INITIAL COMMENTS
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This report is a result of on-site complaint investigations conducted on June 25, 2025 and October 28, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pyramid Healthcare Inc. - Pyramid Pittsburgh was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to maintain the grounds clean, safe, sanitary and in good repair at all times.During the physical plant inspection that was conducted on October 28, 2025, a black substance and dirt was observed on and around the windows and blinds in the dining room.These findings were reviewed with facility staff during the onsite complaint investigation.
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Plan of Correction
The blinds identified in the dining room were replaced by 11/10/25. All blinds will be replaced by 2/1/26. Blinds were a monthly cleaning task, they were moved to weekly cleaning. Housekeeping staff are responsible for the weekly cleaning. They will document it on their cleaning checklist, which is monitoring by the Housekeeping Supervisor. Periodic checks will also be conducted by Associate Executive Director to ensure the schedule is being followed and documented appropriately. |
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.
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Observations
Based on a review of client records, the facility failed to document progress notes in one of one client records.Client #1 was admitted to inpatient rehabilitation on August 12, 2025 and discharged on August 18, 2025. There were no individual or group progress notes documented for client #1.These findings were reviewed with facility staff during the onsite complaint investigation.
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Plan of Correction
The primary counselor for the client referenced is no longer with the company. Chart audits are completed weekly for all counselors by facility Associate Executive Director to address documentation deficiency. Clinical Director will begin checking documentation daily for all clinicians to address progress notes not being completed within 24 hours of the service provided, beginning 2/2/26. These reviews will be an effort to monitor compliance with progress note completion. Clinicians will received an email notification daily of outstanding documentation. Trends will be reviewed during monthly supervisions and supervisions may be increased if needed. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in one of one client records.Client #1 was admitted to inpatient rehabilitation on August 12, 2025 and discharged on August 18, 2025. There was no discharge summary documented for client #1.These findings were reviewed with facility staff during the onsite complaint investigation.
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Plan of Correction
The primary counselor for the client referenced is no longer with the company. Clinical Director will begin reviewing all discharge summaries for completion and quality beginning 2/2/26. These reviews will be conducted daily for all residential clients. Follow ups for any missing or significant quality issues will be sent to the counselor immediately and followed up on the following day. If there are quality issues that do not require immediate attention will be addressed at monthly supervision. |
709.15(b) LICENSURE Subchapter B.Licensing Procedures.Right to en
709.15. Right to enter and inspect.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
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Observations
Based on a review of administrative documentation and staff interview, the facility failed to provide full and free access to the records of the facility.While onsite at the facility on October 28, 2025, DDAP staff requested documentation regarding a power outage at the facility resulting in need for emergency lighting. The documentation was not available at the time of the onsite complaint investigation. The Facility Director agreed to send the requested documentation to DDAP staff via email and a deadline of October 30, 2025 was established. After the documentation was not received by the deadline, the docuementation was again requested by DDAP staff. To date, the requested documentation was not provided to DDAP staff.
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Plan of Correction
Failure to provide requested documentation was due to an internal communication breakdown. Below you will find the requested documentation. Going forward, the following internal communication process has been established to ensure timely response/submission of the requested documentation/information because of an audit. Site Leadership will apprise quality management and compliance departments of audit outcomes, if they were not already included in exit interviews of findings, so they can track required follow-up action steps and deadlines for completion/submission as well as collaborate with additional internal departments as appropriate.
7:00 pm - Outage begins at PPIP. Emergency lighting turned on
7:10 pm ? Kenny (Maintenance Manager) arrived onsite to provide support. Original Generator overheated and was shut down. Emergency lighting turned off
7:30 pm ? Maintenance/Facilities leadership reached out for extra maintenance and facilities support.
8:30 pm - George/Steve (Regional Facilities): Supplies were brought to the location ? Flashlights, Lanterns.
9:30 pm ? Maintenance Manager from West Virginia his site to bring a 5500-kw generator to PPIP ? Generator supplied hallway, outside and exit lights.
11:00 pm ? Clients went to bed.
12:00 am ? The generator arrived at PPIP.
12:30 am - Core 24 arrived to drop off a second generator. Generator 1 was connected to the building.
5:00 am ? Power returned to the building.
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