INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on November 5-6, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Tadiso 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on applicable personnel records reviewed, the facility failed to provide documentation of clinical supervision training for a clinical supervisor who does not meet the required experience supervising others in two of three records.Staff #5 was promoted to a clinical supervisor on January 3, 2025 and was still in this position at the time of the inspection. After a review of staff #5 ' s personnel record, they do not have two years experience supervising others and they did not complete a core curriculum in clinical supervision training approved by the Department until October 21, 2025.Staff #6 was hired as a clinical supervisor on January 6, 2025 and was still in this position at the time of the inspection. After a review of staff #6 ' s personnel record, they do not have two years experience supervising others and they did not complete a core curriculum in clinical supervision training approved by the Department until October 15, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Any counselor who presents with qualifications to apply for a Clinical Supervisor position will take the Relias learning Clinical Supervisor training by November 25, 2025, and new Counselors who present with qualifications will take the training during onboarding.
If a Clinical Supervisor is hired from outside the agency, prior to onboarding, the candidate will complete the Clinical Supervisor training on Relias.
Human Resource Department will monitor and assign the training. The Director of Behavioral Health will verify training was completed prior to promotion and/or hiring of any Clinical Supervisor.
This will ensure prior to promotion the Clinical Supervisor will have the training on record.
The courses are already in all qualified counselors' Relias training plan for the 25-26 calendar year. |
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 personnel records, the facility failed to provide written individual training plans per the facility ' s policy and procedure in one of ten records. The facility ' s policy and procedure manual states individual training plans will be completed by July 30 each year.Staff #7 was promoted to a clinical supervisor on June 1, 2019 and was still in this position at the time of the inspection. Staff #7 ' s individual training plan was to be completed by July 30, 2025; however, this was not completed until October 13, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training reviews have been changed to quarterly, effective 7/1/2025, this will ensure that all managers are following and reviewing them at least quarterly.
The Human Resource Department will keep track and send out quarterly messages to make sure all managers complete his/her training packages for all their supervisees. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill log for the months of December 2024 through October 2025, the facility failed to provide documentation of a fire drill being conducted the month of February 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure that the required monthly fire drill is completed, the Director of Security will set a reminder on their electronic calendar for the 25th of each month.
This will ensure that the drill is completed if it has not been done.
The Director of Security will also assign one of the security officers to assist the Director of Security each month with the drills to act as a backup for doing the drills each month. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on applicable patient records reviewed, the facility failed to provide documentation of a random drug-screening urinalysis for each patient and at least eight times a year in one of four records.Patient #3 was admitted to outpatient on June 28, 2023 and was discharged on August 18, 2025. The facility only documented seven random drug-screening urinalyses from June 2024 to June 2025.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When a patient presents for a UDS, Laboratory Techs will review the EHR on the patient to verify that at least 8 UDS have been conducted based on the patient's admission date. If the patient requires further UDS's based on admission date, the Laboratory Tech will place hold on the patient to retrieve the UDS within the allotted time.
If a patient presents to medical with a scanned third-party UDS, a general note will be completed to identify the UDS in the Case History for auditing purposes.
CMO, and Director of Accreditation and Licensing will relay this information to all counselors and the Director of Behavioral Services so they are aware of where this documentation may be stored.
IT will develop a general note that any staff who is provided a scanned UDS can document and identify date of the stored document.
The Chief Medical Officer and the Medical Director will oversight compliance with this regulation. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to include the results of an annual physical examination by the narcotic treatment physician in four of four applicable records.Patient #1 was admitted to outpatient on January 17, 2023 and was still active at the time of the inspection. The annual physical examination was due no later than January 17, 2025; however, it was not completed at the time of the inspection.Patient #3 was admitted to outpatient on June 28, 2023 and was discharged on August 18, 2025. The annual physical examination was due no later than June 28, 2025; however, it was not completed prior to discharge.Patient #6 was admitted to outpatient on October 16, 2006 and was still active at the time of the inspection. The annual physical examination was due no later than October 16, 2025; however, it was not completed at the time of the inspection.Patient #7 was admitted to outpatient on June 26, 2019 and was still active at the time of the inspection. The annual physical examination was due no later than June 26, 2025; however, it was not completed at the time of the inspection.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The first day of each month, the Medical Department will pull a service due report on annual physical exams and schedule them at least 30 days before due.
Medical personnel will review EMR at each session to verify that an annual physical examination was completed each year from the patient's date of admission.
Quality Assurance personnel will randomly review patient charts to check that an annual physical occurred each year.
IT will reassess EMR programming to ensure the trigger to perform an annual physical exam is set for 11 months from admission.
Staff practitioners will also now manually audit intermittently to double-check EMR programming.
Inconsistencies in the EMR triggers and manual audits will immediately be brought to the attention of IT.
The Chief Medical Officer will monitor and ensure compliance with this regulation. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on applicable patient records reviewed, the facility failed to have an annual evaluation of each patient ' s status that was completed by the patient ' s counselor and was reviewed, dated, and signed by the medical director in one of three records. The annual evaluation period shall start on the date of the patient ' s admission to a narcotic treatment program.Patient #3 was admitted to outpatient on June 28, 2023 and was discharged on August 18, 2025. The annual evaluation was due by June 28, 2025; however it was not completed until June 30, 2025. This finding was reviewed with the facility staff during the licensing process.This is a repeat citation from the December 17-28, 2024, November 16-17, 2023, and November 28-30, 2022 annual licensing inspections.
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Plan of Correction
Annual Clinical evaluations have been changed to populate at month 11, allowing 30 days for counselors to complete and have the medical provider sign off on the form before the 12-month due date.
Clinical supervisors will monitor services due reports weekly to ensure clinical evaluations are completed within the required time frame.
IT will reassess EMR programming to ensure the trigger to perform an annual clinical evaluation is set for 11 months from admission.
Counselors and Quality Assurance personnel will also now manually audit intermittently to double-check EMR programming.
Inconsistencies in the EMR will immediately be brought to the attention of IT. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on applicable client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client per the facility ' s policy and procedure manual in three of three records. The facility ' s policy and procedure states an individual treatment and rehabilitation plan will be completed within thirty days of admission.Client #2 was admitted to outpatient on January 7, 2025 and was discharged on April 15, 2025. The comprehensive treatment and rehabilitation plan was to be developed no later than February 7, 2025; however this was not completed prior to discharge.Client #4 was admitted to outpatient on May 27, 2025 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was to be developed no later than June 27, 2025; however this was not completed until July 1, 2025.Client #5 was admitted to outpatient on June 2, 2025 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was to be developed no later than July 2, 2025; however this was not completed until August 11, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual will be updated as follows: The Individual treatment and rehabilitation plan will be completed on or before the second attended counseling session.
The counselor will complete the treatment plan update by session number two.
Clinical supervisors will monitor treatment plan due dates in supervision using staff services due reports to ensure patients are being seen within the required time frame. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services in two of two records. Client #4 was admitted to outpatient on May 27, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on July 1, 2025; however, there was no documentation of type of services.Client #5 was admitted to outpatient on June 2, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on August 11, 2025; however, there was no documentation of type and frequency of services.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health will have IT add Type and Frequency of services template in the treatment plan to include individual counseling and/or group counseling options.
The individual updating the treatment plan will be required to select both type and frequency of services at each update to complete the service.
The Director of Behavioral Health will be responsible for ensuring the POC is implemented and monitored.
Clinical supervisors will randomly review counselors' treatment plans to check for documentation of type and frequency of service.
Quality assurance will check charts during reviews for treatment plans for documentation of type and frequency of service in the treatment plan. |
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 client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in four of six applicable records.Client #1 was admitted to outpatient on January 17, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on January 13, 2025 and the next update was due by March 15, 2025; however this was not completed until March 19, 2025. A treatment and rehabilitation plan update was completed on March 19, 2025 and the next update was due by May 19, 2025; however this was not completed until May 22, 2025.A treatment and rehabilitation plan update was completed on May 22, 2025 and the next update was due by July 22, 2025; however this was not completed until July 23, 2025.A treatment and rehabilitation plan update was completed on July 23, 2025 and the next update was due by September 23, 2025; however this was not completed until September 24, 2025.Client #3 was admitted to outpatient on June 28, 2023 and was discharged on August 18, 2025. A treatment and rehabilitation plan update was completed on October 22, 2024 and the next update was due by December 22, 2024; however this was not completed until May 14, 2025. Additionally, the next treatment plan update was due by July 14, 2025; however this was not completed until July 18, 2025.Client #5 was admitted to outpatient on June 2, 2025 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed on August 11, 2025 and the next update was due by October 11, 2025; however this was not completed at the time of the inspection. Client #7 was admitted to outpatient on June 26, 2019 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on January 7, 2025 and the next update was due by March 9, 2025; however this was not completed until March 26, 2025. The next treatment plan update was due by May 26, 2025; however this was not completed until July 17, 2025.The next treatment plan update was due by September 17, 2025; however this was not completed until October 21, 2025.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the December 17-18, 2025 and November 16-17, 2023 annual licensing inspections.
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Plan of Correction
Counselors will document treatment plan due dates on their counseling tracker as they are updated, which will be utilized in weekly supervision to ensure that patients are being seen for updates prior to 60 days.
Clinical supervisors will monitor treatment plan due dates using staff services due reports in supervision to ensure patients are being seen within the required time frame. Medication holds will be used if patients are not attending scheduled counseling services to ensure treatment plan updates are completed by the due date. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual in one of two records. The policy and procedure indicates a discharge summary be completed within thirty days of discharge.Client #2 was admitted to outpatient on January 7, 2025 and was discharged on April 15, 2025. The discharge summary was due to be completed no later than May 15, 2025; however, this was not completed until May 19, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will monitor counselor services due report weekly to ensure counselors are completing all discharge summaries within the allotted time frame. The clinical supervisor will review the discharge reports due with counselor during supervision.
The clinical supervisor who is responsible for monitoring and discharging suspended patients will notify the counselor and/or assigned supervisor at the time of patient discharge to ensure they are aware of deadlines. |
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.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.A plan of correction for annual evaluations was submitted and approved by the Department for the December 17-18, 2024, November 16-17, 2023, and November 28-30, 2022 annual licensing inspections. Annual evaluations were again found to be a deficiency in the November 5-6, 2025 annual licensing inspection.A plan of correction for treatment plan updates was submitted and approved by the Department for the December 17-18, 2024 and November 16-17, 2023 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the November 5-6, 2025 annual licensing inspection.This was reviewed with the facility staff during the licensing process.This is a repeat citation from the December 17-18, 2024 annual licensing inspection.
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Plan of Correction
The Director of Accreditation and Licensing will review POC monthly with Administrative Heads to ensure the details of the administrative citation are followed and monitored to ensure compliance in the areas of need.
Clinical Supervisors will monitor their supervisees' trackers for annual clinical evaluations and treatment plans.
Quality Assurance will intermittently monitor patient charts for compliance in the areas of concern. |