INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 2-4, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Marworth 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that one applicable employee received a minimum of 4 hours of TB/STD training using a department approved curriculum within the regulatory timeframe
Employee #5 has been in the position of counselor since November 4, 2024, and was current in that position at time of licensing process. Employee #5 was due to have the communicable disease training no later than November 4, 2025; however, the TB/STD training was not completed at the time of licensing process.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #5 will complete the required TB/STD communicable disease training. Employee#5 is registered for the required TB/STD course on August 5, 2026. A comprehensive audit of counselor personnel files will be conducted by counseling managers to ensure the communicable disease training requirements are completed within the required timeframes. A standardized tracking system (e.g., training log) will be implemented by counseling managers to monitor required training deadlines. Counseling individual supervisors will be assigned responsibility for tracking and verifying completion of leadership training requirements on a quarterly basis. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure the facility director completed at least 12 clock hours of annual training in one of one applicable personnel record reviewed.
Employee #1 was hired as the facility director on November 28, 2022, and was active in that position at the time of licensing inspection. The personnel record documented only 4 hours of the required 12 hours annual training for the training year for July 2024 through June 2025.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The Facility Director will complete a minimum of 12 training hours annually. An annual training tracking system will be implemented by individual supervisors to document completed hours and monitor progress toward required totals throughout the training year. Audits of this tracking system will be done on quarterly basis by the clinical supervisor and findings will be brought to the attention of executive leadership as needed. |
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 the review of client records, the facility failed to follow their policy to contact a client ' s emergency contact within twelve hours of leaving against medical advice in one out of two applicable records reviewed.
Client #3 was admitted to the detox level of care on September 3, 2025, and left against medical advice on September 5, 2025.? There was no documentation that the emergency contact was notified.
This is a repeat citation from the June 5, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical director will provide re-education on the facility's AMA discharge policy, including the requirement to notify emergency contacts within 12 hours and properly document this action in the client record. An AMA note template will be created and added into electronic medical record to prompt staff to call and document interaction with emergency contact. Clinical Director will implement a standardized checklist for AMA events to ensure all required actions, including emergency contact notification, are completed and documented. Counseling managers will conduct monthly audits of AMA discharges to monitor compliance and provide corrective feedback as needed. The policy and procedure for AMA discharges will be reviewed and reinforced with all clinical staff to ensure clear understanding and consistent adherence. Executive management will be notified if there are consistent deficiencies noted throughout these audits. |
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 a review of client records, the facility failed to offer a copy of an informed and voluntary consent to release information form in ten out of twenty-one records reviewed.
Client #1 was admitted to the detoxification level of care on August 30, 2025, and was discharged on September 2, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for the funding source signed August 31, 2025, was offered to the client.
Client #5 was admitted to the detoxification level of care on June 1, 2026, and was active at the time of inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for the funding source signed May 29, 2026, was offered to the client.
Client #6 was admitted to the detoxification level of care on June 1, 2026, and was active at the time of inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for the funding source signed May 27, 2026, was offered to the client.
Client #7 was admitted to the detoxification level of care on June 2, 2026, and was active at the time of inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for the funding source signed June 2, 2026, was offered to the client.
Client #12 was admitted to the inpatient level of care on May 6, 2026, and was active at the time of inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for the funding source signed May 6, 2026, was offered to the client.
Client #13 was admitted to the inpatient level of care on May 13, 2026, and was active at the time of inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for the funding source signed May 12, 2026, was offered to the client.
Client #14 was admitted to the inpatient level of care on May 11, 2026, and was active at the time of inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for the funding source signed May 11, 2026, was offered to the client.
Client #19 was admitted to the outpatient level of care on March 23, 2026, and was active at the time of inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for the funding source signed March 19, 2026, was offered to the client.
Client #20 was admitted to the outpatient level of care on April 24, 2026, and was active at the time of inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for the funding source signed April 22, 2026, was offered to the client.
Client #21 was admitted to the outpatient level of care on March 24, 2026, and was active at the time of inspection. The client was previously admitted to the inpatient level of care on March 10, 2026 and discharged to the outpatient level of care on March 24, 2026, within the project. There was no documentation that a copy of an informed and voluntary consent to release information form for the funding source, signed March 5, 2026, was offered to the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility will revise the current consent form to include a designated section allowing staff to document whether a patient has accepted or declined a copy of the finalized release, ensuring consistent and compliant documentation of the patient's decision. This revision will be completed by Geisinger Epic personnel within 60 days of acceptance of this Plan of Correction. Following completion of the build, the updated consent form will be submitted to the system's Forms Committee for review and approval within 30 days.
Effective immediately and until the revised consent form is fully approved and implemented, Marworth staff will document that a copy of the finalized release was offered to the patient, along with the patient's decision to accept or decline the copy. This information will be recorded in the "Description" field of the release. Compliance with this interim process will be monitored through routine chart audits conducted by supervisory staff. |
709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on a review of client records, the facility failed to record medication errors in the client record in two out of fourteen applicable records reviewed.
Client # 9 was admitted to residential treatment on October 3, 2025, and was discharged October 28, 2025. Client #9 was prescribed Thiamine HCI tablet once a day; however, there was no documentation that the client received or refused this medication October 3, 2025, October 4, 2025, October 5, 2025, October 6, 2025, October 9, 2025, October 13, 2025, October 14, 2025, and October 15, 2025.
Client #11 was admitted to residential treatment on January 21, 2026, and was discharged January 31, 2026. Client #11 was prescribed Norvasc 10 mg tab; however, there was no documentation that the client received or refused this medication on January 30, 2026
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
Nursing staff will perform a comprehensive review of all medications scheduled and documented in the electronic Medication Administration Record (eMAR) within Epic prior to the end of each shift. Any medications not administered as scheduled will be promptly identified, and a clear, clinically appropriate reason for the omission will be documented in the MAR in accordance with regulatory and facility standards.
The deficiencies cited occurred during the period in which the facility utilized the Tier electronic health record system. This system did not provide real-time alerts or prompts for missed or overdue medication administrations, limiting the ability to proactively identify documentation gaps.
The facility has since transitioned to the Epic electronic health record system, which includes real-time alerting functionality for overdue and missed medications. Nursing staff are trained to actively monitor these alerts and reconcile all medication administration records prior to shift completion. This process supports timely documentation, enhances medication safety, and promotes compliance with accepted standards of nursing practice and regulatory requirements.
To ensure ongoing compliance, the Nursing Manager (or designee) will conduct routine audits of the MAR for missed and omitted medications. Audits will be completed bi-weekly, and findings will be reviewed with staff. Any identified deficiencies will result in prompt re-education and corrective action as indicated.
Results of audits will be reported through the facility's QI/PI committee and to the medical director. |
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 notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the facility in three out of four applicable records reviewed.
Client #4 was admitted to the detoxification level of care on January 19, 2026, and was involuntarily discharged on January 22, 2026. The record did not contain documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
Client #10 was admitted to the residential level of care on December 20, 2025, and was involuntarily discharged on January 16, 2026. The record did not contain documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
Client #16 was admitted to the outpatient level of care on October 16, 2025, and was involuntarily discharged on November 24, 2025. The record did not contain documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical director will update policy on administrative/involuntary termination of patients and educate all applicable staff on the policy to include requiring written notification of involuntary termination. Written notice will be provided by printing administrative discharge notification form and mailing to patient's address on file. Clinical director will implement a standardized discharge checklist to ensure that written notification is completed and documented in every involuntary termination case. Counseling managers will perform monthly audits of involuntary discharge records to ensure ongoing compliance and provide immediate corrective feedback when deficiencies are identified. The policy and procedure related to administrative/involuntary termination will be reviewed and reinforced with all clinical staff to ensure clarity, consistency, and accountability in practice.
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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 provide a complete client record, which is to include follow-up information within seven days of discharge, per facility policy, in one out of one applicable record reviewed.
Client #3 was admitted to the detoxification program on September 3, 2025, and was discharged on September 5, 2025. A follow-up was due no later than September 12, 2025, however, there was no documentation in client record that one occurred.
This finding was reviewed with the facility during the licensing process.
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Plan of Correction
Administrative assistant will conduct follow-up calls to discharged patients within seven days of discharge for all discharged patients. Administrative assistant will place a contact note in chart documenting the encounter. Clinical Director will conduct monthly audits to monitor compliance.
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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 facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of seven records reviewed.
Client #18 was admitted to the outpatient level of care on December 22, 2025, and was discharged on January 27, 2026. The treatment plans dated December 22, 2025, and January 9, 2026 indicated group sessions three times per week. The record documented the client only received two group sessions for the weeks of December 30, 2026, December 31, 2026, January 6, 2026, January 7, 2026, January 13, 2026, and January 14, 2026.
Client #19 was admitted to the outpatient level of care on March 23, 2026, and was active at the time of inspection. The treatment plans dated April 3, 2026, and April 10, 2026, indicated individual sessions twice per week and group sessions three times per week. There was no documentation that the client received individual sessions during the week of April 13-17, 2026. There was no documentation that the client received group sessions since April 13, 2026.
Client #21 was admitted to the outpatient level of care on March 24, 2026, and was active at the time of inspection. The treatment plans dated April 22, 2026, May 1, 2026, and May 15, 2026, indicated individual sessions twice per week. There was no documentation that the client received individual sessions during the weeks of May 11-15, 2026, and May 18-22, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff will document all attempts to contact patients who miss scheduled individual or group therapy sessions in the electronic health record. Documentation will include the date, time, method of contact, and outcome of each attempt, in accordance with facility policy and documentation standards. Additionally, all missed group and individual sessions will include clear documentation of the reason for the absence. To ensure compliance, the Clinical Manager (or designee) will conduct retrospective weekly audits of all active patient charts as well as charts of patients discharged within the previous week. These audits will focus on identifying any missing or incomplete documentation related to missed group or individual sessions and required patient contact attempts.
Weekly audits will be conducted for a period of four (4) consecutive weeks, followed by monthly audits thereafter to ensure sustained compliance.
Any deficiencies identified during the audit process will result in prompt staff re-education and, if indicated, progressive corrective action in accordance with facility policy.
Audit findings will be compiled and reported to the Clinical Director on a weekly basis during the initial four-week monitoring period, and monthly thereafter.
Results will also be incorporated into the facility's QI/PI program to support ongoing monitoring and continuous improvement. |