INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 15, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Peace and Harmony House 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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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on an administrative review, the facility failed to ensure the project director annually prepared, updated, and signed the written manual delineating the project policies and procedures.
At the time of the inspection, documentation was provided by facility staff indicating the written manual was last updated and signed by the project director on December 5, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has implemented a yearly policy and procedure manual review and sign-off process. A designated annual sign-off page has been added as the first page of the Policy and Procedure Manual. The Facility Director will ensure that the manual is reviewed annually, with the review and approval documented by the required signature and date.
As part of this process, the Facility Director will ensure that all policies and procedures are reviewed and appropriately signed by the Facility Director/Project Director or other designated parties, as applicable. Annual review and approval will be completed and documented to ensure the Policy and Procedure Manual remains current and meets DDAP requirements.
Responsible Party: Facility Director/Project Director
Frequency: Annually and as needed when policies or procedures are revised.
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709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on release of information forms in two of fourteen client records reviewed.
Client # 13 was admitted to the partial hospitalization activity on January 21, 2026 and was discharged on February 17, 2027. The release of information form to an external provider was signed and dated by the client on January 21, 2026. The release of information form had "other" indicated as the specific information to be disclosed and the corresponding space to indicate what that specific information was blank.
Client # 14 was admitted to the partial hospitalization activity April 15, 2026 and was discharged on July 24, 2026. The release of information form to a government agency was signed and dated by the client on April 14, 2026. The release of information form had "other" as the specific information to be disclosed and the corresponding space to indicate what that specific information was blank.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon identification of the deficiency, the agency reviewed and corrected the consent documentation in the two identified records. In addition, all existing referral-related consents were reviewed to identify any similar concerns, and any consents requiring clarification or correction were updated accordingly.
All clinical staff have been notified of the identified deficiency and educated on the proper completion of the applicable consent section. Staff were instructed that the specific information authorized for disclosure must be clearly identified and that all required portions of the consent must be completed.
Ongoing Monitoring:
Effective immediately, the Clinical Supervisor/Lead Counselor will review 100% of new intake documentation, including applicable consents and releases, prior to upload/finalization in the client's record. The review will verify that consents are complete, properly dated and signed, and clearly identify the information authorized for disclosure.
In addition, every 30 days, the Clinical Supervisor/Lead Counselor will conduct a second-level review of all intakes completed within the preceding 30 days to verify continued compliance with consent documentation requirements. This review will serve as a second round of oversight separate from the initial intake documentation review.
Any identified deficiencies will be addressed promptly with the responsible staff member, and additional education or guidance will be provided as needed.
This monitoring process will continue every 30 days as an ongoing quality assurance measure to ensure compliance with applicable Department of Drug and Alcohol requirements and prevent recurrence of the identified deficiency.
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