INITIAL COMMENTS
|
This report is a result of an on-site provisional licensing inspection conducted on September 1, 2026, through September 2, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site provisional licensing inspection, Auberle 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:
|
Plan of Correction
|
704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
|
Observations
704.2a - Based on a review of the policy and procedure manual, the facility failed to document the project ' s governing body approved the written compliance plan related to project staffing. Policy and procedures were revised, and there is no documentation of adoption by the governing body. These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
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.
|
Observations
Based on a review of the facility policy and procedure for staff development, the facility failed to provide a written procedure designating a timeframe for training feedback.These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times.The following was observed by DDAP staff:-Apartment 307 was observed to have peeling paint on the outside door of the apartment.-Apartment 308 was observed to have peeling paint on the outside door of the apartment.-Disposable cups provided to clients to drink from during medication times were observed to be stored in an unsanitary compartment in the medication room.-The Daycare Room was observed to have three broken child-locks on the refrigerator door.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility has taken corrective action to address all identified physical plant deficiencies.
Apartments 307 and 308: An external contractor was hired to address the peeling paint on both apartment entrance doors. The repairs were completed by the end of September 2026.
Medication Room: The unsanitary storage conditions for disposable medication cups were corrected on September 1, 2026, immediately upon being brought to the facility's attention. The cups were relocated to an appropriate sanitary storage area.
Daycare Room: The broken refrigerator child-safety locks were addressed on September 1, 2026, during the DDAP inspection. A replacement child-safety lock was purchased and installed to ensure the refrigerator remained appropriately secured.
Ongoing Monitoring and Prevention of Recurrence: To ensure continued compliance with DDAP physical plant regulations, the FHC Program Manager will conduct and document monthly physical plant inspections of all residential apartments, common areas, medication storage areas, daycare spaces, and other facility areas. Inspections will assess cleanliness, sanitation, building conditions, safety equipment, storage practices, and necessary repairs.
Staff will be responsible for promptly reporting any identified physical plant concerns to FHC management. The Program Manager will document deficiencies, coordinate necessary repairs with Facilities Management, and maintain a record of corrective actions and completion dates. Identified safety or sanitation concerns requiring immediate attention will be addressed promptly.
The FHC Director will provide oversight by reviewing monthly inspection documentation, monitoring outstanding corrective actions, and ensuring that identified deficiencies are resolved. Any recurring concerns will be evaluated to determine whether additional preventive measures are necessary.
All identified deficiencies have been corrected. The facility will continue to monitor physical plant conditions through routine inspections to ensure the environment remains clean, safe, sanitary, and in good repair. |
705.9 (4) (i) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of residents and staff to a safe location.
|
Observations
Based on a review of procedures, the facility failed to document written emergency procedures for staff and residents to follow in case of an emergency, which included the evacuation and transfer of residents and staff to a safe location.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility's Emergency Procedures Policy was revised to include written procedures for staff and residents to follow during emergencies, including evacuation and transfer to a safe location. The revised policy was reviewed by a DDAP representative to ensure it met departmental standards and was subsequently approved and implemented. On October 16, 2026, the policy was uploaded into the agency's records management system and distributed to all employees for mandatory review and acknowledgment. All staff are required to review and electronically acknowledge the policy, with documentation maintained in the agency's records management system.
Ongoing Monitoring and Responsible Staff: The FHC Program Manager will be responsible for monitoring staff compliance with the Emergency Procedures Policy by reviewing employee acknowledgment records and ensuring that all current and newly hired staff have completed the required review. Any outstanding acknowledgments will be addressed through direct follow-up with employees.
The FHC Director will provide oversight through ongoing reviews of policy acknowledgment records and emergency preparedness documentation to ensure continued compliance. Any identified deficiencies will be addressed through corrective action, additional staff education, or policy revisions as necessary. The Emergency Procedures Policy will also be reviewed at least annually and updated as needed to maintain compliance with DDAP regulations. |
705.9 (4) (ii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(ii) Assignments of staff during emergencies.
|
Observations
Based on a review of procedures, the facility failed to document written emergency procedures for staff and residents to follow in case of an emergency, which included the assignments of staff during emergencies. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility's Emergency Procedures Policy was revised to include written procedures for staff and residents to follow during emergencies, including specific staff assignments and responsibilities during emergency situations. The revised policy was reviewed by a DDAP representative to ensure it met departmental standards and was subsequently approved and implemented. On October 16, 2026, the policy was uploaded into the agency's records management system and distributed to all employees for mandatory review and acknowledgment. All staff are required to review and electronically acknowledge the policy, with documentation maintained in the agency's records management system.
Prevention of Recurrence and Ongoing Monitoring: To prevent recurrence, the FHC Program Manager will ensure that all newly hired employees review and acknowledge the Emergency Procedures Policy during orientation and that existing staff review any subsequent revisions. Emergency procedures, including staff assignments and responsibilities, will also be reinforced through staff training and emergency drills.
The FHC Program Manager will review policy acknowledgment records monthly to identify and address any outstanding requirements. The FHC Director will conduct reviews to verify compliance with these requirements and ensure that any identified deficiencies are promptly corrected.
The Emergency Procedures Policy will be reviewed annually and whenever changes to facility operations, emergency response procedures, or regulatory requirements occur. Any necessary revisions will be distributed to staff for review and acknowledgment to ensure continued compliance with DDAP regulations. |
705.9 (4) (iii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(iii) The evacuation and transfer of residents impaired by alcohol or other drugs.
|
Observations
Based on a review of procedures, the facility failed to document written emergency procedures for staff and residents to follow in case of an emergency, which included the evacuation and transfer of residents impaired by alcohol or other drugs. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility's Emergency Procedures Policy was revised to include written procedures for staff and residents to follow during emergencies, including the safe evacuation and transfer of residents impaired by alcohol or other drugs. The revised policy was reviewed by a DDAP representative to ensure it met departmental standards and was subsequently approved and implemented. On October 16, 2026, the policy was uploaded into the agency's records management system and distributed to all employees for mandatory review and acknowledgment. All staff are required to review and electronically acknowledge the policy, with documentation maintained in the agency's records management system.
To prevent recurrence, the FHC Program Manager will be responsible for ensuring that all current and newly hired staff review and acknowledge the Emergency Procedures Policy and receive instruction on procedures for safely evacuating and transferring residents who may be impaired by alcohol or other drugs. These procedures will be reinforced during staff orientation, emergency preparedness training, and facility emergency drills.
The FHC Program Manager will monitor compliance through monthly reviews of staff acknowledgment and training records and documentation of emergency drills. Any identified gaps will be addressed through additional training and follow-up. The FHC Director will provide oversight through reviews of emergency preparedness documentation and will ensure that corrective actions are implemented when deficiencies are identified. The policy will be reviewed annually and updated as necessary to maintain continued compliance with DDAP regulations. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel records, the facility failed to provide documentation of all staff being instructed on the use of the fire extinguisher upon employment in three of four records. Staff #2 was contracted as a counselor on June 10, 2026 and was still in this position at the time of the inspection. Documentation that the staff was instructed on the use of the fire extinguisher was not completed until July 21, 2026.Staff #3 was contracted as a counselor on June 10, 2026 and was still in this position at the time of the inspection. Documentation that the staff was instructed on the use of the fire extinguisher was not completed until July 21, 2026.Staff #5 was promoted to counselor on June 1, 2026 and was still in this position at the time of the inspection. Documentation that the staff was instructed on the use of the fire extinguisher was not completed until September 10, 2026.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility has implemented an additional mandatory fire safety training requirement to ensure all newly hired staff receive instruction on fire extinguisher use upon employment. All new employees will be required to complete the "OSHA ? Fire Safety and Fire Extinguisher Types" training through the agency's personnel management system within their first week of employment. This training will serve as an initial instructional requirement to bridge the gap between an employee's start date and their scheduled agency orientation, where fire safety procedures and fire extinguisher use are reviewed in greater detail.
To prevent recurrence, the FHC Program Manager will be responsible for ensuring that all newly hired employees are assigned the required training upon hire and complete it within their first week of employment. Training completion will be documented and maintained electronically within the agency's personnel management system. Any employee who does not complete the training within the required timeframe will receive immediate follow-up to ensure completion.
The FHC Program Manager will monitor compliance through monthly reviews of employee training records to verify that all newly hired staff have completed the required training within the established timeframe. The FHC Director will provide oversight through reviews of training compliance and will ensure that any identified deficiencies are addressed through corrective action and additional staff education as necessary. These monitoring procedures will remain ongoing to ensure continued compliance with DDAP fire safety training requirements.
|
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records, the facility failed to provide documentation of all staff being instructed to perform assigned tasks during emergencies in three of four records. Staff #2 was contracted as a counselor on June 10, 2026 and was still in this position at the time of the inspection. Documentation that the staff was instructed to perform assigned tasks was not completed until July 21, 2026.Staff #3 was contracted as a counselor on June 10, 2026 and was still in this position at the time of the inspection. Documentation that the staff was instructed to perform assigned tasks was not completed until July 21, 2026.Staff #5 was promoted to counselor on June 1, 2026 and was still in this position at the time of the inspection. Documentation that the staff was instructed to perform assigned tasks was not completed until September 10, 2026.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility has revised and implemented its Emergency Procedures Policy to include specific staff responsibilities during emergencies, including fire safety and evacuation procedures. Effective October 16, 2026, the policy was uploaded into the agency's personnel management system for mandatory review and acknowledgment. All new employees will be required to review the policy and complete the "OSHA ? Fire Safety and Fire Extinguisher Types" training within their first week of employment, prior to receiving more detailed instruction during agency orientation. Completion will be documented and maintained electronically within the personnel management system.
To prevent recurrence, the FHC Program Manager will be responsible for ensuring that all newly hired employees are assigned the Emergency Procedures Policy and required fire safety training upon hire. The Program Manager will verify that both requirements are completed within the employee's first week of employment and follow up immediately on any outstanding requirements. Emergency responsibilities, fire safety procedures, and evacuation expectations will also be reinforced during staff orientation and facility emergency drills.
The FHC Program Manager will monitor continued compliance through monthly reviews of employee training and policy acknowledgment records, ensuring that all staff have completed the required training and understand their assigned emergency responsibilities. Any deficiencies identified will be documented and addressed through additional training and corrective action.
The FHC Director will be responsible for overseeing implementation of the corrective actions and conducting reviews of training records, policy acknowledgments, and emergency drill documentation to verify continued compliance. The Emergency Procedures Policy will also be reviewed annually and updated as necessary to ensure ongoing compliance with DDAP regulations. |
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.
|
Observations
Based on a review of the facility fire drill log for the months of February 2026 through August 2026, the facility failed to maintain a written fire drill record including documentation of exit routes used during the fire drill.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility has updated its fire drill documentation procedures to ensure all required information, including exit routes used during each drill, is recorded. Fire drills and associated documentation are now overseen by FHC management in conjunction with the agency's Facilities Maintenance Team based out of the McKeesport office. Clear instructions have been established for completing and maintaining fire drill logs in accordance with DDAP and OSHA requirements.
To prevent recurrence, the FHC Program Manager will be responsible for ensuring that all fire drills are conducted as required and that documentation is completed accurately and in its entirety. Staff responsible for conducting fire drills will be instructed on the required documentation, including the date and time of the drill, evacuation time, number of participants, exit routes utilized, and any identified concerns. The Program Manager will review each completed fire drill log to verify that all required information has been recorded. Any missing or incomplete information will be addressed promptly with the responsible staff member, and additional instruction will be provided as necessary.
The FHC Program Manager will monitor continued compliance through monthly reviews of fire drill records to ensure drills are completed according to the required schedule and documentation remains accurate and complete. The FHC Director will provide oversight through reviews of fire drill documentation and will coordinate with the Facilities Maintenance Team to address any identified concerns related to evacuation procedures, exit routes, or facility safety.
These monitoring procedures will remain ongoing to ensure that fire drills are conducted, documented, and maintained in accordance with applicable DDAP fire safety requirements. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
|
Observations
Based on a physical plant inspection, the facility failed to maintain protective caps over each electrical outlet.Clients are permitted to bring their children to the facility. No electrical caps were observed in the shared dining room, youth room (next to the desk by the door), lobby, library, hallways, and apartments 201, 205, 206, 207, 208, 301, 302, 303, 305, 306, 307 and 308.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility addressed the identified electrical outlet concerns through an inspection and corrective work completed by a contracted electrical company on August 27, 2026. On September 3, 2026, FHC management conducted a review of all electrical outlets throughout the facility and ensured that every outlet was secured with protective safety caps while awaiting DDAP's decision to approve or deny the facility's regulatory exception request.
In a letter dated September 25, 2026, DDAP formally approved the facility's request to utilize tamper-resistant (TR) receptacles in place of protective safety caps. Following approval, protective caps remained in place on all outlets not identified as tamper-resistant.
To prevent recurrence, the FHC Program Manager will be responsible for ensuring that all electrical outlets remain compliant with the approved DDAP exception. Staff will be instructed to report any missing protective caps, damaged outlets, or other electrical safety concerns immediately to FHC management. Any outlets that are not tamper-resistant must remain secured with protective safety caps. The Program Manager will coordinate with the agency's Facilities Maintenance Team to ensure that any identified deficiencies are promptly corrected.
The FHC Program Manager will monitor continued compliance through monthly physical plant inspections, including verification that tamper-resistant outlets remain intact and protective caps are present on all non-tamper-resistant outlets. Any deficiencies will be documented, reported to Facilities Maintenance, and tracked through completion.
The FHC Director will provide oversight through reviews of physical plant inspection documentation and outstanding corrective actions to ensure continued compliance with the approved DDAP exception and applicable electrical safety requirements.
Corrective Action Completion Date: September 3, 2026. All electrical outlets were secured with protective safety caps on this date, bringing the facility into compliance while awaiting DDAP's determination. The regulatory exception was subsequently approved on September 25, 2026. |
709.24 (a) 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:
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document the governing body adopted the written plan for the coordination of client treatment and rehabilitation services. Policy and procedures were revised, and there is no documentation of adoption by the governing body. These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
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.
|
Observations
Based on a review of the facility policy and procedure manual, the facility failed to provide a written procedure for documentation of physical exam within seven days, progress notes, and a procedure for clients who leave Against Medical Advice. Additionally, facility has conflicting policies about case consultation timeframes.These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
709.26 (a) LICENSURE Personnel Management
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document the governing body adopted written project personnel policies and procedures in compliance with State and Federal employment laws. Policy and procedures were revised, and there is no documentation of adoption by the governing body. These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on staff records reviewed, the facility failed to provide documentation of an annual written individual staff performance evaluations reviewed and signed by the employee in one of one record. Staff #1 was promoted to the project and facility director on April 4, 2025. An annual performance evaluation was documented, but it included multiple dates that did not verify when the evaluation was completed or when it was reviewed and signed by the employee.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility has coordinated with the agency's Human Resources Department to address inconsistencies in annual performance evaluation documentation. The evaluation process has been reviewed to ensure accurate and consistent dates for completion, employee review, and acknowledgment. The facility has also coordinated with Human Resources to review and correct discrepancies in the identified personnel record, ensuring that the evaluation documentation accurately reflects when the evaluation was completed, reviewed, and signed.
To prevent recurrence, annual performance evaluations will be completed in alignment with the agency's fiscal year requirements. The FHC Director will be responsible for ensuring that annual evaluations for assigned staff are completed within the established timeframe and that documentation includes the appropriate completion date, employee review date, and employee acknowledgment. Human Resources will provide guidance regarding evaluation requirements and maintain the required documentation in employee personnel records.
The FHC Director will monitor continued compliance through reviews of staff evaluation due dates and completion records in coordination with Human Resources. These reviews will identify upcoming evaluations, missing documentation, and discrepancies in completion or acknowledgment dates. Any identified deficiencies will be communicated to the appropriate supervisor and Human Resources for correction, with follow-up to verify completion.
Human Resources will also monitor annual evaluation documentation for completeness and consistency with agency requirements. These ongoing monitoring procedures will ensure that performance evaluations are completed, reviewed, acknowledged, and maintained in accordance with applicable DDAP personnel requirements. |
709.28 (a) (1) 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:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document a written procedure for the confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.The policy and procedure manual was requested on September 1, 2026. There was no confidentiality policy documented in the policy manual provided.These findings were reviewed with the facility staff during the licensing process.This is a repeat citation from the April 30, 2026 licensing inspection.
|
Plan of Correction
The facility has developed a Confidentiality of Client Identity and Records Policy addressing the security, maintenance, access, and release of electronic and paper client records. The policy identifies the FHC Director as responsible for oversight of client record confidentiality and establishes procedures for safeguarding records, restricting access to authorized personnel, and ensuring information is released only in accordance with applicable confidentiality requirements.
The revised policy was reviewed by a DDAP representative to ensure all required regulatory elements were included and has been submitted to the governing body for formal approval, anticipated by November 16, 2026. Upon approval, documentation of adoption will be maintained on file, and the policy will be incorporated into the facility's policy and procedure manual.
To prevent recurrence, the FHC Clinical Manager will be responsible for implementing the policy at the facility level, ensuring that all current employees review and acknowledge the policy and that newly hired employees receive instruction on confidentiality and record security during orientation. Staff will be instructed on proper storage, access, maintenance, and release of client records, including the protection of electronic records and securing paper documentation when not in use.
The FHC Clinical Manager will monitor continued compliance through reviews of record storage practices, access procedures, and staff policy acknowledgment records. Any identified deficiencies will be documented and addressed through immediate corrective action, additional staff education, or revisions to facility procedures as necessary.
The FHC Director will provide oversight through quarterly reviews of confidentiality practices, policy acknowledgment documentation, and identified corrective actions to ensure continued compliance with DDAP regulations and applicable confidentiality requirements. The policy will also be reviewed annually and updated as necessary. |
709.28 (a) (2) 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:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document a written procedure for the identification of project staff having access to records, and the methods by which staff gain access.The policy and procedure manual was requested on September 1, 2026. There was no confidentiality policy documented in the policy manual provided.These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
|
Observations
Based on a review of client records, policy and procedures, personnel records and administrative documentation, the facility failed to maintain a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.On September 1, 2026, personnel records were requested for review at the beginning of the inspection. Documentation in the personnel records was provided to the Department in pieces and had to be requested multiple times. Additionally, when the Department requested fire drill logs and personnel documents, the facility informed DDAP Staff that those items were not housed within the facility. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures that include administration of medication by individuals permitted to administer by Pennsylvania law, when self administered by the client and drug storage areas. The facility failed to document policies and procedures that include who, what, when, where, how and why. The policies reviewed failed to document staff titles, their responsibilities, and timeframes of completion of those procedures.These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
An approved Plan of Correction is not on file. |
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.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures that include inspection of medication storage areas that ensure compliance with State and Federal laws and program policy. The policy did not include who inspects the storage area or how often the area is inspected.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
|
Observations
Based on a review of the facility ' s medication book, the facility failed to ensure that all required documentation was documented on the reports in three of seven client records.Medication reports were reviewed from July 1 - August 31, 2026.Client #7 was still an active client at the time of the inspection. A review of the Controlled Count Medication Sheet found:Buprenorphine Naloxone 8mg/2mg Flim - Count started at 15 on 7/8/26 at 8pm as 15, then 1 film was given and the new count was 14 then on 7/9/26 at 8am the count was 17 and 1 film was given ending the count at 16, then on 7/9/26 at 2pm the starting count was now 13 and 1 film was given ending the count at 12.A review of the Medication Administration Record found:Quetiapine Fumarate 150 MG Tab - Take 1 tablet by mouth at bedtime for sleep total dose of 175mg - There was no documentation of when the medication started, the following dates did not show documentation that the medication was taken 8/1-14/2026 since they did not put a line through those dates indicating that official start date.Quetiapine Fumarate 25 MG Tab - Take 1 tablet by mouth at bedtime for sleep total dose of 175mg - There was no documentation of when the medication started, the following dates did not show documentation that the medication was taken 8/1-14/2026 since they did not put a line through those dates indicating that official start date.Client #9 was still an active client at the time of the inspection. A review of the Medication Administration Record found:Sertraline HCL 50 MG Capsule - Take 1 capsule by mouth - Marked on the form that the client took their medication on the following days 7/8/26 and 7/9/2026, but on the medication notes it states the client hospitalized; unavailable for medication administration.Prenatal Folic Acid + DHA Supplement - Take 1 tablet by mouth once daily - Marked on the form that the client took their medication on the following days 7/8/26 and 7/9/2026, but on the medication notes it states the client hospitalized; unavailable for medication administration.Emtricitabine - Tenofovir 200 MG Tablet - Take 1 tablet by mouth once daily. - There was no documentation of when the medication started, the following dates did not show documentation that the medication was taken 8/1-10/2026 since they did not put a line through those dates indicating that official start date.Omeprazole DR 40 MG Capsule - Take 1 capsule by mouth once daily for anxiety - There was no documentation of when the medication started, the following dates did not show documentation that the medication was taken 8/1-10/2026 since they did not put a line through those dates indicating that official start date.Client #10 was still an active client at the time of the inspection. A review of the Medication Administration Record found:Quetiapine Fumarate 100 MG Tablet - Take tablet by mouth at bedtime for 7 days, then increase to 1 tablet by mouth at bedtime. On the form it is documented that the medication was discontinued on 7/3/2026, but on 7/4/2026 and 7/5/2026 it is marked that she took the medication.Vilazodone HCL 20 MG Tablet - Take one tablet by mouth once daily - There was no documentation of when the medication started, the following dates did not show documentation that the medication was taken 7/1-6/2026 since they did not put a line through those dates indicating that official start date.Quetiapine Fumarate 200 MG Tab - Take 1 tablet by mouth at bedtime for sleep - There was no documentation of when the medication started, the following dates did not show documentation that the medication was taken 7/1-5/2026 since they did not put a line through those dates indicating that official start date.ClearLax (Polyethylene Glycol Powder) 17 GM - Mix 17 grams in 8 ounces of water and take by mouth once daily. Maximum use 2 weeks. 8/19/2026 at 8 am is marked as refused, but on the medication note section there was no documentation of the client ' s refusal. On 7/24/26 and 7/28/2026 at 8am those dates we left blank and there was no documentation on the medication note section of why it wasn ' t ' t marked or if the client received their medication or not.This finding was reviewed with the facility staff during the licensing process.This is a repeat citation from the April 30, 2026 and January 21, 2026 licensing inspections.
|
Plan of Correction
The facility has implemented corrective measures to address medication documentation errors associated with the transition to an electronic Medication Administration Record (MAR) system and staff not consistently following established procedures. All medication administration staff were retrained on September 16, 2026, regarding proper MAR documentation, medication start and discontinuation dates, refusals, controlled substance counts, and required medication notes. The Facility Director has also implemented random, unannounced MAR audits, including reviews during medication administration and after medication passes, to monitor accuracy and staff compliance. Identified errors will be addressed through immediate corrective feedback and additional training as needed. These ongoing monitoring efforts are intended to prevent recurring deficiencies and ensure accurate medication documentation. |
709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures that include who, what, when, where, how and why for the security of drugs, including, but not limited to, the loss, theft or misuse of drugs.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
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.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures that include who, what, when, where, how and why for 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.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures that include how to respond to unusual incidents. The policy did not include how to respond to theft, burglary, break-in or similar incident at the facility.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures that include how to respond to unusual incidents. The policy did not include how to respond to fire or structural damage to the facility.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures that include how to respond to unusual incidents. The policy did not include prompt review and identification of the causes directly or indirectly responsible for the unusual incident.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures that include how to respond to unusual incidents. The policy did not include implementation of a timely and appropriate corrective action plan, when indicated.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures that include how to respond to unusual incidents. The policy did not include ongoing monitoring of the corrective action plan.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility's Unusual Incident Reporting Policy has been revised to include procedures for ongoing monitoring of corrective action plans, including staff responsibilities, documentation requirements, and follow-up to ensure corrective actions are effective and sustained. The revised policy was submitted to a DDAP representative for review, which has been completed, and subsequently forwarded to the governing body for formal review and approval. Approval is anticipated by November 16, 2026, with documentation of adoption maintained on file. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on a review of facility policy and procedures and client records, the facility failed to document a physical examination in three of three client records.Facility policy states that referrals will be made for physical examinations within seven days of admission. There were no physical examinations documented in client records #4, 5, and 6.Client #4 was admitted on June 10, 2026 and was discharged on August 31, 2026.Client #5 was admitted on June 17, 2026 and was still active at the time of the inspection.Client #6 was admitted on June 17, 2026 and was still active at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document case consultations as per agency policy in three of five client records.There were two conflicting facility policies regarding case consultations. One stated that case consultations would be conducted 30 days after admission and then as needed thereafter and the other stated that case consultations would be conducted quarterly, at minimum. DDAP staff confirmed with the project director verbally that case consultations are to be conducted quarterly at minimum. Case consultations were not conducted at least quarterly in client records #1, 2 and 3.Client #1 was admitted on February 17, 2026 and discharged on July 21, 2026. One case consultation, documented February 19, 2026 was documented in client record #1. There was no documentation that a case consultation was documented for the April / May / June quarter.Client #2 was admitted on December 22, 2025 and discharged on August 2, 2026. There were no case consultations documented in client record #2.Client #3 was admitted on January 24, 2026 and discharged on July 14, 2026. There were no case consultations documented in client record #3.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
he facility has reviewed and revised its Case Consultation Policy to eliminate conflicting timeframes and establish a consistent requirement for case consultations to be completed at least every 90 days. The revised policy establishes clear expectations for the completion and documentation of case consultations.
A standardized documentation process has been developed, tested, and reviewed, with implementation within the Electronic Health Record (EHR) scheduled for November 2, 2026. Any member of the clinical or case management team may enter case consultation notes into the client's EHR to ensure that consultations are appropriately documented.
To prevent recurrence, the FHC Clinical Supervisor will be responsible for implementing the revised case consultation requirements, communicating documentation expectations to the clinical and case management teams, and ensuring staff are trained on the standardized EHR documentation process. The Clinical Supervisor will also monitor upcoming case consultation deadlines to ensure consultations are completed at least every 90 days.
The FHC Clinical Supervisor will conduct ongoing chart audits to verify that case consultations have been completed and documented within the required 90-day timeframe. Any missing or overdue consultations will be identified and assigned to the appropriate clinical or case management staff member for prompt completion. The Clinical Supervisor will document identified deficiencies and follow up to verify that corrective actions have been completed.
The FHC Director will provide oversight through reviews of chart audit findings and corrective actions to ensure continued compliance with the Case Consultation Policy and applicable DDAP requirements.
|
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
|
Observations
Based on applicable client records reviewed, the facility failed to document follow-up contact in three of three client records. The facility ' s policy states that follow-up contact will be attempted and documented within thirty days of discharge.Client #1 was admitted on February 17, 2026 and discharged on July 21, 2026. Follow-up contact was due to be completed no later than August 21, 2026; however, there was no documentation that follow-up contact was attempted. Client #2 was admitted on December 22, 2025 and discharged on August 2, 2026. Follow up contact was due to be completed no later than September 2, 2026; however, there was no documentation that follow-up contact was attempted. Client #3 was admitted on January 24, 2026 and discharged on July 14, 2026. Follow up contact was due to be completed no later than August 14, 2026; however, there was no documentation that follow-up contact was attempted. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
709.54(a)(2) LICENSURE Receiving/storing/preserving
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(2) Receiving, storing and preserving of food stuff.
|
Observations
Based on a physical plant inspection, the facility failed to receive, store, and preserve food stuff per the facility policy and procedures. The facility policy states that all food items shall be received, stored, labeled, and preserved in a manner consistent with food safety standards. The following was observed by DDAP Staff:-Open containers of ketchup and barbeque sauce were observed in the kitchen refrigerator that were not labeled.-An open bag of shredded cheese was observed in the kitchen freezer that was not labeled.These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
709.15(b) LICENSURE Subchapter B.Licensing Procedures.Right to en
709.15. Right to enter and inspect.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
|
Observations
Based on a review of administrative documentation, the facility failed to provide full and free access to the records of the facility.Personnel records, training records, and fire drill logs were requested for review at the beginning of the inspection. Facility staff informed DDAP Staff that those items were not housed within the facility. During the two day inspection, documentation was requested multiple times. Due to the reluctance by off-site staff to present the requested documents, the department did not have full and free access to the records of the facility.This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of medication records, the facility failed to comply with plans of correction that were approved by the Department.A plan of correction for documentation of medication being provided as prescribed by a physician was submitted and approved by the Department for the April 30, 2026 and January 21, 2026 licensing inspections. Documentation of medication being provided as prescribed by a physician was again found to be a deficiency in the September1-2, 2026 licensing inspection.This was reviewed with the facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |