INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 9, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, St. Joseph Institute, LLC, 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of administrative information, the facility failed to collect feedback on completed trainings.
The facility policy and procedures state that feedback is to be collected for completed trainings, both internal and external.
The training year beginning January 1, 2024, through December 31, 2024, was reviewed, and feedback was not collected for any external trainings.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility will implement a post-training evaluation process to collect staff feedback following required HealthStream trainings. Completion of this feedback form will be mandatory for staff to receive continuing education credit for required trainings.
Summit BHC's Director of Learning and Development has reviewed options for incorporating evaluation functionality within the virtual HealthStream platform. The function is to go live by February 28th, 2026.
The Director of Human Resources will conduct an audit of all first-quarter 2026 trainings completed by St. Joseph Institute staff after March 31, 2026, to verify compliance with the feedback submission requirement. The audit findings will be documented and presented during the Committee of the Whole (CoW) meetings to demonstrate adherence to corrective measures and ongoing monitoring.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of administrative information, the facility failed to inspect storage areas as required.
The facility policy and procedures state that all medication storage areas are inspected by the Director of Nursing at least quarterly.
There were no inspections documented from April 2025 through October 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
On December 10, 2025, the Director of QI/Compliance educated the Director of Nursing (DON) on the facility policy and the importance of inspecting medication storage areas and completing audits quarterly, and the DON signed an attestation confirming receipt and understanding of this education. The DON will complete the Medication Room/Medication Pass Audit Form and the Infection Control/Prevention Audit Form on a quarterly basis, maintain all completed forms in a designated binder, and ensure accessibility for review. The CEO and the Director of QI/Compliance will audit this binder quarterly for one year to verify compliance with medication room inspections, and the results of these audits will be presented at the Committee of the Whole (CoW) meeting. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to include the type and frequency of treatment and rehabilitation services on the treatment plan in seven of seven records.
The individual treatment plans indicated a frequency but not the type of treatment and rehabilitation services.
Client #8 was admitted to the inpatient level of care on August 27, 2025, and discharged on October 6, 2025.
Client #9 was admitted to the inpatient level of care on August 5, 2025, and discharged on October 8, 2025.
Client #10 was admitted to the inpatient level of care on July 16, 2025, and discharged on July 24, 2025.
Client #11 was admitted to the inpatient level of care on August 2, 2025, and discharged on August 17, 2025.
Client #12 was admitted to the inpatient level of care on September 19, 2025, and was still active at the time of the inspection.
Client #13 was admitted to the inpatient level of care on November 6, 2025, and was still active at the time of the inspection.
Client #14 was admitted to the inpatient level of care on October 25, 2025, and was still active at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
To ensure adherence to this requirement, the Director of Clinical Services (DCS) will conduct a training on 1/7/2026 with the Clinical Team to ensure type and frequency of treatment and rehabilitation services on the treatment plan. The DCS will complete comprehensive audits on 100% of patient charts on a weekly basis for the initial three-month period following implementation. After this period, ongoing compliance will be monitored through monthly chart audits. All clinical staff will sign attestation forms confirming receipt of education and training related to this corrective action. Audit findings will be reported during the Committee of the Whole (CoW) meetings. |