D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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PYRAMID RIDGEVIEW BEHAVIORAL HEALTH CENTER
4447 GIBSONIA ROAD
GIBSONIA, PA 15044

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Survey conducted on 07/31/2025

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on July 31, 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 Ridgeview Behavioral Health 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(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.
Observations Based on a review of personnel records, the facility 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 Department approved curriculum in one out of four applicable records reviewed. Employee #5 was hired as a counselor on April 29, 2024, and was still in the position at the time of the inspection. There was no documentation that the required 4 hours of TB/STD were completed within the required first year of employment. Employee #7 was hired as a counselor on April 29, 2024, and was still in the position at the time of the inspection. There was no documentation that the required 4 hours of TB/STD were completed within the required first year of employment. This is a repeat citation from the August 01, 2024 licensing inspection. These findings were reviewed with facility staff during the licensing process.	Plan of Correction Executive Director will run a monthly training report and identify deficient trainings. Pyramid Healthcare is offering required trainings monthly. Executive Director will ensure all deficient staff sign up for a required training and make supervisors aware of the need for staff to sign up so they can assist in tracking attendance and follow through. Staff will have 30 days to sign up and attend the training from the notification they receive from ED and their direct supervisor. Supervisors will track staff's progress and report to ED during monthly supervisor meetings. Staff will be taken off the schedule if they are not signed up within 2 months and not be put back on until they have completed the deficient training.
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.
Observations Based on a review of client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in seven out of seven client records reviewed. Client #1 was admitted to the inpatient level of care on June 18, 2025 and still active at the time of the inspection. There was no documentation that a copy of the informed and voluntary consent to release information form for a funding source dated June 18, 2025, was offered to the client. Client #2 was admitted to the inpatient level of care on June 17, 2025, and still active at the time of the inspection. There was no documentation that a copy of the informed and voluntary consent to release information form for a funding source dated June 17, 2025, was offered to the client. Client #3 was admitted to the inpatient level of care on June 19, 2025, and still active at the time of the inspection. There was no documentation that a copy of the informed and voluntary consent to release information form for a funding source dated June 19, 2025, was offered to the client. Client #4 was admitted to the inpatient level of care on September 26, 2024 and was discharged on November 13, 2024. There was no documentation that a copy of the informed and voluntary consent to release information form for a funding source dated September 26, 2024, was offered to the client. Client #5 was admitted to the inpatient level of care on May 27, 2025, and was discharged on July 03, 2025. There was no documentation that a copy of the informed and voluntary consent to release information form for a funding source dated May 27, 2025, was offered to the client. Client #6 was admitted to the inpatient level of care on May 25, 2025, and was discharged on July 02, 2025. There was no documentation that a copy of the informed and voluntary consent to release information form for a funding source dated May 25, 2025, was offered to the client. Client #7 was admitted to the inpatient level of care October 25, 2024 and was discharged on December 05, 2024. There was no documentation that a copy of the informed and voluntary consent to release information form for a funding source dated October 25, 2024, was offered to the client. These findings were reviewed with facility staff during the licensing process.	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 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 the intake meeting on (8/29/25). 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 chart monitors with direct care staff to ensure compliance. Executive Director will supervise the Clinical Supervisor weekly to monitor the plan of correction. Executive Director will meet with direct care staff weekly to ensure their understanding and compliance. Executive Director will provide updates to the Regional Director bi-weekly to ensure compliance with plan of correction.
709.53(a)(5) LICENSURE Progress 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: (5) Progress notes.
Observations Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed within 24 hours of therapy sessions, per facility policy, in seven of seven records reviewed. Client #1 was admitted on June 18, 2025 and still active at the time of the inspection. The record contained a progress note for an individual session occurring on June 19, 2025, that was not completed until June 23, 2025. Additionally, the record contained progress notes for group sessions occurring on June 19, 2025, June 25, 2025, June 26, 2025, June 27, 2025, June 27, 2025, June 30, 2025, July 01, 2025, July 09, 2025, July 19, 2025, July 20, 2025 and July 27, 2025, that were not completed until June 23, 2025, June 30, 2025, June 30, 2025, June 30, 2025, June 30, 2025, July 27, 2025, July 12, 2025, July 27, 2025, July 27, 2025, and July 30, 2025, respectively. Client #2 was admitted on June 17, 2025 and still active at the time of the inspection. The record contained progress notes for individual sessions occurring on June 19, 2025, and June 25, 2025, that were not completed until June 20, 2025, and June 27, 2025. Additionally, the record contained progress notes for group sessions occurring on June 19, 2025, June 23, 2025, June 26, 2025, June 27, 2025, July 01, 2025, July 06, 2025, July 20, 2025 and July 27, 2025, that were not completed until June 23, 2025, June 25, 2025, June 30, 2025, June 30, 2025, July 09, 2025, July 12, 2025, July 27, 2025, and July 30, 2025, respectively Client #3 was admitted on June 19, 2025 and still active at the time of the inspection. The record contained progress notes for individual sessions occurring on July 02, 2025, July 10, 2025, and July 25, 2025, that were not completed until July 09, 2025, July 12, 2025, and July 28, 2025. Additionally, the record contained progress notes for group sessions occurring on June 20, 2025, June 24, 2025, June 27, 2025, June 30, 2025, July 01, 2025, July 02, 2025, July 03, 2025, July 04, 2025, July 07, 2025, July 21, 2025, July 22, 2025, July 25, 2025, that were not completed until June 23, 2025, June 27, 2025, July 01, 2025, July 03, 2025, July 09, 2025, July 09, 2025, July 09, 2025, July 10, 2025, July 11, 2025, July 27, 2025, July 24, 2025, and July 27, 2025, respectively. Client #4 was admitted on September 26, 2024, and discharged on November 13, 2024. The record contained progress notes for individual sessions occurring on October 15, 2024, October 22, 2024, October 29, 2024, and November 04, 2024, that were not completed until October 18, 2024, October 24, 2024, October 31, 2024, and November 06, 2024, respectively. Additionally, the record contained progress notes for group sessions occurring on September 27, 2024, October 07, 2024, October 08, 2024, October 09, 2024, October 16, 2024, October 20, 2024, October 23, 2024, October 28, 2024, October 29, 2024, October 30, 2024, October 31, 2024, November 11, 2024, and November 12, 2024, that were not completed until September 30, 2024, October 10, 2024, October 14, 2024, October 12, 2024, October 20, 2024, June 19, 2025, November 01, 2024, November 01, 2024, November 01, 2024, November 03, 2024, November 03, 2024, November 15, 2024, and November 15, 2024, respectively. In addition, the record contained progress notes for group sessions occurring October 09, 2024, November 04, 2024, and November 07, 2024, that were not completed at the time of the inspection. Client #5 was admitted on May 27, 2025 and discharged on July 03, 2025. The record contained progress notes for individual sessions occurring on June 02, 2025, and June 09, 2025, that were not completed until June 26, 2025, and June 15, 2025. Additionally, the record contained progress notes for group sessions occurring on June 01, 2025, June 02, 2024, June 02, 2025, June 03, 2025, June 03, 2024, June 04, 2024, June 05, 2025, June 06, 2025, June 08, 2025, June 09, 2025, June 10, 2025, June 11, 2025, June 12, 2025, June 13, 2025, June 17, 2025, June 18, 2025, June 18, 2025, June 19, 2025, June 20, 2025, June 20, 2025, June 25, 2025, June 27, 2025, June 30, 2025, July 01, 2025, and July 02, 2025, that were not completed until June 26, 2025, June 04, 2025, June 04, 2025, June 26, 2025, June 26, 2025, June 30, 2025, July 05, 2025, June 09, 2025, July 05, 2025, July 27, 2025, July 15, 2025, July 15, 2025, July 15, 2025, July 16, 2025, June 22, 2025, June 22, 2025, June 22, 2025, June 29, 2025, June 29, 2025, July 27, 2025, July 30, 2025, and July 30, 2025, respectively. In addition, the record contained a progress note for a group session occurring on May 29, 2025, that was not completed at the time of the inspection. Client #6 was admitted on May 25, 2025, and discharged on July 02, 2025. The record contained progress notes for individual sessions occurring on June 05, 2025, June 23, 2025, and July 02, 2025, that were not completed until June 27, 2025, June 26, 2025, and July 09, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on May 24, 2025, May 29, 2025, May 29, 2025, May 30, 2025, June 07, 2025, June 09, 2025, June 12, 2025, June 16, 2025, June 17, 2025, June 18, 2025, June 18, 2025, June 19, 2025, June 19, 2025. June 20, 2025, June 20, 2025, June 20, 2025, June 21, 2025, June 30, 2025, June 30, 2025, July 01, 2025, and July 02, 2025, that were not completed until June 21, 2025, June 02, 2025, June 04, 2024, June 06, 2025, June 17, 2025, June 27, 2025, June 27, 2025, June 24, 2025, June 24, 2025, June 22, 2025, June 23, 2025, June 23, 2025, June 23, 2025, June 23, 2025, June 23, 2025, June 25, 2025, July 03, 2025, July 27, 2025, July 09, 2025 and July 09, 2025, respectively. In addition, the record contained a progress note for a group session occurring June 27, 2025, that was not completed at the time of the inspection. Client #7 was admitted on October 25, 2024 and discharged on December 05, 2024. The record contained progress notes for group sessions occurring on November 04, 2024, November 06, 2024, November 07, 2024, November 24, 2024, November 25, 2024, December 01, 2024, December 02, 2024, December 02, 2024, December 03, 2024, December 04, 2024, and December 05, 2024, that were not completed until November 07, 2024, November 08, 2024, November 09, 2024, November 27, 2024, December 03, 2024, December 04, 2024, December 08, 2024, December 08, 2024, December 07, 2024, and December 08, 2025 respectively . These findings were reviewed with facility staff during the licensing process.	Plan of Correction Clinical Supervisor will review documentation requirement timelines with all clinical staff during clinical meeting on 9-2-25 and it will be reflected in the meeting minutes. Clinical Supervisor will review chart audits weekly and ensure compliance. Any staff who are not meeting requirements will be addressed during monthly supervision with ED or Clinical Supervisor. If deficiencies continue, then the staff will be placed on a performance improvement plan.