INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 21-22, 2026, 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 Inc. 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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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policy manual, the facility failed to document a psychosocial evaluation within 24 hours of admission or transfer from higher level of care, per facility policy, in three of seven records reviewed.
Client # 1 was admitted to the inpatient level of care on March 3, 2026, and was discharged on March 24, 2026. The psychosocial evaluation was not completed prior to discharge.
Client # 2 was admitted to the inpatient level of care on October 18, 2025, and was discharged on November 2, 2025. The psychosocial evaluation was not completed until October 21, 2025.
Client # 4 was admitted to the inpatient level of care on January 5, 2026, and was discharged on March 13, 2026. The psychosocial evaluation was not completed prior to discharge.
This is a repeat citation from the June 5, 2024, and August 11, 2025, annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Pyramid Healthcare has created a new targeted clinical assessment team starting on 7/8/26 to help support facility clinical staff. All new admissions will be met with for psychosocial completion within 24 hours of admission. Any barriers to completion will be documented in the chart. The Clinical Director and/or Clinical Assessment Team leadership will verify psychosocial evaluation completion through weekly chart audits, beginning 8/24/26. |
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 records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in four of seven records reviewed.
Client # 1 was admitted to the inpatient level of care on March 3, 2026, and was discharged on March 24, 2026. The treatment plan completed on March 4,2026, indicated that the client was to receive one individual session per week; however, the record did not document any individual sessions the week of March 8, 2026 through March 14, 2026.
Client # 2 was admitted to the inpatient level of care on October 18, 2025, and was discharged on November 2, 2025. The treatment plan completed on October 20, 2025, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session the week of October 26, 2025 through November 2, 2025.
Client # 4 was admitted to the inpatient level of care on January 5, 2026, and was discharged on March 13, 2026. The treatment plans completed on February 3, 2026, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session the weeks of February 15, 2026 to February 21, 2026, or March 1, 2026 to March 7, 2026.
Client # 5 was admitted to the inpatient level of care on June 23, 2026, and was active at the time of licensing process. The treatment plan completed on June 26, 2026, indicated that the client was to receive group sessions daily; however, the record contained no documentation of group sessions on July 12, 2026, July 13, 2026, or July 15, 2026.
This is a repeat citation from the August 11, 2025, annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will ensure daily group notes are completed by counselors within 24 hours of the service. When a planned service can't be provided, the reason, engagement attempts, and follow-up will be documented in the client record. Executive Director will ensure the daily auditing is completed through implementation of daily tracking sheet beginning 8/24/26. Additionally, Clinical Director will conduct weekly audits to ensure individual sessions are completed 1x/week. Retraining will occur with the clinical team regarding expectations to provide services in accordance with the treatment plan by 8/25/26. |
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 ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in three of four applicable records reviewed.
Client # 1 was admitted to the inpatient level of care on March 3, 2026, and was discharged on March 24, 2026. The record did not contain documentation of follow-up information.
Client # 3 was admitted to the inpatient level of care on April 10, 2026, and was discharged on May 8, 2026. The record did not contain documentation of follow-up information.
Client # 4 was admitted to the inpatient level of care on January 5, 2026, and was discharged on March 13, 2026. The record did not contain documentation of follow-up information.
This is a repeat citation from the June 5, 2024, and August 11, 2025, annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Director will retrain responsible staff on the 7-day follow-up call policy by 8/26/26. Case managers will be responsible for updating contact information and accurate discharge date for discharging clients. Administrative Assistant will complete follow-up calls daily, and document that it was completed in the discharge bundle for clients within 7 days following discharge. This will be monitored through regular chart audits by CD. |
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 the review of client records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information was submitted and approved by the Department for the June 5, 2024, and August 11, 2025, annual licensing renewal inspections. Follow-up information was again found to be a deficiency in the July 21-22, 2026, licensing inspection.
A plan of correction to document a psychosocial evaluation within 24 hours of admission or transfer from higher level of care, per facility policy, was submitted and approved by the Department for the June 5, 2024, and August 11, 2025, annual licensing renewal inspections. Documentation of psychosocial evaluation within 24 hours of admission or transfer from higher level of care, per facility policy was again found to be a deficiency in the July 21-22, 2026, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to having repeat citations in 2026, indicating prior POC were not followed to result in change, RD will meet with ED monthly on all DDAP citations and POCs. RD and ED will complete monthly supervision reviewing if POC is being implemented and is working to correct citation deficiency. This will begin 8/17/26. |