INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 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, Treatment Trends 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(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 personnel records, the facility failed to ensure that two applicable employees received a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.Employee # 3 was hired as a counselor on September 26, 2024 and is still in that position. Employee #3 was due to have the communicable disease trainings no later than September 26, 2025; however, neither the HIV/AIDS training or the TB/STD training were completed as of the date of the inspection.Employee # 5 was hired as a counselor on December 5, 2024 and is still current in that position. Employee # 8 was due to have the communicable disease trainings no later than December 5, 2025; however, the TB/STD training was not completed as of the date of the inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address the deficiency on 1/07/2026 regarding the two staff members missing required DDAP trainings within the first year of hire, the Director discussed with the two employees the missing HIV/AIDS and TB STD trainings. Employee #3 had completed the HIV/AIDS training but failed to submit the training evaluation and certificate to HR. She immediately submitted the completion Certificate for HIV. The missing TB/STD training availability was review and staff member reported she is registered for the training on January 27, 2026 and is on the waitlist. She has also registered for the 3/27/2026 TB/STD training and on the waitlist.
Director reviewed with Employee #5 TB/STD training availability. Employee #5 is registered for the TB/STD training 3/27/2026 and is on the waitlist.
Director or clinical supervisor will review in supervision at least once, every two months the DDAP required trainings. The employee training checklist will be printed for review what is completed and what is still needing to be taken.
DDAP Waiver was requested on 1/12/2026 regarding the two employees.
The Director met with Executive Director and Associate Executive Director on 1/12/2026 to discuss creating an in-house Communicable Disease training. This is still in the planning stage.
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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 # 3 was admitted to the outpatient level of care on August 20, 2025 and was involuntarily discharged on October 15, 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
To address the deficiency on 1/07/2026 regarding the facility failed to notify a client of their involuntary termination in writing, the Director created a discharge letter including the notification of the unsuccessful discharge, date this occurred, notifying the client they can reapply in 30 days, along with the appeals process of writing a letter to the Director and either bringing it to the office or emailing it to the Director. The email address was recorded.
The Director reviewed with Staff in Staff Meeting dated 1/13/2026. The need to mail the termination notice to the client. The support staff will complete this task.
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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 a review of outpatient client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in three of five applicable records reviewed. Client #1 was admitted on July 3, 2025 and was discharged October 30, 2025. A treatment and rehabilitation plan was documented in the record on July 21, 2025, the treatment and rehabilitation plan update was due no later than September 21, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until October 16, 2025. Client #2 was admitted on May 8, 2025 and was discharged October 28, 2025. An updated treatment and rehabilitation plan was documented in the record on July 24, 2025, the next treatment and rehabilitation plan update was due no later than September 24, 2025; however, there were no additional updated treatment and rehabilitation plans documented in the client record.Client #5 was admitted on April 1, 2025 and was a current client at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on August 16, 2025, with the next update due no later than October 16, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until December 8, 2025. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address the deficiency on 1/07/2026 regarding failure to review and update treatment plan every 60 days. Client #1 and #2 treatment plan update, it is the client's counselor or designee responsibility to update treatment plans within 60 days. To prevent future out of compliance, the Director reviewed updating treatment plans in Staff meeting with the staff on 1/13/2026. Director and Associate Clinical Supervisor will review treatment plans updates within ongoing individual supervision. |