INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 21, 2025 through August 22, 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee # 13 was promoted to the position of counselor assistant on September 29, 2024. Employee # 13 had a high school diploma at the time of promotion, and may counsel clients only under the direct supervision of a trained counselor or clinical supervisor for the first 3 months of employment and under close supervision for the next 9 months. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision in each week reviewed.
Close supervision is defined by regulation as follows: "Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week."
This is a repeat citation from the June 7, 2024, June 30, 2023, and July 27, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A tracker will be utilized by both the Clinical Director and Executive Director to track all counselor assistant supervisions. CD and ED will meet weekly to ensure all documentation is completed. A weekly meeting with all counselor assistants will occur until they completed all needed requirement to move to a full counselor. This meeting will occur every Friday at 12 noon with Langhorne Leadership. Person responsible Clinical Director and Executive Director. First meeting is planned for October 3rd |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that counselor assistants documented to the facility director, upon the completion of each calendar year, that they are continuing to work towards counselor status in three of three applicable personnel records reviewed.
Employee # 11 has been in the position of counselor assistant since December 24, 2023. There was no documentation to the facility director that they were working toward counselor status by the end of the 2024 calendar year as of the date of the inspection.
Employee # 12 has been in the position of counselor assistant since December 24, 2023. There was no documentation to the facility director that they were working toward counselor status by the end of the 2024 calendar year as of the date of the inspection.
Employee # 13 has been in the position of counselor assistant since September 29, 2024. There was no documentation to the facility director that they were working toward counselor status by the end of the 2024 calendar year as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
October 3rd Langhorne leadership will meet with all the counselor assistants. Review all the expectation of the role including but not limited to completing trainings, attending supervisions and observations. We will also discussed the performance evaluations and send calendar reminders for the completion of the evaluations. This will also be tracked on the counselor assistant supervision tracker. Person responsible will be: Intake supervisor and Clinical Director . Overseeing the tracker and the meeting is Executive Director.
The tracker will be utilized by both the Clinical Director, Intake Supervisor and Executive Director to track all counselor assistant supervisions. Leadership will meet weekly to ensure all documentation is completed. A weekly meeting with all counselor assistants will occur until they completed all needed requirement to move to a full counselor. This meeting will occur every Friday at 12 noon with Langhorne Leadership. Person responsible Clinical Director and Executive Director.
The plan for supervisors would include during the weekly meetings with the CA to inform and monitor the information needed to obtain counselor status. The information will be documented on the yearly training plan in the month of December of any progress with certification and education including but not limited to transcripts. Person responsible Leadership team and Executive Director.
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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 on August 22, 2025, the facility failed to keep the grounds of the facility in good repair at all times as Bedrooms 8 and 10 of the Main Building had electrical outlet boxes that were not tightly affixed to the wall. In Bedroom 8, the outlet box was hanging out of the wall several inches. In Bedroom 10, the outlet box was attached to the baseboard, which was not tightly affixed to the wall.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately following the inspection all repairs were made. To ensure the building is in good repair a monthly walkthrough will be documented on a tracker and the maintenance supervisor and a member of Langhorne Leadership will complete the walkthrough. The walk through will happen the 3rd Wednesday of the month. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection on August 22, 2025, the facility failed to ensure that exits from the residential facility were unobstructed. The emergency exit stairwell from the Lakehouse was blocked at the top and bottom of the stairs by chained signs stating " Danger Do Not Enter. "
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
the obstruction was immediately removed.
The maintenance supervisor and leadership will complete walkthroughs on a monthly basis and document on a tracker. The Assistant Director will ensure documentation. Every 2nd Wednesday of the month. (fire Saftey) a walk through will occur and any obstruction will be removed.
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705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection on August 22, 2025, the facility failed to light interior exits and stairs at all times as the light in the Farmhouse emergency exit stairwell was unlit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The light was immediately fixed .
The maintenance supervisor and leadership will complete walkthroughs on a monthly basis and document on a tracker. The Assistant Director will ensure documentation. Every 2nd Wednesday of the month. (fire Safety) a walk through will occur and any obstruction will be removed and any safety hazard will be fixed.
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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 client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in two of three applicable records reviewed. The facility failed to follow their policy related to Against Facility Advice (AFA) discharges of calling the emergency contact within twelve hours.
Client # 10 was admitted on February 18, 2025 and discharged Against Facility Advice (AFA) on March 4, 2025. The record did not contain documentation that the emergency contact was called within 12 hours.
Client # 11 was admitted on February 14, 2025 and discharged Against Facility Advice (AFA) on March 13, 2025. The record did not contain documentation that the emergency contact was called within 12 hours.
This is a repeat citation from the June 7, 2024 annual licensing renewal inspection.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Plan of correction for contacting emergency contact with in 12 hours: Retraining of staff at the all staff meeting on Oct 15,2025 by Executive Director/Clinical Director and the follow up will be managed by the Behavioral Health Manager/Nursing Manager will ensure her staff are completing calls by conducting weekly audits on all non-routine charts. |
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 one of three applicable personnel records reviewed.
Employee # 11 has been in the position of counselor assistant since December 24, 2023 and is current in that position. The annual written staff performance evaluation documented in the record was not signed by the employee as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee. To ensure all performance evaluation are conducted in a timely manner and completed by a signature the supervisors of the department will complete the yearly performance evaluation. Langhorne leadership including Assistant Director and Executive Director will review the importance of the evaluation and ensuring they are signed. This will be discussed in the next leadership meeting on Oct 3rd. All evaluation will be updated and completed by Oct 25,2025. During the During the Friday meeting with the CA it will be reviewed about the status of any upcoming performance evaluations. |
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 eleven of eleven applicable client records reviewed.
Client # 1 was admitted to the inpatient non-hospital detoxification level of care on April 13, 2025 and transferred to the inpatient non-hospital rehabilitation level of care on April 19, 2025, and was subsequently discharged on May 27, 2025. There was no documentation the client was offered a copy of the release of information form.
Client # 2 was admitted to the inpatient non-hospital detoxification level of care on February 13, 2025 and transferred to the inpatient non-hospital rehabilitation level of care on February 18, 2025, and was subsequently discharged on March 4, 2025. There was no documentation the client was offered a copy of the release of information form.
Client # 3 was admitted to the inpatient non-hospital detoxification level of care on February 13, 2025 and was discharged on February 16, 2025. There was no documentation the client was offered a copy of the release of information form.
Client # 4 was admitted to the inpatient non-hospital detoxification level of care on June 2, 2025 and was discharged on June 8, 2025. There was no documentation the client was offered a copy of the release of information form.
Client # 5 was admitted to the inpatient non-hospital detoxification level of care on November 8, 2024 and was discharged on November 11, 2024. There was no documentation the client was offered a copy of the release of information form.
Client # 6 was admitted to the inpatient non-hospital detoxification level of care on March 9, 2025 and was discharged on March 14, 2025. There was no documentation the client was offered a copy of the release of information form.
Client # 7 was admitted to the inpatient non-hospital detoxification level of care on June 18, 2025 and transferred to the inpatient non-hospital rehabilitation level of care on June 23, 2025, and was subsequently discharged on July 22, 2025. There was no documentation the client was offered a copy of the release of information form.
Client # 9 was admitted to the inpatient non-hospital rehabilitation level of care on October 10, 2024 and was discharged on November 7, 2024. There was no documentation the client was offered a copy of the release of information form.
Client # 11 was admitted to the inpatient non-hospital rehabilitation level of care on February 14, 2025 and was discharged on March 13, 2025. There was no documentation the client was offered a copy of the release of information form.
Client # 13 was admitted to the inpatient non-hospital rehabilitation level of care on July 25, 2025 and was active at the time of the inspection. There was no documentation the client was offered a copy of the release of information form.
Client # 14 was admitted to the inpatient non-hospital rehabilitation level of care on July 11, 2025 and was discharged on August 22, 2025. There was no documentation the client was offered a copy of the release of information form.
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.
Langhorne's clinical 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 Clinical Meeting on 1st Tuesday of the month. by 10/7/2025This 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project, in one of two applicable records reviewed.
Client # 5 was admitted to the inpatient non-hospital detoxification level of care on November 8, 2024 and was involuntarily discharged on November 11, 2024. The record did not contain documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
This is a repeat citation from the June 7, 2024, June 30, 2023, and July 27, 2022 annual licensing renewal inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure all staff are aware that the DMP is completed and a copy offered to the client even if they are AFAing or AMAing. This is built into the discharge plan. The clinical director will train staff on Oct 7th. The CD will complete chart audits monthly to ensure they are being completed. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on the review of the client records and discussion with facility staff, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the physical or sexual assault by staff or a client.
There was documentation of a client assault on May 27, 2025; however, there was no documentation that a written unusual incident report was ever filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
to ensure all incident report are completed. All identified staff will be trained in completing the UE, at the all staff meeting 9-10-25 the staff will review the report and how to will be completed before the shift is over for any unusual incidences. All incident report must be approved from compliance and placed on the tracker. Any report that need to be sent out to DDAP or MCO will be reviewed by compliance. Assistant Director or Executive Director will review all reports ensure compliance. |
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.
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Observations
Based on the review of client records and discussion with facility staff, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel.
There was documentation of the presence of ambulance and police personnel on November 11, 2024; however, there was no documentation that written unusual incident reports were ever filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
to ensure all incident report are completed. All identified staff will be trained in completing the UE, at the all staff meeting 9-10-25 the staff will review the report and how to will be completed before the shift is over for any unusual incidences. All incident report must be approved from compliance and placed on the tracker. Any report that need to be sent out to DDAP or MCO will be reviewed by compliance. Assistant Director or Executive Director will review all reports ensure compliance. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) 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 within seven days of discharge, per facility policy, in three of four applicable records reviewed.
Client # 3 was admitted to the inpatient non-hospital detoxification level of care on February 13, 2025 and was discharged on February 16, 2025. Follow-up information was not documented in the record until March 18, 2025.
Client # 4 was admitted to the inpatient non-hospital detoxification level of care on June 2, 2025 and was discharged on June 8, 2025. Follow-up information was not documented in the record until June 27, 2025.
Client # 5 was admitted to the inpatient non-hospital detoxification level of care on November 8, 2024 and was discharged on November 11, 2024. Follow-up information was not documented in the record until March 18, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
: The Administrative Assistant will keep track of all calls for clients that left treatment. Calls will be placed on a Follow Up Call tracker Assistant director will have over sight. This will be discussed in weekly leadership meeting to ensure compliance. AD will train the Administrative Assistant and meet with her weekly for the next two months and then move to monthly supervision.
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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 six 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 and is to be signed by more than one staff member.
Client # 8 was transferred to the inpatient non-hospital rehabilitation level of care on April 19, 2025 and was discharged on May 27, 2025. The case consultation note dated April 21, 2025, was only signed by one staff member.
Client # 10 was transferred to the inpatient non-hospital rehabilitation level of care on February 18, 2025 and was discharged on March 4, 2025. A case consultation was due no later than February 25, 2025; however, none was completed.
Client # 11 was admitted to the inpatient non-hospital rehabilitation level of care on February 14, 2025 and was discharged on March 13, 2025. The case consultation note dated February 19, 2025 was not complete.
Client # 12 was transferred to the inpatient non-hospital rehabilitation level of care on June 23, 2025 and was discharged on July 22, 2025. A case consultation was due no later than June 30, 2025; however, it was not completed until July 9, 2025.
Client # 13 was admitted to the inpatient non-hospital rehabilitation level of care on July 25, 2025 and was active at the time of the inspection. A case consultation was due no later than August 1, 2025; however, it was not completed until August 14, 2025.
Client # 14 was admitted to the inpatient non-hospital rehabilitation level of care on July 11, 2025 and was discharged on August 22, 2025. A case consultation was due no later than July 18, 2025; however, none was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will retrain her staff on the need of Case consults and the requirements surrounding case consults, this will occur on September 9th. Clinical Director will have counselor present during clinical meetings weekly and require a signature as well as complete chart audits monthly to ensure all documentation is in the chart. |
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 within seven days of discharge, per facility policy, in two of four applicable records reviewed.
Client # 9 was admitted to the inpatient non-hospital rehabilitation level of care on October 10, 2024 and was discharged on November 7, 2024. Follow-up information was not documented in the record until March 14, 2025.
Client # 10 was transferred to the inpatient non-hospital rehabilitation level of care on February 18, 2025 and was discharged on March 4, 2025. Follow-up information was not documented in the record until March 14, 2025.
This is a repeat citation from the June 7, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Assistant will keep track of all calls for clients that left treatment. Calls will be placed on a Follow Up Call tracker Assistant director will have over sight. This will be discussed in weekly leadership meeting to ensure compliance. AD will train the Administrative Assistant and meet with her weekly for the next two months and then move to monthly supervision |
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 administrative and client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for ensuring counselor assistants received required supervision was submitted and approved by the Department for the June 7, 2024, June 30, 2023, and July 27, 2022 annual licensing inspections. Ensuring required counselor assistant supervision was again found to be a deficiency in the August 21, 2025 through August 22, 2025 licensing inspection.
A plan of correction for ensuring involuntarily terminated clients receive written notification was submitted and approved by the Department for the June 7, 2024, June 30, 2023, and July 27, 2022 annual licensing inspections. Ensuring written notification was provided was again found to be a deficiency in the August 21, 2025 through August 22, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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Due having repeated citations the Regional Director will meet with Executive Director and review tracker monthly. ED and RD will review the tracker during supervision to ensure that all plan of corrections implemented and completed in a timely manner. Due by 10/25/25, ED will review monthly, the progress of all plan of corrections in the Leadership meetings. |