INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9, 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, 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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704.10 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 # 10 has been in the position of counselor assistant since July 1, 2024. 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
CA will ensure that they provide documentation by the end of each calendar year that they are continuing to work towards counselor status by providing ED and CS with a written letter of intent and proof of continued enrollement in an educational program of higher learning. This requirement will be reviewed with CA by 8/31/25 to ensure CA is aware of necesary documentation and time frames to submit said documentation. |
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 one applicable employee received a minimum of 4 hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee # 10 was hired as a support staff member on October 24, 2022 and was promoted to counselor assistant on July 1, 2024. Employee # 10 was due to have the communicable disease trainings no later than October 24, 2024; however, the TB/STD training was not completed until March 26, 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor(CS) or Executive Director(ED) will run monthly training transcripts and CS will review during individual supervision where due dates will be set and follow up shall occur to assess conpletion on or before identified due date.
ED will follow up with CS during monthly supervision for updates about monthly training status. |
704.12(a)(5) LICENSURE Partial Hosp Ratio
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 10:1.
The overall facility Full Time Equivalent (FTE) is determined by dividing the total number of hours the facility devotes to their substance use disorder clients by the facility's work week. Then, in order to obtain the facility's ratio, the total number of drug and alcohol clients is divided by the FTE.
The overall facility client to counselor ratio calculation is as follows:
56/40 = 1.4(FTE); 16/1.4 = 11, which equals to a client/counselor ratio of 11:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to the growing volume the PHP program has demonstrated there is a need for 2 FTE. PTE will be transitioned out of servicing this level of care. ED and CS will ensure the ratio remains in compliance with DDAP standards. |
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 nine of nine applicable client records reviewed.
Client#1 was admitted to the partial hospitalization level of care on April 24, 2025 and transferred to the outpatient level of care on May 16, 2025 and was subsequently discharged on June 24, 2025.
Client #2 was admitted to the partial hospitalization level of care on October 23, 2024 and transferred to the outpatient level of care on November 8, 2024 and was subsequently discharged on April 3, 2025.
Client #3 was admitted to the partial hospitalization level of care on September 11, 2024 and transferred to the outpatient level of care on October 9, 2024 and was subsequently discharged on March 24, 2025.
Client #4 was admitted to the partial hospitalization level of care on February 6, 2025 and transferred to the outpatient level of care on March 7, 2025 and was still active at the time of the inspection.
Client #5 was admitted on May 15, 2025 and was active at the time of the licensing inspection.
Client #6 was admitted on May 21, 2025 and was active at the time of the licensing inspection.
Client #10 was admitted on August 19, 2024 and discharged on May 27, 2025.
Client #13 was admitted on April 14, 2025 and was still active at the time of the licensing inspection.
Client #14 was admitted on February 20, 2025 and was still active at the time of the licensing inspection.
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 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.
ED and CS 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 weekly staff meeting and individual supervision by 8/31/25.This re-education will be recorded in the meeting minutes/notes.
In order to monitor compliance with our plan of correction, the CS will be responsible for weekly supervision with direct care staff to ensure compliance. ED will supervise the CS weekly to monitor the plan of correction. Executive Director will provide updates to the Regional Director bi-weekly to ensure compliance with plan of correction.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four of six applicable records reviewed.
Client # 9 was transferred from a higher level of care on November 8, 2024 and was discharged on April 3, 2025. A treatment plan update was completed on November 21, 2024, and the next treatment plan update was due no later than January 20, 2025; however, the update was not completed until March 19, 2025.
Client # 10 was admitted on August 19, 2024 and was discharged on May 27, 2025. A treatment plan update was completed on October 16, 2024, and the next treatment plan update was due no later than December 15, 2024; however, the update was not completed until May 20, 2025.
Client # 11 was transferred from a higher level of care on October 9, 2024 and was discharged on March 24, 2025. A treatment plan update was completed on October 15, 2024, and the next treatment plan update was due no later than December 14, 2024; however, the update was not completed until January 2, 2025. The next treatment plan update was due to be completed by March 3, 2025; however, no additional treatment plan updates were completed prior to discharge.
Client # 14 was admitted on February 20, 2025 and was active at the time of the inspection. A treatment plan update was completed on April 10, 2025, and the next treatment plan update was due no later than June 9, 2025; however, the update was not completed until June 24, 2025.
This is a repeat citation from June 11, 2024, August 2, 2023, July 21, 2022, and August 30, 2021 annual licensing renewal inspections.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
A treatment plan report will be run weekly by ED that highlights clients with expired and upcoming treatment plan dates. ED will remind staff in weekly supervision of upcoming treatment plan dates so treatment plans are not missed.
If treatment plan dates are exceeded there will be a memo to chart indicating why the treatment plan could not be completed/updated prior to the expiration date.
CS will review documentation needs with counslor and identify a completion date. Any staff accumulating more than 3 outstanding treatment plans will have supervision increased to weekly to support barriers contributing to outstanding treatment plan completion.
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709.93(a)(5) LICENSURE Client records
709.93. 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.
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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 service, in four of seven records reviewed.
Client # 9 was transferred from a higher level of care on November 8, 2024 and was discharged on April 3, 2025. The record contained progress notes for individual sessions that occurred on November 21, 2024, January 28, 2025, and February 26, 2025, that were not completed until December 2, 2024, February 19, 2024, and March 14, 2025, respectively.
Client # 10 was admitted on August 19, 2024 and was discharged on May 27, 2025. The record contained progress notes for group sessions that occurred on September 17, 2024, and September 19, 2024, that were not completed until September 30, 2024. Additionally, the record contained progress notes for group sessions that occurred on October 1, 2024, and January 29, 2025, that were not completed until October 20, 2024, and March 3, 2025, respectively.
Client # 11 was transferred from a higher level of care on October 9, 2024, and was discharged on March 24, 2025. The record contained progress notes for individual sessions that occurred on January 31, 2025, and March 7, 2025, that were not completed until February 17, 2025, and March 23, 2025, respectively. Additionally, the record contained progress notes for group sessions that occurred on January 28, 2025, and February 11, 2025, that were not completed until February 12, 2025, and March 8, 2025, respectively.
Client # 14 was admitted on February 20, 2025 and was active at the time of the inspection. The record contained a progress note for an individual session that occurred on April 10, 2025, that was not completed until April 27, 2025. Additionally, the record contained progress notes for group sessions that occurred on March 20, 2025, April 3, 2025, and June 19, 2025, that were not completed until March 28, 2025, April 11, 2025, and June 30, 2025, respectively.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy is being adjusted to allow more than 24 hour completion. Broading the espectation to allow more time for completion should remedy these concerns. DAP notes will be checked at the end of each calander week by CS. |
709.93(a)(8) LICENSURE Client records
709.93. 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 and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in four of six applicable records reviewed. The facility policy manual indicates that case consultation notes will be completed every 90 days.
Client # 9 was transferred from a higher level of care on November 8, 2024 and was discharged on April 3, 2025. The first case consultation was completed in a higher level of care on November 5, 2024, and the next case consultation was due to be completed by February 3, 2025; however, the next consultation was not completed until March 19, 2025.
Client # 10 was admitted on August 19, 2024 and was discharged on May 27, 2025. The first case consultation was completed on October 15, 2024, and the next case consultation was due to be completed by January 13, 2025; however, no case consultations were completed prior to discharge.
Client # 11 was transferred from a higher level of care on October 9, 2024 and was discharged on March 24, 2025. The first case consultation was completed in a higher level of care on October 8, 2024, and the next case consultation was due to be completed by January 6, 2025; however, the next consultation was not completed until February 18, 2025.
Client # 14 was admitted on February 20, 2025 and was active at the time of the inspection. The first case consultation note was due to be completed by May 21, 2025; however, no case consultations were completed prior to the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Caseload tracking system has been implemented which highlights all due dates for all documentation. Caseload trackers will be revised during individual supervision sessions by counselor and CS. |
709.93(a)(11) LICENSURE Client records
709.93. 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 within 7 days of discharge, per facility policy, in three out of four applicable records reviewed.
Client # 9 was transferred from a higher level of care on November 8, 2024 and was discharged on April 3, 2025. The client record did not contain documentation of follow-up information.
Client # 10 was admitted on August 19, 2024 and was discharged on May 27, 2025. Follow-up information was not documented until June 16, 2025.
Client # 11 was transferred from a higher level of care on October 9, 2024 and was discharged on March 24, 2025. Follow-up information was not documented until April 11, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Once discharge plan is routed to CS for signature CS will be promted to review client records to ensure follow up call was placed. If follow up call is not documented CS will reach out to client or CS will prompt counselor to make the outreach call that day. |
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 records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to review and update treatment and rehabilitation plans at least every sixty days for clients in the outpatient activity was submitted and approved by the Department for the August 30, 2021, July 21, 2022, August 2, 2023, and the June 11, 2024 licensing inspections. Failing to review and update treatment and rehabilitation plans at least every sixty days was again found to be a deficiency in the July 9, 2025, licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Regional Director and ED will monitor the plan of correction(POC) to ensure compliance with stated plans by running weekly monitoring reports and reviewing them in weekly staff meeting. ED will review compliance weekly with CS to ensure plans of corrections are being followed.
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