INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 25, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Spark Wellness Elkins Park 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(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 personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training during the facility's January 1, 2025 through December 31, 2025 training year in two of three applicable personnel records reviewed.
Employee # 4 was hired as a counselor on May 11, 2022. The personnel record documented 23 hours of training received during the training year reviewed.
Employee # 5 was hired as a counselor on August 1, 2023. The personnel record documented 23.25 hours of training received during the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each month, the Clinical Director will remind each team member in the weekly team meeting about the required hours for their position to be completed.
The Clinical Director will also keep a spreadsheet and update it with training hours completed to better assess where each employee is in their hours requirements. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
The project had an exception to the regulation requiring an audit if the project's gross income is less than $500,000. However, the project provided a copy of their 2024 tax return indicating the gross income exceeded $500,000 for the project's previous fiscal year; therefore, the exception is no longer valid, and a financial audit was to be completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/9/26, ownership has been notified by Clinical Director of the need for a financial audit with projected income levels.
Ownership was also notified if the financial number is projected to be lower than $500,000 to apply for an exemption.
Ownership have applied for the exception again. If it is denied, audit will be completed by July 1, 2026 |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in two of nine client records reviewed.
Client # 5 was admitted to the outpatient activity on August 18, 2025 and was still active at the time of the inspection. There was evidence of a disclosure to a family member during a family counseling session on February 9, 2026; however, there was no consent to release information signed by the client documented in the record prior to the disclosure.
Client # 9 was admitted to the outpatient activity on July 24, 2025 and was discharged on October 30, 2025. There was evidence of a disclosure to a family member during a family counseling session on September 15, 2025; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/9/26, the Clinical Director will be doing intake chart checks to assess that all necessary consents have been signed.
Also on 3/9/26, clinicians will be made aware that any type of family involvement in treatment will need a ROI for that individual. |
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 client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in five of six applicable client records reviewed.
Client # 3 was admitted to the outpatient activity on August 5, 2025 and was still active at the time of the inspection. A treatment plan update was completed on December 2, 2025 and the next update was due no later than February 3, 2026; however, the update was not completed at the time of the inspection.
Client # 4 was admitted to the outpatient activity on May 12, 2025 and was still active at the time of the inspection. A treatment plan update was completed on July 23, 2025 and the next update was due no later than September 23, 2025; however, the update was not completed until November 1, 2025. Additionally, the next update was due no later than January 1, 2026; however, the update was not completed until January 23, 2026.
Client # 5 was admitted to the outpatient activity on August 18, 2025 and was still active at the time of the inspection. A treatment plan update was completed on October 6, 2025 and the next update was due no later than December 6, 2025; however, the update was not completed until January 23, 2026.
Client # 6 was admitted to the outpatient activity on March 25, 2025 and discharged on October 30, 2025. The individual treatment and rehabilitation plan was completed on March 26, 2025 and an update was due no later than May 26, 2025; however, the update was not completed prior to discharge.
Client # 7 was admitted to the outpatient activity on June 9, 2025 and was discharged on December 1, 2025. A treatment plan update was completed on August 6, 2025 and the next update was due no later than October 6, 2025; however, the update was not completed until October 30, 2025.
This is a repeat citation from the February 26, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/9/26, the Clinical Director will be conducting chart checks for each clinician on a weekly basis. This chart check will include information that includes upcoming paperwork that will be due, including treatment plan updates, with their due date.
As to the clients listed, each of their treatment plan updates will be completed by 3/13/26. |