INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26, 2025 through June 27, 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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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 seventeen of seventeen client records reviewed.
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.
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 staff meeting on 8.7.2025. This re-education will be recorded in the meeting minutes/notes.
In order to monitor compliance with our plan of correction, the Executive Director will be responsible for monthly supervision with direct care staff to ensure compliance. Executive Director will provide updates to the Regional Director monthly to ensure compliance with plan of correction. |
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 the review of outpatient client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in two of six applicable records reviewed.
Client #14 was admitted on August 2, 2024, and was discharged on March 14, 2025. An updated treatment and rehabilitation plan was documented in the record on November 8, 2024, with the next update due no later than January 8, 2025; however, there was no updated treatment and rehabilitation plans documented in the client record until January 23, 2025.
Client #17 was admitted on September 26, 2024, and was discharged on February 10, 2025. An updated comprehensive treatment and rehabilitation plan was documented in the record on October 7, 2024, with the updated treatment and rehabilitation plans due no later than December 7, 2024; however, there were no updated treatment and rehabilitation plans documented in the client record until January 9, 2025.
This is a repeat citation from the July 30, 2024 and July 20, 2023 annual licensing renewal inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Counselors were reeducated, 7.24.2025, on the use of their case trackers to monitor due dates of treatment plan reviews. Counselors will review these daily to ensure that they are completing reviews as needed and by their due dates. ED will review case trackers in supervisions and discuss barriers to completing treatment plans with any clients. Administrative Assistant will utilize Treatment Plan Compliance Report bi-weekly to ensure clients have active treatment plans. Upcoming treatment plans will be reviewed in monthly staff meetings. Date: 7.24.2025 |
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.
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Observations
Based on a review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in three of eight applicable client records reviewed.
Client #13 was admitted on December 10, 2024, and was discharged on April 23, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on December 19, 2024, indicated that the client was to receive one group counseling session per week; however, there were no group counseling sessions documented in the client record for the weeks of December 22, 2024 through December 28, 2024 and December 29, 2024 through January 4, 2025.
Client #15 was admitted on December 9, 2024, and was discharged on May 15, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on December 9, 2024, indicated that the client was to receive one group counseling session per week; however, there were no group counseling sessions documented in the client record for the weeks of December 22, 2024 through December 28, 2024 and December 29, 2024 through January 4, 2025.
Client #16 was admitted on August 29, 2024, and was discharged on January 27, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on September 5, 2024, indicated that the client was to receive one group counseling session per week; however, there were no group counseling sessions documented in the client record for the weeks of December 22, 2024 through December 28, 2024 and December 29, 2024 through January 4, 2025.
This is a repeat citation from the July 30, 2024 and July 20, 2023 annual licensing renewal inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Counselors were reeducated, 7.24.2025, on ensuring clients are provided services as stated on their treatment plan, even when holidays fall on scheduled group days. In the event of this occurring, for instance, Christmas, clients will be offered a make-up service. Staff will also document in the chart the group that was missed for this holiday and include the make-up date/service offered. Date 7.24.2025 |
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 entered every 90 days, per the facility's policy, in three of eight applicable records reviewed.
Client #13 was admitted on December 10, 2024, and was discharged on April 23, 2025. A case consultation note was not documented in the record within 90 days of the date of service, per the facility's policy.
Client #15 was admitted on December 9, 2024, and was discharged on May 15, 2025. A case consultation note was not documented in the record within 90 days of the date of service, per the facility's policy.
Client #16 was admitted on August 29, 2024, and was discharged on January 27, 2025. A case consultation note was not documented in the record within 90 days of the date of service, per the facility's policy.
This is a repeat citation from the July 30, 2024 annual licensing renewal inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Counselors were reeducated, 7.24.2025, on the importance of case consults and will ensure all case consults occur within 90 days of client's admission. All staff were educated on the importance of signing documents daily, specifically case consults, in staff meeting on 7/24/2025. Counselors will maintain a case tracker for all clients that highlight upcoming due dates for documentation to ensure compliance. They will check these daily to ensure completion of case consults.
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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 corrections that were approved by the Department.
A plan of correction for updating and reviewing the treatment and rehabilitation plan every 60 days was submitted and approved by the Department for the July 30, 2024, and July 20, 2023, annual licensing inspections. Updating and reviewing the treatment and rehabilitation plan every 60 days was again found to be a deficiency in the June 27, 2025, licensing inspection.
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 30, 2024, and July 20, 2023, annual licensing inspections. Assuring that counseling services are provided according to the individual treatment and rehabilitation plan was again found to be a deficiency in the June 27, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to monitor compliance with our plan of corrections, Executive Director will maintain supervision with clinicians where case trackers are reviewed as well as dates of upcoming treatment plans. Executive Director will also utilize the report ran by the AA and review in all staff meetings of any client needing treatment plan review to ensure staff are aware of upcoming due dates. AA will provide this report to ED bi-weekly. Executive Director will provide updates to Regional Director on compliance will plan of correction in monthly supervision. |