INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28, 2025 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide direct observation by a trained counselor or clinical supervisor for the first 3 months of employment or for the next 9 months, under close supervision.
Employee #3 was hired on May 13, 2025 and was still employed at the time of the inspection. She had no documentation of direct or close supervision.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Upon review of the survey on 8/28/25, the Project Director met with the staff member in question and the other counselors in the building and arranged for all sessions conducted by the clinician in question to be observed by a counselor/supervisor either via zoom or in person. This will then be documented in the progress notes or all clients. Additionally, should the schedule be reviewed and a client be unable to be seen due to staff unavailable to observe, the client will be rescheduled. The staff in question has also been scheduled weekly for 1-1 supervisions with the Project Director, to discuss her cases, clinical issues, and skill development. Furthermore, the Project Director will apply for an exception through DDAP for this clinician, citing her education, work experience, and skill demonstration.
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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 the Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that 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 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.
Employee #2 was hired as counselor on May 20, 2024. Her TB/STD training was due no later than May 20, 2025; however, it was not completed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
In an individual supervision held with the identified clinician on 9/8/25, the regulation was reviewed and barriers to the training completion were identified. The training is currently on the individual's training plan, and she has been directed weekly to search the training management system for training availability. If she is waitlisted, she is to print that documentation out and submit to her supervisor. Additionally, she is assigned training courses in Relias that address the subject matter of the training in question. These are to be completed within by 10/31/25. Should these trainings not be completed and/or she not be enrolled in and complete a DDAP training by 1/1/26, disciplinary action will be taken, and she may be removed from a caseload until the training have been obtained.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #3 was hired on May 13, 2025 as a counselor assistant and was still in the position as of the date of the inspection. The training was completed on June 4, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director has developed and shared with all supervisors a new hire training plan that has gone into effect on 9/8/25. In that training plan all new hires are assigned training in the use of fire extinguishers within their first 7 days of employment. At that 7 day mark, the supervisor must submit the completed training log to the Project Director for review. If the needed training has not been obtained, the employee will not be permitted to engage in client care, until the training is obtained. The situation will also be reviewed with the supervisor in a supervision with the Project Director. Should this incident recur, disciplinary action will be taken.
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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 a review of outpatient client records, the facility failed to document an individual treatment and rehabilitation plan with the client and within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states the treatment plan must be completed within 30 days following admission.
Client #1 was admitted on February 10, 2025 and was still active at the time of the inspection. The comprehensive treatment plan was completed on July 28, 2025.
Client #2 was admitted on October 4, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was completed on March 12, 2025.
Client #5 was admitted on November 14, 2024 and was discharged on June 17, 2025. The comprehensive treatment plan was completed on January 9, 2025.
Client #7 was admitted on October 21, 2024 and discharged on February 20, 2025. No treatment plan was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During a team meeting to be held on 9/8/25, the team will review the citation, along with the policy for comprehensive tx plan completion. Each team member will be requested to attest to the policy review and an understanding of how and within what timeframe to complete the document. To ensure compliance, the team will have a tracking spreadsheet that populates for the clinician when every tx plan is due. This will be reviewed daily by the supervisor and the clinicians. The supervisor will review all charts that have a comprehensive tx plan due the previous day to ensure it has been completed. Should a comprehensive tx plan be found to be not completed or incomplete, the staff member will be offered individual supervision and retraining on the issue. The clinician will also be directed to correct/complete the plan at the next scheduled session, and then update the tracking sheet and submit the chart to the supervisor. Should an error occur again, disciplinary action will be taken. If the document is unable to be corrected or submitted for an extenuating circumstance, a special note shall be placed in the client record.
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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 document treatment plan updates within the regulatory timeframe in four out of five applicable records reviewed.
Client #2 was admitted on October 4, 2024 and was still active at the time of the inspection. A treatment plan update was completed on May 8, 2025 and the next update was due no later than July 8, 2025; however, none was completed.
Client #3 was admitted on February 4, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 3, 2025 and an update was due no later than May 3, 2025; however, none was completed.
Client #4 was admitted on December 9, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on January 9, 2025 and the next update was due no later than March 9, 2025; however, it was not completed until May 7, 2025.
Client #5 was admitted on November 14, 2024 and was discharged on June 17, 2025. A treatment plan update was completed on March 11, 2025 and an update was due no later than May 11, 2025; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the October 6, 2021, August 11, 2022, August 9, 2023 and August 29, 2024 licensing inspection.
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Plan of Correction
During a team meeting to be held on 9/8/25, the team reviewed the citation, along with the policy for updating tx plans. Each team member will be requested to attest to the policy review and an understanding of how and within what timeframe to complete the document. To ensure compliance, the team will have a tracking spreadsheet that populates for the clinician when every tx plan is due. This will be reviewed daily by the supervisor and the clinicians. The supervisor will review all charts that have a tx plan update due the previous day to ensure it has been completed. Should an update be found to be not completed or incomplete, the staff member will be offered individual supervision and retraining on the issue. The clinician will also be directed to correct/complete the plan, within 1 business day, review with the client at the next scheduled session, and then update the tracking sheet and submit the chart to the supervisor. Should an error occur again, disciplinary action will be taken. If the document is unable to be corrected or submitted for an extenuating circumstance, a special note shall be placed in the client record.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of outpatient client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in five out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed at 30, 90,180, 270, 365 days and annually thereafter following admission.
Client #1 was admitted on February 10, 2025 and was still active at the time of the inspection. No consultations were completed.
Client #2 was admitted on October 4, 2024 and was still active at the time of the inspection. A case consultation was completed on October 4, 2024 and the next one was due no later than January 4, 2025; however, it was not completed until March 12, 2025.
Client #3 was admitted on February 4, 2025 and was still active at the time of the inspection. A case consultation was completed on February 4, 2025 and the next one was due no later than May 4, 2025; however, none was completed.
Client #5 was admitted on November 14, 2024 and was discharged on June 17, 2025. A case consultation was completed on November 14, 2024 and the next one was due no later than February 14, 2025; however, none was completed.
Client #7 was admitted on October 21, 2024 and discharged on February 20, 2025. A case consultation was completed on October 21, 2024 and the next one was due no later than January 21, 2025; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Following the completion of the audit, the Project Director amended the case consult policy to now reflect a case consult due within 30 days of admission and upon discharge from tx. During a team meeting to be held on 9/8/25, the team will review the citation, along with the new policy for case consult completion. Each team member will be requested to attest to the policy review and an understanding of how and within what timeframe to complete the document. To ensure compliance, a member of the supervisory team will audit all client files at 30 days from admission and upon discharge to ensure that case consults have been completed. Should a consult be found to be missing, the staff member will be offered individual supervision and retraining on the issue. The staff member will also be directed to complete the case consult within the next 3 days and provide it upon completion to the supervisor. Should an error occur again, or the document not be completed within the outlined period and submitted a supervisor, disciplinary action will be taken.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of outpatient client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in two out of three applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed 30 days following discharge.
Client #5 was admitted on November 14, 2024 and was discharged on June 17, 2025. None was completed.
Client #7 was admitted on October 21, 2024 and discharged on February 20, 2025. None was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During a team meeting to be held on 9/8/25, the team will review the citation, along with the policy for follow-up completion. Each team member will be requested to attest to the policy review and an understanding of how and within what timeframe to complete the document. To ensure compliance, discharge dates will be tracked on a shared spreadsheet and reviewed daily by all team members. At 30 days post-discharge, all charts will be pulled and reviewed by a supervisor to ensure that all follow-ups have been completed. Should a follow-up be found to be not completed or incomplete, the staff member will be offered individual supervision and retraining on the issue. The staff member will also be directed to complete the follow-up before end of business the next day and submitted to the supervisor. Should an error occur again, or the document not be completed within the allotted time frame and reviewed with a supervisor, disciplinary action will be taken.
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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 outpatient client records, the facility failed to comply with plans of correction that were approved by the Department.
Plan of corrections for treatment plan updates were submitted and approved by the Department for the October 6, 2021, August 11, 2022, August 9, 2023 and August 29, 2024 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the August 28, 2025 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
During a team meeting to be held on 9/8/25, the team reviewed the citation, along with the policy for updating tx plans. Each team member will be requested to attest to the policy review and an understanding of how and within what timeframe to complete the document. To ensure compliance, the team will have a tracking spreadsheet that populates for the clinician when every tx plan is due. This will be reviewed daily by the supervisor and the clinicians. The supervisor will review all charts that have a tx plan update due the previous day to ensure it has been completed. Should an update be found to be not completed or incomplete, the staff member will be offered individual supervision and retraining on the issue. The clinician will also be directed to correct/complete the plan, within 1 business day, review with the client at the next scheduled session, and then update the tracking sheet and submit the chart to the supervisor. Should an error occur again, disciplinary action will be taken. If the document is unable to be corrected or submitted for an extenuating circumstance, a special note shall be placed in the client record.
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