INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 3, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, GPHA Dental and Behavioral Health Center 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's April 2025 through May 2026 fire drill logs, the facility failed to maintain a written fire drill record, which is to include the documentation of which exit route was used during the fire drill.
At the time of the inspection, the January 13, 2026 fire drill log did not include documentation of which exit route was used during the fire drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure full compliance with 705.28. Fire Safety (d) (4), a meeting was held with the security officer, direct supervisor, clinical supervisor and site director immediately following the audit on June 3, 2026, to discuss the findings and corrective action steps moving forward.
After each Fire drill, the drill facilitator, clinical supervisor, and site director will meet briefly to discuss the outcome of the fire drill and review the data entry to ensure that all fields are completed and meet all standards outlined in 705.28. Fire Safety such as the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. Once the Fire Drill has been discussed and the fire drill form has been completed, the fire drill facilitator and site director or clinical supervisor will sign off as verification that the regulatory standards has been met.
Monitoring of fire drills will be conducted quarterly by the quality assurance department. Findings from the fire drill report will be reviewed during the first monthly meeting following the quarterly review. The report will include relevant information such as compliance with regulatory standards, trends for evacuation timeliness, participants, and barriers encountered.
Monitoring On Going
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709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to ensure informed and voluntary consent to release information forms included the name of the person, agency, or organization to whom disclosure is made in one of seven client records reviewed.
Client # 5 was admitted on August 13, 2025 and was discharged on February 11, 2026. There was a consent to release information form, signed by the client on August 13, 2025, which indicated the name of the person to whom disclosure would be made to as "PCP", which is not specific enough of a name, person, or organization.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.28 (c) (1) LICENSURE
Confidentiality:
To comply with § 709.28. Confidentiality. (c) (1) A request to have an adjustment made in the electronic health record was submitted on 6/9/2026. On July 13, 2026, the requested adjustment was finalized.
Notification of the EHR change occurred during morning check-in on July 14, 2026. The field on the consent form that captures: (1) Name of the person, agency or organization to whom disclosure was already a required field. However, the field now notes as an example in bold italic: PCP is not the name of a person, agency, or organization.
Additionally, a targeted supervision session occurred June 10, 2026, with the employee directly linked to the infraction to inform staff of the error, to review standard 709.28. Confidentiality, and offer additional training or support.
Ongoing monitoring: DA Clinical Supervisors/Coordinators will review active clients over the next 30 days to ensure all informed and voluntary consent forms meet compliance standards. As an additional training measure, the directly linked employee will complete one peer review of at least 10 charts, auditing the consent forms.
The Admission and Discharge Manager will conduct biweekly audits of new admissions to confirm that informed and voluntary consent forms are completed according to standards. If any consent forms are found to be noncompliant, corrections will be made during the client's next scheduled and attended session.
Audit findings will be presented quarterly to the BH Leadership Team.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling sessions were provided according to the individual treatment and rehabilitation plan in five of seven client records reviewed.
Client # 1 was admitted on February 13, 2026 and was still active at the time of inspection. A treatment plan update, completed on April 14, 2026, indicated the client was to receive one individual therapy session per week. There was no documentation in the record indicating the client received any individual sessions during the weeks of April 19, 2026; April 26, 2026; May 10, 2026, and May 17, 2026.
Client # 2 was admitted on November 20, 2025 and was still active at the time of inspection. A treatment plan update, completed on May 18, 2026, indicated the client was to receive one individual therapy session per week. There was no documentation in the record indicating the client had received any individual sessions during the weeks of May 10, 2026 and May 24, 2026.
Client # 5 was admitted on August 13, 2025 and was discharged on February 11, 2026. A treatment plan update, completed on January 12, 2026, indicated the client was to receive one individual therapy session biweekly. There was no documentation in the record indicating the client had received any individual sessions from January 12, 2026 to the date of discharge.
Client # 6 was admitted on April 7, 2025 and was discharged on October 12, 2025. A treatment plan update, completed on September 12, 2025, indicated the client was to receive one individual therapy session biweekly. There was no documentation in the record indicating the client had received any individual sessions from September 13, 2025 to the date of discharge.
Client # 7 was admitted on November 28, 2025 and was discharged on February 22, 2026. A treatment plan update, completed on January 23, 2026, indicated the client was to receive one individual therapy session biweekly. There was no documentation in the record indicating the client had received any individual sessions from January 24, 2026 to the date of discharge.
This is a repeat citation from the April 15, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92(c) LICENSURE
Treatment and rehabilitation services:
709.92. Treatment and rehabilitation services. (c) The project shall ensure that counseling services are provided according to the individual treatment and rehabilitation plan.
To ensure compliance with §709.92(c), the Program has implemented procedures to ensure counseling services are delivered in accordance with each member's individual treatment and rehabilitation plan while supporting member engagement, individualized care, and value-based treatment principles.
Effective July 27, 2026, treatment and rehabilitation plans will utilize a flexible, member-centered approach that allows treatment services to be based on the member's clinical needs, treatment goals, preferences, and ability to participate in treatment. Counselors and members will collaborate to establish an appropriate treatment schedule that promotes recovery and meaningful engagement in services.
The treatment and rehabilitation plan will generally encourage members to participate in a minimum of three treatment services per month, which may include any combination of: Individual counseling sessions; and/or Group therapy sessions.
Members may participate in up to eight treatment services per month when clinically indicated and mutually agreed upon by the member and counselor. Additional services scheduled will be documented in the plan section of the progress note with clinical justification as needed. The impact of additional services received will be discussed in the updated treatment and rehabilitation plan.
In addition to counseling services, members may access other supportive services as clinically appropriate, including: Peer Support Services, Community Health Worker Services, Psychiatric Evaluation, and Medication Management Services.
Members who fail to attend a scheduled treatment session will receive follow-up and reengagement efforts consistent with agency policy. Engagement interventions may include appointment reminders, telephone outreach, motivational interventions, and other clinically appropriate activities intended to support continued participation in treatment.
If a member is unable to participate in the minimum anticipated treatment frequency despite engagement efforts, the treatment and rehabilitation plan will be reviewed and revised to reflect the member's current level of participation, clinical needs, treatment goals, and readiness for treatment. Modifications to service frequency will be documented in the clinical record and incorporated into the updated treatment and rehabilitation plan.
Monitoring and Oversight
Clinical Supervisors will ensure that the frequency of individual counseling and group therapy sessions identified in each treatment and rehabilitation plan is entered into the DA Tracker. The DA Tracker will be reviewed weekly to monitor compliance with scheduled treatment frequency and identify members who may require additional outreach, treatment plan review, or engagement interventions.
Clinical Supervisors will document monitoring activities and provide ongoing oversight to ensure counseling services are delivered in accordance with the individualized treatment and rehabilitation plan and remain compliant with §709.92(c).
Quality Assurance
As part of the program's continuous quality improvement process, treatment scheduling and service utilization data will be reviewed regularly to ensure counseling services are being provided in accordance with member treatment plans. Findings will be used to identify opportunities for improvement in treatment engagement, service delivery, and compliance with §709.92(c).
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