INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 27, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Passages to Recovery, Inc. 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 administrative information, the facility failed to provide written individual training plans for three of three staff members.The facility policy states that individual training plans will be reviewed and updated at the beginning of the January-December training year.Staff #1 was hired in a support staff role on June 30, 2025 and promoted to the project and facility director on March 18, 2026. The training plan for 2026 was not completed at the time of the inspection.Staff #2 was hired as a counselor on March 25, 2025 and was still in this position at the time of the inspection. The training plan for 2026 was not completed until February 28, 2026.Staff #3 was hired as a support staff on April 4, 2025 and was still in this position at the time of the inspection. The training plan for 2026 was not completed at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery Clinical Director will ensure that an individualized written training plan, appropriate to each employee's skill level, is developed annually with input from both the employee and supervisor. If a clinical staff member's job description changes, a new training plan will be developed with the Clinical Director at the time of the position change.
The staff person that was out of compliance has completed the required training; all other staff are compliant for required trainings. Passages to Recovery Clinical Director and Chief of Staff will Develop clinical and support staff training plans and monitor trainings quarterly to ensure all staff are compliant with state training regulations.
The staff member's individual training plan was updated to align with the training requirements outlined in the revised job description. The Clinical Director and Chief of Staff will ensure that individual training plans are reviewed and updated whenever a staff member's job description changes to ensure all required training is completed. |
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 staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in one of two staff records.Staff #2 was hired as a counselor on March 25, 2025. The HIV/AIDS training was to be completed no later than March 25, 2026; however, this was not completed until May 8, 2026.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery Clinical Director will oversee and ensure that all staff and volunteers 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 within the first 2 years of employment. The Clinical Director will also assure that counselors and counselor assistants will complete the training in the first year of employment.
The staff person that was out of compliance has completed the required training; all other staff are compliant for required trainings. Passages to Recovery Clinical Director and Chief of Staff will Develop clinical and support staff training plans and monitor trainings quarterly to ensure all staff are compliant with state training regulations. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the facility's fire drill log for the months of June 2025 through May 2026, the facility failed to utilize alternating exits during monthly fire drills. All of the fire drills utilized the front exit.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery will utilize alternating exits during monthly fire drills. The Clinical Supervisor will ensure alternative exits are used and documented when conducting monthly fire drills according to DDAP regulations.
Passages to Recovery Clinical Supervisor will oversee, conduct, and document monthly fire drills to ensure compliance. |
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 the facility policy and procedure manual, the facility failed to provide a written procedure on designating a timeframe for the comprehensive treatment plan and discharge summary.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery administrative staff will revise the Policy and Procedure Manual regarding treatment and rehabilitation services for clients by July 15, 2026. The revised policy will require that all comprehensive treatment plans be completed by the third counseling session. Additionally, the policy will require that discharge summaries must be completed prior to discharge or within ten (10) days following discharge.
To ensure ongoing compliance with these requirements, the Clinical Supervisor will conduct monthly chart audits to verify that treatment plans and discharge summaries are completed within the timeframes established by policy. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in five of seven records.Client #1 was admitted to outpatient on December 30, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on January 29, 2026. A treatment and rehabilitation plan update was due no later than March 31, 2026; however, this was not completed until April 24, 2026.Client #2 was admitted to outpatient on November 14, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on February 2, 2026. A treatment and rehabilitation plan update was due no later than April 4, 2026; however, this was not completed until April 6, 2026.Client #3 was admitted to outpatient on February 12, 2026 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on March 23, 2026. A treatment and rehabilitation plan update was due no later than May 25, 2026; however, this was not completed at the time of the inspection.Client #5 was admitted to outpatient on August 4, 2025 and was discharged on January 15, 2026. A treatment and rehabilitation plan update was completed on September 12, 2025. A treatment and rehabilitation plan update was due no later than November 12, 2025; however, this was not completed until December 9, 2025.Client #7 was admitted to outpatient on November 3, 2025 and was discharged on March 30, 2026. A treatment and rehabilitation plan was developed on November 24, 2025. A treatment and rehabilitation plan update was due no later than January 24, 2026; however, this was not completed until March 30, 2026.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Passages to Recovery Clinical Supervisor has informed and instructed all clinical staff that treatment and rehabilitation plans must be reviewed and updated prior to, and no later than, every 60 days in accordance with regulatory requirements. To ensure ongoing compliance, the Clinical Supervisor will conduct monthly chart audits to verify that all treatment and rehabilitation plans are completed, reviewed, and updated within the required 60-day timeframe.
Passages to Recovery clinical staff developed an audit spreadsheet and conducted chart audits of current client records to assess compliance. Monthly audits of all client charts will continue to ensure ongoing compliance. |
709.93(a)(8) LICENSURE Client records
709.93. 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.
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Observations
Based on applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in seven of seven applicable records. The facility policy and procedure manual indicate an initial case consultation to occur within ten days of admission, then every ninety days thereafter. Client #1 was admitted to outpatient on December 30, 2025 and was still active at the time of the inspection. The initial case consultation was due to occur no later than January 9, 2026; however, this was not completed until May 14, 2026.Client #2 was admitted to outpatient on November 14, 2025 and was still active at the time of the inspection. The initial case consultation was due to occur no later than November 24, 2025; however, this was not completed until December 4, 2025. The next ninety-day case consultation was to occur no later than March 4, 2026; however, this was not completed until March 9, 2026.Client #3 was admitted to outpatient on February 12, 2026 and was still active at the time of the inspection. The initial case consultation was due to occur no later than February 22, 2026; however, this was not completed at the time of the inspection. Client #4 was admitted to outpatient on September 20, 2025 and was discharged April 30, 2026. There were no case consultations documented prior to discharge.Client #5 was admitted to outpatient on August 4, 2025 and was discharged on January 15, 2026. There were no case consultations documented prior to discharge. Client #6 was admitted to outpatient on September 10, 2025 and was discharged on April 30, 2026. The initial case consultation was due to occur no later than September 20, 2025; however, this was not completed until September 28, 2025. The ninety-day case consultation was due to be completed no later December 28, 2025; however, this was not completed until December 30, 2025. The next ninety-day case consultation was due to be completed no later than March 2, 2026; however, this was not completed prior to discharge. Client #7 was admitted to outpatient on November 3, 2025 and was discharged on March 30, 2026. There were no case consultations documented prior to discharge. This finding was reviewed with facility staff during the licensing process.This is a repeat citation from the June 16, 2025 annual licensing inspection.
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Plan of Correction
Passages to Recovery administrative staff revised the Policy and Procedure Manual regarding the revised policy require that the initial case consultation will occur within 30 days of admission and every ninety days thereafter.
To ensure ongoing compliance with these requirements, the Clinical Supervisor will conduct regular chart audits to verify that case consultations are completed within the timeframes established by policy.
The Clinical Supervisor and Chief of Staff provided guidance to clinical staff regarding case consultation requirements. The Clinical Supervisor will conduct weekly chart audits to ensure clinical staff review ERS alerts and complete all required case consultations in a timely manner. All current client records will be reviewed for compliance, and ongoing monitoring will ensure that future client records remain compliant with case consultation requirements. |
709.93(a)(11) LICENSURE Client records
709.93. 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.
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Observations
Based on applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in four of four records. The policy and procedure manual indicates follow-up contact must be made within seven and thirty days of discharge.Client #4 was admitted to outpatient on September 20, 2025 and was discharged April 30, 2026. The seven-day follow-up contact was due to be completed no later than May 6, 2026; however, this was not completed at the time of the inspection.Client #5 was admitted to outpatient on August 4, 2025 and was discharged on January 15, 2026. The thirty-day follow-up contact was due to be completed no later than February 15, 2026; however, this was not completed until February 26, 2026.Client #6 was admitted to outpatient on September 10, 2025 and was discharged on April 30, 2026. The seven-day follow-up contact was due to be completed no later than May 6, 2026; however, this was not completed at the time of the inspection.Client #7 was admitted to outpatient on November 3, 2025 and was discharged on March 30, 2026. The thirty-day follow-up contact was due to be completed no later than April 30, 2026; however, this was not completed until May 1, 2026.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery's clinical staff will complete seven-day and thirty-day follow-up contacts with all discharged clients in accordance with the organization's policies and procedures governing client discharge and continuing care.
To ensure ongoing compliance with these requirements, the Clinical Supervisor will conduct regular chart audits to verify that seven-day and thirty-day follow-up contacts are completed and documented within the timeframes established by agency policy.
The Clinical Supervisor and Chief of Staff provided guidance to clinical staff regarding new follow up policies and requirements. The Clinical Supervisor will conduct weekly chart audits to ensure clinical staff review ERS alerts and complete all required client 30-day follow-ups in a timely manner. All current client records will be reviewed for compliance, and ongoing monitoring will ensure that future client records remain compliant with follow-up requirements. |