INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, My Sister ' s Place Thomas Jefferson University 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure an individual training plan was developed annually for each employee, with the plan being appropriate to that employee's skill level and developed with input from both the employee and the supervisor, in two of five applicable personnel records reviewed.
Employee # 1 was hired as the project director on October 6, 2024. The individual training plan was completed on December 2, 2024; however, there was no documentation indicating the plan was developed with input from the supervisor.
Employee # 2 was hired as the facility director on January 2, 2023. The individual training plan was completed on December 2, 2024; however, there was no documentation indicating the plan was developed with input from the supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that a written individual training plan is developed annually for each employee, appropriate to the employee's skill level, and developed with documented input from both the employee and the supervisor. This will take place in supervision with supervisor and employee.
Supervisor participation and signature on all individual training plans at the time of development and annual review are required. A standardized individual training plan template will be used for all staff to ensure consistency and compliance with regulatory requirements.
Supervisors will be trained on the requirement to collaborate with employees during the annual training plan process and to document their input.
Person responsible- Facility Director and Administrative Assistant
Training Plan will be updated for employee #1 and #2 to reflect employee/supervisor input. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's December 2024 through November 2025 fire drill logs, the facility failed to ensure their written fire drill logs included documentation of whether the fire alarm or smoke detector was operative at the time of the drill.
At the time of the inspection, the May 2025 through September 2025 fire drill logs did not include documentation of whether the fire alarm or smoke detector was operative at the time of the drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that all written fire drill records include documentation of whether the fire alarm or smoke detector was operative at the time of each drill, as required by regulation.
The facility has revised its fire drill log template to include a required field documenting whether the fire alarm or smoke detector was operative at the time of the drill. Staff responsible for conducting and documenting fire drills will be re-educated on the required elements of fire drill documentation.
Supervisor will check the documentation for completion.
Person Responsible: Facility Director and Facility Operations Supervisor. |
711.51(b)(6) LICENSURE Psychosocial Evaluation
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document as part of their intake procedures, per facility policy, a psychosocial evaluation in five of seven applicable records reviewed.
The facility policy and procedure manual states that a psychosocial evaluation is to be completed within 15 days of admission.
Client # 1 was admitted on January 10, 2025 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed by January 25, 2025; however, it was completed on November 5, 2025.
Client # 2 was admitted on July 14, 2025 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed by July 29, 2025; however, it was completed on August 27, 2025.
Client # 4 was admitted on May 22, 2025 and was discharged on August 29, 2025. The psychosocial evaluation was due to be completed by June 6, 2025; however, it was completed on June 18, 2025.
Client # 6 was admitted on April 16, 2025 and was discharged on October 2, 2025. The psychosocial evaluation was due to be completed by May 1, 2025; however, it was completed on May 19, 2025.
Client # 7 was admitted on July 3, 2025 and was discharged on November 28, 2025. The psychosocial evaluation was due to be completed by July 18, 2025; however, it was completed on July 28, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that a psychosocial evaluation is completed and documented as part of intake procedures within 15 days of admission, in accordance with facility policy.
The facility has implemented a standardized intake tracking process to monitor required intake documentation, including psychosocial evaluations and due dates. Clinical staff will receive re-education on intake timelines and documentation requirements. Supervisory staff will review intake documentation to ensure psychosocial evaluations are completed within required timeframes.
In the event that the documentation cannot be completed in the timeframe the appropriate document disclaimer will be completed.
Persons responsible: Clinical Supervisor and Facility Director. |
711.52(c)(2) LICENSURE Type/Frequency of TX
711.52. Treatment and rehabilitation services.
(c) 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 client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of seven applicable client records reviewed.
Client # 3 was admitted on August 1, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 2, 2025, but the type of treatment and rehabilitation services was not documented on the treatment plan.
Client # 4 was admitted on May 22, 2025 and was discharged on August 29, 2025. The individual treatment and rehabilitation plan was completed on June 16, 2025, but the type of treatment and rehabilitation services was not documented on the treatment plan.
Client # 5 was admitted on August 4, 2025 and was discharged on October 29, 2025. The individual treatment and rehabilitation plan was completed on September 2, 2025, but the type of treatment and rehabilitation services was not documented on the treatment plan.
Client # 6 was admitted on April 16, 2025 and was discharged on October 2, 2025. The individual treatment and rehabilitation plan was completed on May 12, 2025, but the type of treatment and rehabilitation services was not documented on the treatment plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that each individual treatment and rehabilitation plan includes written documentation of both the type and frequency of treatment and rehabilitation services, including whether services are provided through individual and/or group modalities.
Clinical staff will be re-educated on documenting both the type and frequency of services within the existing treatment plan format.
Clinical Supervisor will confirm it is completed before signing off on the treatment plan.
Person Responsible: Clinical Supervisor and Facility Director |
711.53(c)(2)(ii) LICENSURE Specific Information Disclosed
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(ii) The 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 five of seven client records reviewed.
Client # 2 was admitted on July 14, 2025 and was still active at the time of the inspection. The release of information forms to an individual and another treatment provider were signed by the client on September 23, 2025; however, there was no specific information to be disclosed documented on the release forms.
Client # 3 was admitted on August 1, 2025 and was still active at the time of the inspection. The release of information form to a government agency was signed by the client on August 4, 2025; however, there was no specific information to be disclosed documented on the release form.
Client # 5 was admitted on August 4, 2025 and was discharged on October 29, 2025. The release of information form to a government agency was signed by the client on August 4, 2025; however, there was no specific information to be disclosed documented on the release form.
Client # 6 was admitted on April 16, 2025 and was discharged on October 2, 2025. The release of information form to a recovery house was signed by the client on September 22, 2025; however, there was no specific information to be disclosed documented on the release form.
Client # 7 was admitted on July 3, 2025 and was discharged on November 28, 2025. The release of information form to a government agency was signed by the client on July 3, 2025; however, there was no specific information to be disclosed documented on the release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will implement a standardized review process for all ROI forms at the time of completion and prior to supervisory sign-off.
Appropriate staff will receive refresher training on proper completion of ROI forms, with emphasis on documenting the specific information to be disclosed. Staff will be required to verify that the "specific information to be disclosed" section is completed before finalizing the form.
Supervisors will review all ROI forms during routine chart audits to ensure compliance. A minimum of 3 current client records will be audited monthly and new intake client charts will be reviewed within 1 business day of admission to review for compliance. Any identified deficiencies will be addressed through immediate corrective action and additional staff coaching as needed.
For the charts reviewed in audit that are currently still active in the program ROI's will be redone.
Completed by 1/31/2026 |
711.53(c)(2)(iii) LICENSURE Purpose of Disclosure
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(iii) The purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on release of information forms in five of seven client records reviewed.
Client # 2 was admitted on July 14, 2025 and was still active at the time of the inspection. The release of information forms to an individual and another treatment provider were signed by the client on September 23, 2025; however, there was no purpose of the disclosure documented on the release forms.
Client # 3 was admitted on August 1, 2025 and was still active at the time of the inspection. The release of information form to a government agency was signed by the client on August 4, 2025; however, there was no purpose of the disclosure documented on the release form.
Client # 5 was admitted on August 4, 2025 and was discharged on October 29, 2025. The release of information forms to government agencies were signed by the client on August 4, 2025; however, there was no purpose of the disclosure documented on the release forms.
Client # 6 was admitted on April 16, 2025 and was discharged on October 2, 2025. The release of information form to a recovery house was signed by the client on September 22, 2025; however, there was no purpose of the disclosure documented on the release form.
Client # 7 was admitted on July 3, 2025 and was discharged on November 28, 2025. The release of information forms to government agencies were signed by the client on July 3, 2025; however, there was no purpose of the disclosure documented on the release forms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will implement a standardized review process for all ROI forms at the time of completion and prior to supervisory sign-off.
Appropriate staff will receive refresher training on proper completion of ROI forms, with emphasis on documenting the purpose of information disclosure. Staff will be required to verify that the "Purpose of the Disclosure" section is completed before finalizing the form.
Supervisor will review all ROI forms during routine chart audits to ensure compliance. A minimum of 3 current client records will be audited monthly and new intake client charts will be reviewed within 1 business day of admission to review for compliance. Any identified deficiencies will be addressed through immediate corrective action and additional staff coaching as needed.
For the charts reviewed in audit that are currently still active in the program ROI's will be redone.
Staff responsible: Clinical Supervisor
Completed by 1/31/2026 |
711.53(c)(2)(vi) LICENSURE Consent's Expiration Date
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(vi) The expiration date of the consent.
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Observations
Based on a review of client records, the facility failed to document the expiration date of the consent on release of information forms in one of seven client records reviewed.
Client # 6 was admitted on April 16, 2025 and was discharged on October 2, 2025. The release of information form to a probation officer was signed by the client on April 16, 2025; however, there was no expiration date of the consent documented on the release form.
This is a repeat citation from the November 14, 2024 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All active client records will be reviewed to ensure that Release of Information (ROI) forms include a documented expiration date. Any active ROI found to be missing an expiration date will be corrected by obtaining an updated consent form from the client.
Given this is a repeat citation, the facility will implement enhanced safeguards to ensure compliance. Staff will receive targeted retraining on informed and voluntary consent requirements, with specific emphasis on documenting the expiration date of all ROI forms.
Staff will be required to complete a standardized internal checklist confirming that all required ROI elements?including expiration date?are present prior to supervisory review and approval.
Supervisor will review all ROI forms during routine chart audits to ensure compliance. A minimum of 3 current client records will be audited monthly and new intake client charts will be reviewed within 1 business day of admission to review for compliance.
Any identified deficiencies will be addressed through immediate corrective action and additional staff coaching as needed.
For the charts reviewed in audit that are currently still active in the program ROI's will be redone.
Staff responsible: Clinical Supervisor
Completed by 1/31/2026 |