This report is a result of an on-site licensure renewal inspection conducted on March 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, St. Joseph Institute, LLC, 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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Observations
Based on a review of the client records, the facility failed to include the type and frequency of treatment and rehabilitation services on the treatment plan in seven of seven records. Client #1 was admitted to the outpatient level of care on September 30, 2025, and discharged on January 7, 2026.Client #2 was admitted to the outpatient level of care on November 17, 2025, and discharged on February 19, 2026. Client #3 was admitted to the outpatient level of care on December 15, 2025, and discharged on February 12, 2026.Client #4 was admitted to the outpatient level of care on October 1, 2025, and discharged on January 15, 2026.Client #5 was admitted to the outpatient level of care on December 8, 2025, 2025, and was still active at the time of the inspection. Client #6 was admitted to the outpatient level of care on January 26, 2026, and was still active at the time of the inspection. Client #7 was admitted to the outpatient level of care on January 29, 2026, and was still active at the time of the inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Chief Executive Officer (CEO), Director of Quality Improvement and Compliance, and designated corporate support personnel collaborated with the Health Care System (HCS) Electronic Medical Record (EMR) development team to implement functionality that enables documentation of both the type and frequency of treatment and rehabilitation services. This enhancement was completed by the end of January 2026. To ensure adherence to this requirement, the Director of Outpatient Clinical Services will conduct comprehensive audits of 100% of patient charts on a weekly basis for the initial three-month period following implementation. After this period, ongoing compliance will be monitored through monthly chart audits. All clinical staff will be required to sign attestation forms confirming receipt of education and training related to this corrective action. Audit findings will be reported during the Committee of the Whole (CoW) meetings. |