INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 17, 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., Monroe Outpatient, 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:
|
Plan of Correction
|
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on physical plant inspection the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room, as an individual session in office #3 could be heard clearly in group room #1, as the walls connect, at 2:33pm on July 17, 2025. The facility director was able to verify the counseling session could be heard from counselor ' s office through the walls while in the group room.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director submitted a maintenance ticket requesting installation of appropriate soundproofing materials. The soundproofing work is requested to be completed by September 29, 2025. After installation, the facility will test the room to ensure conversations can no longer be heard. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on review of administrative records, the facility failed to conduct unannounced fire dills at least once a month.
A review of fire drill log indicates an unannounced fire drill was not conducted for the months of September 2024 and February 2025.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Pyramid Stroudsburg's Safety Officer will receive re-training on fire drill requirements and the importance of conducting monthly unannounced drills during individual supervision on September 16, 2025. Documentation of this re-training will be included in the supervision note. Moving forward, the Executive Director will review the fire drill log each month to ensure that the required drills are completed and properly documented. |
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.
|
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 fourteen of fourteen client records reviewed.
Client #1 was admitted to the partial hospitalization level of care on August 8, 2024 and was discharged on September 12, 2024. The informed and voluntary consent form for the funder was signed and dated August 8th, 2024; however, there was no documentation that a copy was offered
Client #2 was admitted to the partial hospitalization level of care on April 25, 2025 and was discharged on June 26, 2025. The informed and voluntary consent form for the funder was signed and dated March24, 2025; however, there was no documentation that a copy was offered.
Client #3 was admitted to the partial hospitalization level of care on June 10, 2025 and discharged on July 7, 2025. The informed and voluntary consent form for the funder was signed and dated June 10, 2025; however, there was no documentation that a copy was offered.
Client #4 was admitted to the partial hospitalization level of care on August 14, 2024 and was discharged on September 11, 2024. The informed and voluntary consent form for the funder was signed and dated August 14, 2024; however, there was no documentation that a copy was offered.
Client #5 was admitted to the partial hospitalization level of care on July 7, 2025 and was currently active in that level of care at the time of the inspection. The informed and voluntary consent form for the funder documented in the record was signed and dated August 14, 2024, during a lower level of care; however, there was no documentation that a copy was offered or that it was updated during the change in level of care.
Client #6 was admitted to the partial hospitalization level of care on July 8, 2025 and was active at time of inspection. The informed and voluntary consent form for the funder was signed and dated July 8, 2025; however, there was no documentation that a copy was offered.
Client #7 was admitted to the partial hospitalization level of care on July 9, 2025 and was active at time of inspection. The informed and voluntary consent form for the funder was signed and dated July 9, 2025; however, there was no documentation that a copy was offered.
Client #8 was admitted to the outpatient level of care on February 28, 2025 and was active at time of inspection. The informed and voluntary consent form for the funder was signed and dated February 28, 2025; however, there was no documentation that a copy was offered.
Client #9 was admitted to the outpatient level of care on March 3, 2025 and was active at time of inspection. The informed and voluntary consent form for the funder was signed and dated March 3, 2025; however, there was no documentation that a copy was offered.
Client #10 was admitted to the outpatient level of care on February 10, 2025 and was active at time of inspection. The informed and voluntary consent form for the funder was signed and dated February 10, 2025; however, there was no documentation that a copy was offered.
Client #11 was admitted to the outpatient level of care on December 5, 2024 and was discharged June 26, 2025. The informed and voluntary consent form for the funder was signed and dated December 5, 2024; however, there was no documentation that a copy was offered.
Client #12 was admitted to the outpatient level of care on December 31, 2024 and was discharged July 1, 2025. The informed and voluntary consent form for the funder was signed and dated December 31, 2024; however, there was no documentation that a copy was offered.
Client #13 was admitted to the outpatient level of care on January 21, 2025, and was discharged on April 28, 2025. The informed and voluntary consent form for the funder was signed and dated January 21, 2025; however, there was no documentation that a copy was offered.
Client #14 was admitted to the outpatient level of care on December 18, 2024 and was discharged June 6, 2025. The informed and voluntary consent form for the funder was signed and dated December 18, 2024; however, there was no documentation that a copy was offered.
These findings were reviewed with facility staff during the licensing process.
|
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, including current clients, Clinical Supervisor will be responsible for ensuring completion of the Consent for Treatment, Payment and Healthcare Operations consent with those clients and offering a copy. Clinical Supervisor will have all updated TPO consents completed by September 29th, 2025.
Executive Director 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 the weekly staff meeting by September 29, 2025. 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.
|
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on review of administrative paperwork, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
A review of the facility ' s unusual incident log indicated on July 21, 2025, that emergency medical services were present at the facility for a client to be assessed for treatment; there was no documentation this event was reported to the Department.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director will complete re-training on proper procedures for documenting and reporting unusual incidents to ensure compliance with all regulatory timelines. This training will be assigned through Pyramid's Relias training system by the Training Specialist and will be completed by September 29, 2025. Upon completion, the Executive Director will report to the Regional Director. |
709.83(a)(9) LICENSURE Client records
709.83. 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:
(9) Progress notes.
|
Observations
Based on a review of partial hospitalization client records, the facility failed to follow their written procedure to complete progress notes within 24 hours of a counseling session in three out of seven records reviewed.
Client #2 was admitted to the partial hospitalization program on April 25, 2025 and discharged on June 26, 2025. The record identified group sessions that occurred on May 8, 2025, May 12, 2025, May 16, 2025, and June 6, 2025, were not documented until June 20, 2025, May 19, 2025, June 10, 2025, June 23, 2025 respectively.
Client #5 was admitted to the partial hospitalization program on July 07, 2025, and was still active at the time of the inspection. The record identified a group session occurring on July 10, 2025, that was not documented until July 15, 2025.
Client #7 was admitted to the partial hospitalization program on July 09, 2025 and was still active at the time of the inspection. The record identified an individual session occurring on July 11, 2025, that was not documented until July 14, 2025. Additionally, the record contained a group session occurring on July 10, 2025, that was not completed until July 15, 2025.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Pyramid policy is being updated to extend the allowable time for DAP note completion beyond the current 24-hour limit. This adjustment is intended to address existing concerns by providing additional flexibility. By September 29, 2025, Executive Director will retrain staff on the completion of documentation within internal documentation timeline standards. DAP notes will be reviewed at the end of each calendar week by the Clinical Supervisor and/or Executive Director. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on review of client records the facility failed to following individual treatment according to treatment plan.
Client #8 was admitted to the outpatient program on February 28, 2025 and still active at the time of the inspection. The initial treatment plan dated March 6, 2025 indicated daily individual treatment sessions. There was no documentation that the client received daily individual treatment sessions for the weeks of March 9-15, March 16-22, March23-29, March 30-April 5, April 6-12, April 13-19, April 20-26 and April 27-May 3, 2025.
Client #9 was admitted to the outpatient program on March 3, 2025 and was still active at the time of the inspection. The individual treatment plan dated March 19, 2025 indicated biweekly individual treatment sessions. There was no documentation that the client received individual treatment sessions biweekly for the weeks of April 6-12, April 13-19, April 20-26, April 27-May 3, May 4-10, May 11-17; in addition the individual treatment plan dated May 21, 2025 indicated individual treatment sessions biweekly; however, there is no documentation the client received biweekly treatment sessions May 18-24, May 25-31, and June 1-7, 2025.
Client #10 was admitted to the outpatient program on February 10, 2025 and still active at the time of the inspection. The individual treatment plan dated February 18, 2025 indicated weekly individual treatment sessions. There was no documentation that the client received individual treatment sessions weekly for the weeks of February 23-March 1, March 9-15, March 23-29, 2025; in addition the individual treatment plan dated April 1, 2025 indicated individual treatment sessions weekly; however there is no indication that the client received individual treatment sessions for the weeks of April 6-12, April 20-26, April 27-May 3, May 4-10, May 11-17, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 12, 2024, August 29, 2023, and August 22, 2022 licensing inspections.
|
Plan of Correction
The Clinical Supervisor will facilitate a group supervision session focused on strategies for engaging clients in attending treatment as outlined in their collaboratively developed treatment plans on September 29th, 2025. Additionally, the Clinical Supervisor will review and confirm that the frequency of services specified in each treatment plan is consistent with state regulations and county funder requirements prior to approving and signing the plan. Clinical Supervisor will also review with the Clinical staff on the importance of making more frequent follow up and outreach calls and outreach correspondence. This will be documented in the group supervision note. Counselors will be responsible for contacting their clients and logging their outreach attempts via a call log or memo to chart in the Carelogic EMR System. Executive Director will monitor this process weekly and will complete any follow up missed. |
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.
|
Observations
Based on a review of outpatient client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project, that included progress notes completed within 24 hours of a session, per facility policy in four of seven records reviewed.
Client #9 was admitted to the outpatient program on March 03, 2025 and was active at the time of the inspection. The record contained a progress notes for individual sessions occurring on March 11, 2025, and March 18, 2025, that were not completed until March 13, 2025, and March 23, 2025, respectively. Additionally, the record contained a progress note for a group session occurring on March 19, 2025, that was not documented until March 23, 2025.
Client #11 was admitted to the outpatient program on December 5, 2024 and was discharged on June 26, 2025. The record contained a progress note for an individual session occurring on March 21, 2025, that was not completed until March 23, 2025. Additionally, the record contained progress notes for group sessions occurring on December 13, 2024, December 27, 2024, February 14, 2025, March 21, 2025, March 28, 2025, April 4, 2025, April 11, 2025, April 25, 2025, and May 16, 2025 that were not completed until December 16, 2024, December 30, 2024, February 17, 2025, March 23, 2025, March 31, 2025, April 6, 2025, April 14, 2025, April 28, 2025 and May 18, 2025, respectively.
Client #12 was admitted to the outpatient program on December 31, 2024, and was discharged on July 01, 2025. The record contained a progress note for an individual session occurring on March 21, 2025, that was not completed until March 23, 2025. Additionally, the record contained progress notes for group sessions occurring on January 05, 2025, February 02, 2025, February 09, 2025, February 11, 2025, February 16, 2025, February 25, 2025, March 02, 2025, April 27, 2025, May 25, 2025, June 08, 2025, June 15, 2025, that were not completed until January 11, 2025, February 08, 2025, February 15, 2025, February 13, 2025, February 22, 2025, March 23, 2025, March 08, 2025, May 03, 2025, May 31, 2025, June 14, 2025, and June 21, 2025, respectively.
Client #14 was admitted to the outpatient program on December 18, 2024 and was discharged on June 06, 2025. The record contained progress notes for group sessions occurring on February 14, 2025, March 21, 2025, March 28, 2025, April 04, 2025, April 11, 2025, and May 16, 2025, that were not completed until February 17, 2025, March 23, 2025, March 31, 2025, April 06, 2025, April 14, 2025, and May 18, 2025, respectively
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Pyramid policy is being updated to extend the allowable time for DAP note completion beyond the current 24-hour limit. This adjustment is intended to address existing concerns by providing additional flexibility. By September 29, 2025, Executive Director will retrain staff on the completion of documentation within internal documentation timeline standards. DAP notes will be reviewed at the end of each calendar week by the Clinical Supervisor and/or Executive Director. |
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.
|
Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project, including follow up information within 7 days, per facility policy, in one out of four discharged records reviewed.
Client #14 was admitted on December 18, 2024 and discharged on June 6, 2025. The follow up call was due by June 13, 2025; however, the follow up call was not done until July 8, 2025. (always write out dates)
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Discharge plans are routed to the Clinical Supervisor for signature, the Clinical Supervisor will add their discharge date and anticipated date of the 7-day follow up call to our internal caseload/client tracker. Each staff member will also receive a list of their clients who require follow-up contact weekly in clinical staff meetings.
If no follow-up call is documented, the CS will either contact the client directly or instruct the assigned counselor to complete the call that same day. The Clinical Supervisor will also review the importance of follow-up and outreach calls with the clinical team. All staff will be re-trained on this process during group supervision, and the training will be documented in the group supervision note on September 29th 2025. Executive Director will review counselor discharge list weekly to ensure proper follow up.
|
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.
|
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 assuring that counseling services are provided according to the individual treatment and rehabilitation plan was submitted and approved by the Department for the July 12, 2024, August 29, 2023, and August 22, 2022, annual licensing inspections. Following treatment according to treatment plan was again found to be a deficiency in the July 17, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director will take responsibility for monitoring the implementation of all active Plans of Correction. The Executive Director will complete monthly audits of clinical records to ensure services are delivered in accordance with treatment plans. To assure counseling sessions are provided in accordance to a client's individual treatment plan group supervision will take place by September 29th, 2025 and this will documented in a group supervision note. Counselors will be responsible for documenting any changes to a client's treatment focus in a memo to chart within the EMR, and for updating the treatment plan accordingly. |