INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28, 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one out of four personnel records reviewed.
Employee #5 was hired as a counselor on August 8, 2022, and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2025, through December 31, 2025. Employee # 5's record only documented 20.5 hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director reviewed on 08/03/2026 with the clinical team the required amount of annual training hours required per position. The facility has implemented a revised training monitoring process to ensure compliance with annual counselor training requirements. Training hours for all counselors will be tracked using a centralized training log maintained by leadership. Quarterly audits of training records will be conducted to verify progress toward annual training requirements and identify any deficiencies before the end of the training year. The Executive Director and Clinical Supervisor will review training completion reports on a quarterly basis and provide reminders to staff who are not on track to complete the required annual hours. Personnel files will be reviewed annually and prior to licensing inspections to ensure all training documentation is complete and accurately maintained. This will be documented in the Staff Meeting minutes. Staff retraining will occur as needed based on performance. Retraining will be documented in supervision logs. |