INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on December 3-4, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, St. Joseph Institute, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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 and the Intake Screening and Incoming Referrals policy, the facility failed to follow their policy regarding obtaining client identification in one of five charts reviewed.Per the Intake Screening and Incoming Referrals policy, the Intake Coordinator is to obtain the insurance card and the proper ID from clients during the intake process.Client # 4 was admitted on October 14, 2025, and discharged on October 27, 2025. There was no documentation of proper ID being obtained during the intake process in the client record.
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Plan of Correction
On December 4, 2025, the Director of Admissions provided comprehensive retraining to all Admissions staff regarding the established policies and procedures for obtaining client identification at the time of admission. This retraining included detailed instruction on the proper completion of the Verification of Client Identification Form in circumstances where an admitted client does not present valid identification. Each member of the Admissions team executed an attestation confirming their review and understanding of these requirements. To ensure sustained compliance, the Director of Admissions will conduct audits of 100% of admission charts on a weekly basis for an initial period of three months. Following this period, compliance monitoring will transition to monthly chart audits. Audit findings will be formally documented and presented during the Committee of the Whole (CoW) meetings for ongoing oversight and accountability. |
709.28 (a) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
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Observations
Based on a review of the Protection of Company Information procedures found in the Team Member Handbook, along with staff interviews, the facility failed to follow the written procedure for the disclosure of client-oriented information.Per the Protection of Company Information protocol, only company owned mobile devices and those approved for use by the Corporate IT department are allowed to be used on company networks and for company-related activities.It was disclosed by a staff person that a video camera app, which can access live video footage, was downloaded on their personal cell phone instead of their company cell phone.
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Plan of Correction
On December 5, 2025, the Chief Executive Officer (CEO) met with the Director of Nursing (DON) to address the use of a personal phone for work-related video applications instead of the company-issued cell phone. During the meeting, the DON acknowledged the concern and signed an attestation confirming her understanding of the issue. The DON has removed the video application from her personal phone and will utilize only the company-issued device for all DON-related duties moving forward. At the January staff training on 1/20/2026, all staff will be re-educated by the Director of Human Resources on the use of personal devices as stated in the Employee Manual. All staff will sign attestations that they received the education. |