INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5-7, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Alpine Springs Rehabilitation & Recovery Center, LLC 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director and/or facility director met the qualifications for their position in one record reviewed. Staff #1 became project and facility director on July 14, 2025, but did not have the required educational qualifications prior to the starting the role as director. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project director has filed an exception via the DDAP Exceptions process. We have been approved for a 6 month extension while we search for a suitable canididate.
Doug Datish, CEO is responsible to find and hire this candidate that meets the requirements.
Goal is to be completed by Q2 of 2026 |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the personnel training records, the facility failed to ensure that one counselor completed at least 25 clock hours of annual training in one of one records. Employee #4 was hired as a counselor on December 30, 2024 and still employed. Employee #4 only completed 6 hours of training during the 2025 training year. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director is working with both the Clinical Supervisor as well as the Head of Human Resources to utilize our current internal systems to ensure this training requirement is properly monitored and documented. We are creating a monthly training plan for all counselors that will ensure that the training requirements are met both in terms of hours (25) and approved curriculum derived from regulation 704.11.
Corrective actions will be completed by 2/1/26 |
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.
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Observations
Based on a review of personnel records, the facility failed to ensure staff were instructed in the use of fire extinguishers upon employment in two of five applicable records. Staff #3 was hired on January 20, 2025 and still employed. The training was completed on May 14, 2025.Staff #5 was hired on April 28, 2025 and still employed. The training was completed on May 23, 2025.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director has worked with the Head of HR to ensure that new employees complete the fire extinguisher course within 7 days of their hire date. This included an update to our HR system to be able to monitor this regulation requirement. The HR Director updated the system and it was checked by the Project Director.
Date of completion 2/1/26.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records, the facility failed to conduct monthly fire drills. Fire drill logs were reviewed from January 2025 to December 2025. No fire drills were conducted in October or November 2025. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The staff person in charge of this was replaced prior to the inspection. Project Director will ensure that staff performs regular fire drills as per our internal policies and to meet the regulatory standards.
Our new COO was hired and has followed our internal policies and procedures by performing fire drills per the regulations.
Date of completion 12/1/25. |
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.
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Observations
Based on a review of personnel records and staff interviews, the facility failed to document an annual written individual staff performance evaluation in one of two applicable records reviewed. Staff #2 was promoted to clinical supervisor on January 11, 2021 and still employed. There was no annual staff performance evaluation documented for the year 2025 in the staff record.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will ensure that yearly reviews will be completed on time. The Head of Human Resources has set up reminders inside of our internal HR system to ensure the reviews are completed on time. |
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 notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of three applicable client record.Client #5 was admitted on August 25, 2025, and administratively discharged on October 30, 2025. There was no documentation of the facility notifying the client of the decision to terminate treatment in the client record. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will work with Counseling Supervisor and Nursing Supervisor to ensure we are following our internal policies regarding AMA notification. They will continue to train their staff to follow the internal policies even when confronted with an extraordinary situation.
We hired a COO and this person has created and uses an internal auditing system to ensure this process is completed per the regulations and our internal polices.
Date of completion. 2/1/26 |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of administrative and client records, the facility failed to inform the Department of an unusual incident within the required three days. The facility had an unusual incident occur on July 23 and December 28, 2025 which involved a physical assault. The facility has not submitted a written unusual incident report to the Department at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director has re-trained themself as well as staff regarding the appropriate time frame and nature of what is considered a critical incident.
COO was hired and has created an internal auditing system to monitor this.
Date of completion 2/1/26 |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of administrative and client records, the facility failed to inform the Department of an unusual incident within the required three days. The facility had unusual incidents occur on May 25, August 30, October 4, October 19, and November 8, 2025 all of which involved emergency personnel on site. The facility has not submitted written unusual incident reports for these incidents to the Department at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director has re-trained themself as well as staff regarding the appropriate time frame and nature of what is considered a critical incident.
COO was hired and has created an internal auditing system to monitor this.
Date of completion 2/1/26 |
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against medical advice in one of two applicable residential client records.The facility's policy and procedure states that the client ' s emergency contact will be notified immediately but no later than 12 hours following a client ' s decision to leave the facility against medical advice.Client #3 was admitted on September 15, 2025, and discharged on October 6, 2025. There was a valid consent for the emergency contact in the record but no documented attempt to contact the emergency contact. This finding was reviewed with facility staff during the licensing process.This is a repeat citation from the January 8, 2025 licensing renewal inspection.
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Plan of Correction
Project Director will work with Counseling Supervisor and Nursing Supervisor to ensure we are following our internal policies regarding AMA notification. They will continue to train their staff to follow the internal policies even when confronted with an extraordinary situation.
We hired a COO and this person has created and uses an internal auditing system to ensure this process is completed per the regulations and our internal polices.
Date of completion. 2/1/26 |
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.
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Observations
Based on a review of client records, the facility failed to document follow-up information in four of six applicable residential client records. The facility's policy and procedure states follow-up contact is to be completed for all discharges within 7 days and again at 6 months.There was no follow-up documented in the following client records. Client #1 admitted on June 28, 2025 and discharged on August 18, 2025.Client #2 admitted on August 4, 2025 and discharged on September 12, 2025.Client #4 admitted on September 22, 2025 and discharged on October 29, 2025.Client #5 admitted on August 25, 2025 and discharged on October 30, 2025.This finding was reviewed with facility staff during the licensing process.This is a repeat citation from the January 8, 2025 licensing renewal inspection.
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Plan of Correction
Project Director will work with the Admissions Supervisor to re-write the Follow Up Policy based upon the updated follow up procedure. This policy will be implemented and trained with the admissions staff. The Project Director has also worked with the Director of IT to upgrade the system used to monitor this process. These upgrades will ensure this policy is followed as per regulation 709.53(a)(11)
Completion date: 2/1/26 |