discharge summary within guidelines established by the facility's policy and procedures manual in two of four applicable records reviewed. The facility's policy and procedures manual states that discharge summaries must be completed seven days following discharge.
Client # 3 was admitted on February 25, 2025 and was discharged on March 19, 2025. The record did not contain a discharge summary.
Client # 4 was admitted on October 22, 2024 and was discharged on November 12, 2024. The record did not contain documentation of a discharge summary.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director met with Clinical Director to review this POC on July 29, 2025.
Clinical Director to ensure that Discharge Summaries are completed within the 7-day timeframe by completing weekly chart audits. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information within guidelines established by the facility's policy and procedures manual in three of three applicable records reviewed. The facility's policy and procedures manual states that follow-up must be completed within seven days following discharge.
Client # 1 was admitted on November 23, 2024 and was discharged on January 2, 2025. The record did not contain documentation of follow-up information.
Client # 2 was admitted on December 17, 2024 and was discharged on February 11, 2025. Follow-up information was due to be documented by February 18, 2025; however, follow-up was not documented until February 24, 2025.
Client # 3 was admitted on February 25, 2025 and was discharged on March 19, 2025. The record did not contain documentation of follow-up information.
Client #4 was admitted on October 22, 2024 and discharged on November 12, 2024. The record did not contain documentation of follow-up information.
This is a repeat citation from the August 19, 2022, June 26, 2023, and June 13, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director met with Clinical Director to review this POC on July 29, 2025.
Clinical Director is to ensure that 7-day follow-up calls are completed by the Case Coordinator. CD will monitor compliance via already existing Smartsheet and Executive Director will have additional oversight. Monitoring will occur on a weekly basis for the first 90 days, then monthly after consistent compliance.
Unfortunately, due to several staffing changes within the past year (since prior audit), 7-day follow-up calls were not consistently documented following established processes. In the event that the CC position is vacant, CD will identify another support staff to complete the calls. |
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 and personnel records, the facility failed to comply with plans of corrections that were approved by the Department.
A plan of correction for mandatory communicable disease training was submitted and approved by the Department for the August 4, 2021, August 19, 2022, June 26, 2023, and June 13, 2024 annual licensing inspections. Mandatory communicable disease training was again found to be a deficiency in the July 10, 2025, licensing inspection.
A plan of correction for documenting follow-up within seven days of discharge was submitted and approved by the Department for the August 19, 2022, June 26, 2023, and June 13, 2024 annual licensing inspections. Documenting follow-up was again found to be a deficiency in the July 10, 2025, licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will have ultimate responsibility for ensuring plans of corrections are implemented and will hold Department heads accountable if deadlines are not met. Plans of corrections will be monitored with additional tracking sheets for personnel and clinical records by Department heads and ED. |