INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11, 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level per the facility ' s policy and procedures manual in five out of nine employee records reviewed. The facility ' s policy and procedures manual states that the annual individual training plan is due by December 31.
Employee # 4 has been in the position of counselor since June 16, 2025. Employee # 4 should have had an initial individual training plan developed within 30 days of the date of hire; however, a written individual training plan was not developed until July 22, 2025.
Employee # 5 has been in the position of counselor since June 16, 2025. Employee # 4 should have had an initial individual training plan developed within 30 days of the date of hire; however, a written individual training plan was not developed as of the date of the inspection.
Employee # 6 has been in the position of counselor since May 26, 2025. Employee # 6 should have had an initial individual training plan developed within 30 days of the date of hire; however, a written individual training plan was not developed as of the date of the inspection.
Employee # 7 has been in the position of counselor since August 26, 2024. Employee # 4 should have had an initial individual training plan developed within 30 days of the date of hire; however, a written individual training plan was not developed until December 31, 2024.
Employee # 9 has been in the position of counselor since March 28, 2024. The annual individual training plan documented in the record was dated July 22, 2025.
This is a repeat citation from the June 4, 2024 annual licensing renewal inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will track training plan completion via Smartsheet, which will be audited weekly beginning 9/1/2025.
Program Director will review expectation to submit Individual Training Plans for new staff within the first two weeks of hire and ensure they are uploaded to Relias with leadership team during leadership meeting on 9/9/2025 . Training Plans will be renewed annually, due by 12/31 of each year. Program Director will maintain oversight of Training Plan submissions by deadline via running Relias reports.
Program Director will have Onboarding/Training tracker up to date by 9/30/2025 and will continue weekly audits with communication to leadership team regarding outstanding training plans.
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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 seven applicable employees received a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee # 8 has been in the position of counselor since April 14, 2024. Employee # 8 was due to have the communicable disease trainings no later than April 14, 2025; however, the TB/STD training was not completed as of the date of the inspection.
Employee # 9 has been in the position of counselor since March 28, 2024. Employee # 9 was due to have the communicable disease trainings no later than March 28, 2025; however, the HIV/AIDS training was not completed until July 22, 2025, and the TB/STD training was not completed as of the date of the inspection.
Employee # 10 has been in the position of BHT Tech Supervisor since October 25, 2021. Employee # 10 was due to have the communicable disease trainings no later than December 31, 2024, per the Department approved plan of correction for the June 5, 2024 annual licensing renewal inspection. However, the TB/STD training was not completed as of the date of the inspection.
Employee # 11 has been in the position of BHT Tech since October 4, 2021. Employee # 11 was due to have the communicable disease trainings no later than December 31, 2024, per the Department approved plan of correction for the June 5, 2024 annual licensing renewal inspection. However, the TB/STD training was not completed as of the date of the inspection.
Employee # 12 has been in the position of case manager since March 20, 2023. Employee # 12 was due to have the communicable disease trainings no later than March 20, 2025; however, the TB/STD training was not completed as of the date of the inspection.
Employee # 13 has been in the position of BHT Tech since November 11, 2019. Employee # 13 was due to have the communicable disease trainings no later than December 31, 2024, per the Department approved plan of correction for the June 5, 2024 annual licensing renewal inspection. However, the TB/STD training was not completed until April 10, 2025.
Employee # 14 has been in the position of BHT Tech Supervisor since August 1, 2022. Employee # 14 was due to have the communicable disease trainings no later than December 31, 2024, per the Department approved plan of correction for the June 5, 2024 annual licensing renewal inspection. However, the TB/STD training was not completed as of the date of the inspection.
This is a repeat citation from the June 5, 2024 and July 19, 2023 annual licensing renewal inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review expectation of having all mandatory DDAP trainings completed (for on-demand trainings) and registered for (for live trainings) as a part of employee onboarding plan within the first 2 weeks of hire for dietary, maintenance, and clinical staff, and first month of hire for BHT Staff during leadership meeting on 9/2/2025.
Training compliance to be reviewed monthly in leadership meetings moving forward, results of weekly audit from Program Director as well as Relias Training Reports will be reviewed in these monthly meetings.
All staff with outstanding DDAP required trainings will have these trainings completed by January 1, 2026.
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure CPR certification and first aid training are provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
There was no documentation that 3rd shift staff had CPR certification on May 13, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director to include CPR Certification due dates in weekly training audit beginning week of 9/9/25.
Upcoming due dates to be reviewed in monthly Training Review meeting with leadership team by Program Director.
BHT Manager to ensure that there is at least one CPR Certified employee scheduled on each shift effective 9/9/2025.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the facility director.
Employee # 2 has been in the position of facility director since July 23, 2023. The facility's training year that was reviewed was from January 1, 2024 through December 31, 2024. Employee # 2's personnel record only documented 5.25 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director to Review Relias transcript monthly to ensure training hour requirements are being met. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure that frozen food was kept at or below 0 degrees, as the temperature for freezers # 1 and # 11 was measured at 10 degrees.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Dietary Supervisor to maintain temperature logs daily, escalate any discrepancies in temperature readings from regulatory guidelines to maintenance supervisor and facility director in real time to ensure resolution of discrepancy. Issue with freezers resolved week of 8/18/2025. |
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 one of two applicable records reviewed. The facility failed to follow their policy related to AFA discharges of calling the Emergency Contact within twelve hours.
Client # 6 was admitted on June 9, 2025 and discharged Against Facility Advice (AFA) on July 15, 2025. The record did not contain documentation that the emergency contact was called.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Clinical Director to complete chart reviews for non-routine discharges within 24 hours to ensure there is documentation regarding contact with emergency contact (if present) within 12 hours of the clients departure.
Program Director sent all-staff email on 8/25/25 informing staff the expectation to call emergency contact for all non-routing discharges, will monitor charts in addition to Clinical Director through December 31st, 2025 to ensure compliance.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that personnel records contained an annual written performance evaluation that was reviewed and signed by the employee in two of five applicable personnel records reviewed.
Employee # 2 has been in the position of facility director since July 23, 2023 and is current in that position. There was not an annual written individual staff performance evaluation which was reviewed and signed by the employee in the record at the time of the inspection.
Employee # 9 has been in the position of counselor since March 28, 2024 and is current in that position. There was not an annual written individual staff performance evaluation which was reviewed and signed by the employee in the record at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Managers will ensure compliance with this effort via accessing employee evaluations on UKG and ensuring all appropriate signatures are in place. Program Director will collaborate with HR team in obtaining report for any outstanding signatures/employee evaluations and follow up with individual staff members to ensure compliance. |
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.
Client # 1 was admitted on July 2, 2025 and was active at the time of the inspection. There was no documentation a copy was offered in the record.
Client # 2 was admitted on July 15, 2025 and was active at the time of the inspection. There was no documentation a copy was offered in the record.
Client # 3 was admitted on July 8, 2025 and was active at the time of the inspection. There was no documentation a copy was offered in the record.
Client # 4 was admitted on April 17, 2025 and was discharged on June 6, 2025. There was no documentation a copy was offered in the record.
Client # 5 was admitted on November 8, 2024 and was discharged on December 5, 2024. There was no documentation a copy was offered in the record.
Client # 6 was admitted on June 9, 2025 and was discharged on July 15, 2025. There was no documentation a copy was offered in the record.
Client # 7 was admitted on March 9, 2025 and was discharged on March 26, 2025. There was no documentation a copy was offered in the record.
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.
Facility leadership 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 a memo to chart on the date of review with the client. 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 supervision with direct care staff to ensure compliance. Executive Director will supervise the Clinical Supervisor 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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709.51(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 policies and procedures, the facility failed to document a psychosocial evaluation within 24 hours of admission or transfer from higher level of care, per facility policy, in five of seven records reviewed.
Client # 1 was admitted on July 2, 2025 and was active at the time of the inspection. The psychosocial evaluation was not completed until July 23, 2025.
Client # 2 was admitted on July 15, 2025 and was active at the time of the inspection. The psychosocial evaluation was not completed until July 25, 2025.
Client # 3 was admitted on July 8, 2025 and was active at the time of the inspection. The psychosocial evaluation was not completed until July 17, 2025.
Client # 5 was admitted on November 8, 2024 and was discharged on December 5, 2024. The record did not contain a psychosocial evaluation.
Client # 7 was admitted on March 9, 2025 and was discharged on March 26, 2025. The record did not contain a psychosocial evaluation.
This is a repeat citation from the June 5, 2024 annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility tracking form was established prior to 2025 DDAP audit. Program director to complete weekly audits of level of care assessments to ensure compliance within policy timeline of being completed within 24 hours of admission. Clinical Director to maintain monitoring and tracking on facility tracking form daily to ensure compliance. Program Director to send email to clinical team ensuring they are aware of this expectation on 9/5/2025. |
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 on July 2, 2025 and was active at the time of the inspection. The treatment plan completed on July 3, 2025, indicated that the client was to receive one individual session per week; however, the record did not document individual sessions offered between July 11, 2025 through July 31, 2025.
Client # 2 was admitted on July 15, 2025 and was active at the time of the inspection. The treatment plan completed on July 18, 2025, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session between July 18, 2025 and August 2, 2025.
Client # 4 was admitted on April 17, 2025 and was discharged on June 6, 2025. The treatment plans completed on April 29, 2025, and May 13, 2025, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session between May 7, 2025 and May 19, 2025.
Client # 6 was admitted on June 9, 2025 and was discharged on July 15, 2025. The treatment plan completed on June 11, 2025, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session between June 24, 2025 and July 6, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Plans will be reviewed daily by Clinical Director in treatment team meeting, outlining all expiring treatment plans, as well as initial treatment plans needing to be completed in the next 72 hours. Clinical Director will monitor charts individually to maintain oversight and accountability to these actions. Clinical Director to communicate with individual counselors as well as the clinical team during group supervision outlining the expectations that weekly individual sessions take place and are connected with treatment plan goals. Clinical Director to review DAP notes on a weekly basis to ensure treatment plan goals are being spoken to regarding progress or noncompliance in this area between clinician and client. Program Director to complete weekly audit to ensure completion, and will utilize weekly report outlining compliance with documentation of individual sessions for ongoing assessment. In the event that the client is unable to attend session or refuses session, this will be documented in a memo to chart. |
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 three out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed within seven days following admission.
Client # 2 was admitted on July 15, 2025 and was active at the time of the inspection. A case consultation was due no later than July 22, 2025; however, none was completed.
Client # 4 was admitted on April 17, 2025 and was discharged on June 6, 2025. A case consultation was due no later than April 24, 2025; however, it was not completed until June 6, 2025.
Client # 7 was admitted on March 9, 2025 and was discharged on March 26, 2025. A case consultation was due no later than March 16, 2025; however, it was not completed until March 26, 2025.
This is a repeat citation from the June 5, 2024 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 utilize intake tracking form for all new admissions to monitor oversight for case consultation completion, and communicate with the clinical team the requirement to complete initial case consultations within 7 days of client admission will take place during clinical supervision on 9/17/2025. |
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 three applicable records reviewed.
Client # 4 was admitted on April 17, 2025 and was discharged on June 6, 2025. The record did not contain documentation of follow-up information.
Client # 6 was admitted on June 9, 2025 and was discharged on July 15, 2025. The record did not contain documentation of follow-up information.
Client # 7 was admitted on March 9, 2025 and was discharged on March 26, 2025. The record did not contain documentation of follow-up information.
This is a repeat citation from the June 5, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director to establish tracking form effective 9/15/25 to ensure communication with discharging clients takes place and will maintain oversight of this. Case Managers to be responsible for obtaining up to date contact information for discharging clients and will document follow up call attempts made in the client record. |
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 and personnel records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction for mandatory communicable disease training was submitted and approved by the Department for the June 5, 2024, and July 19, 2023, annual licensing renewal inspections. Mandatory communicable disease trainings were again found to be a deficiency in the August 11, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In order to monitor compliance with our plan of correction, the Clinical Supervisor will be responsible for weekly supervision with direct care staff to ensure compliance. Executive Director will supervise the Clinical Supervisor 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 |