INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 5, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pa Treatment and Healing 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) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one out of two applicable records reviewed.
Employee #3 was hired as a counselor on September 2, 2025, and was current in that position at the time of the licensing inspection. There was no documentation training was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On August 17, 2026, PATH conducted a team meeting during which the agency's emergency preparedness procedures were reviewed with all staff. As part of this review, each staff member was assigned specific duties and responsibilities to be carried out in the event of an emergency. Staff received instruction regarding their assigned roles and were provided an opportunity to ask questions and obtain clarification regarding expectations.
Following completion of the training, each staff member signed an attestation confirming that they had been informed of, trained on, and understood their assigned emergency preparedness responsibilities. Signed attestations will be maintained in each employee's personnel file as documentation of completed training.
**Effective immediately, all newly hired staff will receive emergency preparedness training prior to working their first shift or assuming any independent client-care responsibilities.** Emergency preparedness training will be incorporated into PATH's new-hire orientation process and will include review of the agency's emergency preparedness procedures, the employee's specific duties and responsibilities during an emergency, evacuation and emergency-response expectations, and any responsibilities specific to the employee's assigned facility and position. New employees will be provided an opportunity to ask questions and obtain clarification regarding their responsibilities before beginning their first shift.
Upon completion of the training, each new employee will sign an attestation acknowledging that the emergency preparedness procedures and their assigned responsibilities have been reviewed with them and that they understand the expectations associated with their role. **The Facility Director, or an appropriately designated supervisory staff member in the Facility Director's absence, will be responsible for ensuring that this training is completed and documented prior to the employee's first shift.** The employee will not be permitted to begin independent work responsibilities until the required emergency preparedness training has been completed and documented.
**The Facility Director will monitor ongoing compliance with this requirement** by reviewing new-hire training documentation and personnel files to verify that emergency preparedness training and the signed attestation were completed within the required timeframe. The Facility Director will also ensure that emergency preparedness responsibilities are reviewed whenever staffing assignments, job responsibilities, facility operations, or emergency procedures change. Agency leadership may conduct additional periodic personnel-file reviews to verify continued compliance with the pre-service training requirement.
To ensure ongoing compliance and staff competency, PATH will conduct monthly unannounced/random emergency preparedness drills. The Facility Director and/or designated supervisory staff will monitor staff performance during these drills to verify that employees understand and can appropriately carry out their assigned responsibilities. Drill participation, observations, identified deficiencies, and any corrective actions or retraining will be documented. Emergency preparedness assignments will also be reviewed and modified as necessary when staffing changes occur or when drill results identify opportunities for improvement.
Any staff member who is unable to identify or appropriately perform their assigned responsibilities during an emergency preparedness drill will receive documented retraining. The Facility Director or designated supervisor will be responsible for ensuring that the retraining occurs and for subsequently verifying the employee's competency. Continued failure to demonstrate competency following retraining will be addressed through PATH's progressive disciplinary process, consistent with agency policy.
Through the implementation of mandatory emergency preparedness training prior to an employee's first shift, signed training attestations, supervisory verification, ongoing monitoring, monthly emergency drills, and documented retraining when deficiencies are identified, PATH will ensure that all staff are appropriately trained and able to demonstrate competency regarding their assigned emergency preparedness responsibilities.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of seven records reviewed.
Client #6 was admitted to the outpatient program on May 26, 2026, and was active at time of licensing inspection. A release of information form for a government agency signed by the client on May 26, 2026, did not have documentation that a copy was offered.
This finding was reviewed with facility staff during their licensing process.
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Plan of Correction
On August 17, 2026, all clinical staff received retraining regarding the proper completion and documentation of client consent forms. The training specifically addressed the requirement to document whether the client accepted or declined a copy of each applicable consent form. Staff were reminded that all required elements must be completed accurately to ensure that each consent is valid and compliant with agency policy and applicable regulatory requirements.
The client in question was originally offered a copy of the consent on May 26, 2026. Since this was not documented and the client is still active, the clinician has been given 5 business days to have the client notate on that consent whether or not they accept or decline a copy. If this is not completed within the allotted time frame, disciplinary action will be taken.
To ensure ongoing compliance, the Site Supervisor will conduct monthly random chart audits. The audit will include three randomly selected client records from each clinician for each level of care in which the clinician provides services. Consent documentation will be reviewed for completeness, accuracy, and validity, including documentation of whether the client accepted or declined a copy.
If an incomplete or otherwise invalid consent is identified during an audit, the responsible clinician will be notified and provided seven calendar days to contact the client and correct the identified deficiency. The Site Supervisor will re-review the affected record within 10 calendar days of the initial finding to verify that the required correction has been completed.
If the consent remains incomplete or invalid upon re-review, the clinician will receive individualized one-on-one retraining regarding consent requirements and proper documentation procedures. Repeated noncompliance, defined as three or more identified occurrences, will result in corrective or disciplinary action in accordance with agency policy. |