INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on April 29-30, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pyramid Healthcare, Inc. 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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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 patient records and the Discharge and Transfer Criteria policy, the facility failed to follow its written procedures for the management of treatment and rehabilitation services.Per the Discharge and Transfer Criteria policy, successful discharge status requires four out of five criteria to be met for the correlating level of care the patient is currently discharging from. The requirements for successful or partially successful discharge status for 3.7 WD are symptomology reduction based on CIWA/COWS, and other routinely administered assessments, patient has met recommended length of stay based on ASAM criteria, linked to recommended ongoing services, clinical impression of patient progress as determined by treatment team, and abstinence from substance use as confirmed by UDS, self-report, or observation. If the patient is discharged Against Medical Advice, the patient elects to leave treatment before medically or psychiatrically stable. Patient # 2 was admitted on January 4, 2026, and discharged on January 7, 2026. An assessment dated January 7, 2026, indicates the patient is successfully discharged due to being stable to participate in programming and medically cleared. The Medical Discharge Summary dated 1/7/26 indicates the patient was discharged Against Medical Advice. Documentation of the patient being medically cleared to complete detoxification services is missing from the patient record.Patient # 5 was admitted on April 23, 2026, and discharged on April 27, 2026. An assessment dated April 27, 2026, indicates the patient has been medically cleared and is successfully discharged. The Medical Department Discharge Summary dated April 27, 2026, indicates the patient was discharged Against Medical Advice. Documentation of the patient being medically cleared to complete detoxification services is missing from the patient record.
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Plan of Correction
The facility will ensure compliance with 709.24(a)(3) through the following corrective actions:
- Systemic Changes Implemented:
Applicable staff have received additional review of discharge documentation requirements, including the need for consistency among discharge status, medical clearance, and supporting clinical documentation.
- Interdisciplinary communication processes have been reinforced prior to discharge to support accurate discharge status determinations. This includes ongoing communication among medical, nursing, clinical, and case management staff regarding the client's presentation, treatment progress, and discharge readiness.
- Staff Training:
Clinical, medical, and intake leadership staff have been educated on discharge criteria, discharge status documentation, medical clearance expectations, and the requirement to elevate identified discrepancies for leadership review.
- Monitoring:
Leadership will conduct ongoing review of discharge documentation to verify alignment of discharge status, medical clearance, and supporting clinical documentation, and will address identified discrepancies through follow-up coaching or corrective action, as appropriate.
- Responsible Party:
Clinical Supervisors, Clinical Director, Nurse Manager
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709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
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Observations
Based on a review of employee records, administrative documentation, and the Compliance Handbook, the facility failed to follow personnel policies and procedures which include rules of conduct.Per the Compliance Handbook, employees who are responsible for documenting patient records, accounting and financial records or other business records are expected to perform their duties accurately, truthfully, completely and in a timely manner.Employee # 2 was hired on February 20, 2023, as a Clinical Supervisor and is currently the Director of Intake for Withdrawal Management. Internal investigation documentation substantiated an allegation of completing online training under another employee's credentials.Employee # 4 was hired on October 3, 2025, as a counselor, and was terminated on March 6, 2026. Internal investigation documentation substantiated an allegation of falsification of patient signatures.
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Plan of Correction
The facility will ensure compliance with 709.26(a)(2) through the following corrective actions:
Systemic Changes Implemented:
- The facility conducted internal investigations into the identified incidents and addressed inaccurate or falsified records, including training documentation, through correction and/or removal as appropriate.
- Expectations related to proper use of employee credentials and accurate, truthful, and complete documentation have been reinforced with staff.
- Leadership has reinforced that employees may only complete trainings under their own credentials and are responsible for ensuring all documentation and business records are accurate, truthful, and complete.
- Retraining has occurred with leadership staff that at no time should employee usernames or passwords be requested from staff, and/or saved, in order to eliminate the possibility of training being completed by anyone other than the assigned employee.
Staff Training:
- Applicable staff will receive retraining on the Compliance Handbook and Code of Conduct, including expectations related to:
o Accurate, truthful, and complete documentation
o Appropriate use of system access credentials
- Retraining will occur on or before 6/30/2026 and will be evidenced by training completion records and leadership meeting minutes
Leadership Oversight / Compliance Reinforcement:
- Leadership team members will attend mandatory compliance meetings to:
o Review staff training completion timelines
o Ensure training reports have been reviewed for accuracy and honesty
o Reinforce expectations related to Rules of Conduct and documentation standards
- Meeting minutes will document reinforcement of expectations, including the prohibition of completing trainings under another employee's credentials
Monitoring:
- Leadership will conduct ongoing review of training completion records and documentation practices to verify adherence to Rules of Conduct
- Leadership will ensure that all documentation and training records are accurate, truthful, and completed by the appropriate individual
- Identified discrepancies will be addressed through follow-up coaching or corrective action, as appropriate
Responsible Party:
Executive Director, Human Resources |
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 employee records, the facility failed to include annual written individual staff performance evaluations, copies of which will be reviewed and signed by the employee. Employee # 1 was hired on October 22, 2018, as a Behavioral Health Technician, and is currently an Intake Coordinator. The Annual Performance Evaluation ' s dated 8/1/23, 7/15/24, and 9/15/25 are incomplete.Employee # 2 was hired on February 20, 2023, as a Clinical Supervisor and is currently the Director of Intake for Withdrawal Management. The Annual Performance Evaluation dated 9/15/25 is incomplete.Employee # 3 was hired on August 22, 2022, as a Case Manager, and is currently a Housekeeper. The Annual Performance Evaluation dated 7/15/24 is incomplete.
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Plan of Correction
The facility will ensure compliance with 709.26(b)(3) through the following corrective actions:
- Systemic Changes Implemented:
The facility has initiated review of the specific personnel files cited to ensure missing annual written performance evaluations are completed, reviewed with the employee, and signed as required.
- A tracking process will be established during Pyramid Healthcare's annual evaluation period to support weekly review of evaluation completion by department heads, with oversight by the leadership team, to promote timely compliance.
- Staff Training:
Supervisory staff will receive retraining on annual performance evaluation requirements, including completion standards, submission timelines, and documentation expectations.
- Monitoring:
Throughout the annual evaluation period, which typically occurs on or around October of each year, department heads will be required to provide the Executive Director with status updates during weekly leadership meetings regarding completion of employee evaluations. Leadership will review progress and address overdue evaluations through follow-up with responsible supervisors.
- Responsible Party:
All members of the facility's senior level leadership team, which includes but not limited to, BHT Manager, Office Manager, Clinical Director, Associate Director, Director of Intake and Client Care, Nurse Manager and Executive Director.
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