INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 30, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, TUHS, 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure the full-time equivalent (FTE) counselor caseload for counseling in outpatient programs did not exceed 35 active clients in three of five applicable personnel records reviewed.
The counselor FTE is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee # 3 was hired as a clinical supervisor on March 4, 2024 and was still employed at the time of the inspection. Per the numbers reported in the Staffing Report, the employee's ratio calculation was as follows: 15/40 = 0.375(FTE); 30/0.375 = 80, which equals a FTE client/counselor ratio of 80:1.
Employee # 6 was hired as a counselor on July 1, 2025 and was still employed at the time of the inspection. Per the numbers reported in the Staffing Report, the employee's ratio calculation was as follows: 8/40 = 0.2(FTE); 15/0.2 = 75, which equals a FTE client/counselor ratio of 75:1.
Employee # 7 was hired as a counselor on July 1, 2025 and was still employed at the time of the inspection. Per the numbers reported in the Staffing Report, the employee's ratio calculation was as follows: 8/40 = 0.2(FTE); 15/0.2 = 75, which equals a FTE client/counselor ratio of 75:1.
This is a repeat citation from the May 28, 2028 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Posting requisitions for additional counselor positions (2.0 FTE) will be completed by July 17, 2026. Facility and Program Directors will work closely with HR team to expedite recruitment efforts for hire.
Additionally, the leadership team will engage with medical staff at TUHS to identify possibility of adding additional provider hours to the clinic.
Monthly status report will be provided by the Facility Director to the Episcopal Campus Executive Director. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in two of two applicable personnel records reviewed.
Employee # 6 was hired as a counselor on July 1, 2025. There was documentation in the personnel record indicating the fire extinguisher training was not completed until May 7, 2026.
Employee # 7 was hired as a counselor on July 1, 2025. There was documentation in the personnel record indicating the fire extinguisher training was not completed until May 5, 2026.
This is a repeat citation from the June 27, 2024 and May 28, 2025 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the clinical supervisor in collaboration with the hiring manager will ensure that assigned fire extinguisher training is completed on the first day of employment. As this is a repeat finding, an escalation of compliance reporting will require the Facility Director to submit a fire extinguisher training compliance report, monthly, to the Episcopal campus Executive Director. Any data fallouts from the report will be addressed in accordance with established disciplinary policy. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the facility's June 2025 through June 2026 fire drill logs, the facility failed to conduct fire drills during normal staffing conditions.
During the reviewed timeframe, the facility had posted hours of operation from Monday through Friday from 8:00 a.m. to 4:00 p.m. The logs completed for the fire drills conducted during the months of August 2025 and January 2026 had the time of the drill falling outside the normal posted business hours and normal staffing conditions.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the Program Director will ensure that fire drills are completed during normal staffing conditions. As this is a repeat finding, an escalation of compliance reporting will require the Program Director to submit a fire drill report, monthly, to the Episcopal campus Executive Director. Any data fallouts from the report will be addressed in accordance with established disciplinary policy. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies in two of two applicable personnel records reviewed.
Employee # 6 was hired as a counselor on July 1, 2025. There was documentation in the personnel record indicating the training to perform assigned tasks during emergencies was not completed until May 7, 2026.
Employee # 7 was hired as a counselor on July 1, 2025. There was documentation in the personnel record indicating the training to perform assigned tasks during emergencies was not completed until March 31, 2026.
This is a repeat citation from the June 27, 2024 and May 28, 2025 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the clinical supervisor in collaboration with the hiring manager will ensure that assigned emergency preparedness training is completed on the first day of employment. As this is a repeat finding, an escalation of compliance reporting will require the Facility Director to submit an emergency preparedness compliance report, monthly, to the Episcopal campus Executive Director. Any data fallouts from the report will be addressed in accordance with established disciplinary policy. |
711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance 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.
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Observations
Based on a review of personnel records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to instruct all staff in the use of the fire extinguisher upon staff employment was submitted and approved by the Department for the June 27, 2024 and May 28, 2025 annual licensing inspections. Failing to instruct all staff in the use of the fire extinguisher upon staff employment was again found to be a deficiency in the June 30, 2026 annual licensing inspection.
A plan of correction for failing to ensure all personnel on all shifts are trained to perform assigned tasks during emergencies was submitted and approved by the Department for the June 27, 2024 and May 28, 2025 annual licensing inspections. Failing to ensure all personnel on all shifts are trained to perform assigned tasks during emergencies was again found to be a deficiency in the June 30, 2026 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction monitoring for the June 30, 2026 survey findings will be reviewed monthly among the Facility and Program Directors and Executive Director of the Episcopal Campus to ensure compliance. Any barriers to completion or success will be reviewed with identified strategies assigned during those monthly meetings. Follow-up and subsequent monthly meetings will be focused on POC compliance with any performance matters being addressed through established employee performance/ disciplinary policy. |
711.91(b)(1) LICENSURE Disclosure of Criteria
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document, during their intake and admission process, the disclosure to the client of the criteria for admission, treatment, completion, and discharge in seven of seven client records reviewed.
In every client record reviewed, there was no documentation indicating the criteria for admission, treatment, completion, and discharge was disclosed to the client.
This is a repeat citation from the May 28, 2025 annual licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective immediately, verbiage regarding admission criteria will be added to our client orientation paperwork.
Additionally, verbiage indicating receipt of this information will be included on our consent to treat form which all clients complete at their first appointment. This form is currently contained in our electronic medical record. A request for edits to the form will be submitted by July 17 with EMR updated expected no later than August 14.
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711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in four of five applicable client records reviewed.
Client # 2 was admitted on March 9, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 9, 2026 and the first update was due to be completed no later than May 9, 2026; however, the update was completed on May 28, 2026.
Client # 3 was admitted on January 22, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 22, 2026 and the first update was due to be completed no later than March 22, 2026; however, the update was completed on April 29, 2026.
Client # 6 was admitted on September 22, 2025 and was discharged on March 26, 2026. The individual treatment and rehabilitation plan was completed on September 22, 2025 and the first update was due to be completed no later than November 22, 2025; however, the update was completed on December 11, 2025.
Client # 7 was admitted on December 30, 2025 and was discharged on May 29, 2026. The individual treatment and rehabilitation plan was completed on December 30, 2025 and the first update was due to be completed no later than February 28, 2026; however, the update was completed on March 23, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic staff do understand the regulatory requirement and have designed a master client document tracking tool that is regularly updated and available to front desk staff and providers to mitigate fall outs. The challenge surrounding client appointment compliance continues to impact late treatment plan fallouts. Effectively immediately, the monitoring tool will be amended to reflect a 45 day treatment plan update (target) date to allow the clinic team additional time to improve compliance. Monthly, the Program and Facility Directors will review treatment plan compliance, based on 100% of active chart audits with the Episcopal Campus Executive Director. This audit cadence will continue until 4 consecutive months of 100% compliance is achieved. |