INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, TPALS 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the facility director.
Employee # 1 has been in the position of facility director since January 1, 2016. The facility's training year that was reviewed was from January 1, 2025 through December 31, 2025. Employee # 1's personnel record only documented 8 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has enrolled in and scheduled the required training hours to meet the annual requirement for the current training year. Documentation of the completed training will be submitted to the personnel file upon completion. Employee number one completed 4 hours of training, and it was recorded in his employee chart before all of his training hours for that year were completed by 2/13/2026. Any staff who is not staying on schedule throughout the year with their required hours will be coached or written up at the Facility Director's discretion.
To ensure ongoing compliance with 704.11(d)(2): The clinical supervisor will maintain a training tracking log for all staff, including the project/facility director. The log will include: Required annual hours, completed hours, due dates, and verification of certificates. The Facility Director will meet quarterly with the Clinical Supervisor to review the training process and ensure all required hours are on track for completion. The Clinical Supervisor is responsible for tracking, auditing, and documenting. The facility Director will ensure the timely completion of training hours. This will be implemented on 2.13.2026. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project, in one of one applicable record reviewed.
Client # 4 was admitted to outpatient level of care on April 30, 2025 and was involuntarily discharged on September 17, 2025. The record did not contain documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction for 709.33(a): An Involuntary Termination Notice has been completed for Client #4 and placed in the client record. Staff involved in the discharge have been re-educated on the requirement to provide written notice prior to or at time of involuntary termination. A mandatory step has been added to the discharge process requiring all staff to: Provide written notice to to the client chart. he client and upload the file. We will hold a refresher training on 709.33(a), documentation for all involuntary discharges and that they are uploaded. Clinical Supervisor is responsible to audit 100% of discharges monthly to verify the notice is present. Facility Director will review termination procedures quarterly to ensure compliance and updated policies when needed. |