INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Behavioral Wellness Center at Girard Return Program 1&2 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary, and in good repair at all times for the safety and well-being of residents, employees and visitors. At the time of the inspection, conducted on August 28, 2026 at approximately 10:45 AM, there was a cracked and broken windowpane in the bathroom window of bedrooms 1003 and 1004. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The cracked and broken bathroom windowpanes in bedrooms 1003 and 1004 were repaired on August 28, 2026. Unit staff will continue to conduct and document daily environmental rounds to ensure the facility remains clean, safe, sanitary, and in good repair, thereby supporting the safety and well-being of clients, staff, and visitors.
Completed environmental round sheets will be submitted daily to the Clinical Supervisor for review. The Clinical Supervisor will ensure that work orders are promptly submitted to Environmental Services for any identified deficiencies requiring repair or corrective action. Safety-related deficiencies will be corrected immediately upon identification.
Responsible Party: Clinical Supervisor and Director of Recovery Services. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in one of two applicable client records reviewed. The facility policy and procedure manual stated the emergency contact will be notified after a client is discharged from the facility against medical advice. Client # 7 was admitted on January 13, 2026 and was discharged against medical advice on January 14, 2026. There was no documentation in the record indicating the emergency contact was notified the client was discharged against medical advice at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will work with the Information Technology (IT) Department to incorporate in the electronic discharge information a section regarding emergency contact notification if the participant discharge status is against medical advice/ against facility advice (AMA/AFA). This will be a "hard stop" and unless staff answer a series of questions related to emergency contact notification the computer will not allow them to continue.
Additionally, the Clinical Supervisor will review the Emergency Contact Policy to respective staff during supervision and document accordingly.
a). Responsible Party:
Clinical Supervisor, Behavioral Specialists, and support staff (Community Recovery
Specialist, and Addiction Recovery Assistants)
b). Completion Date: 10/15/26
Staff will document in the client's discharge record the attempt to notify emergency contact when a client leaves the facility AMA/AFA.
a). Responsible Party:
Clinical Supervisor, Behavioral Specialists, and support staff (Community Recovery
Specialist, and Addiction Recovery Assistants)
b). Completion Date: 10/15/26
Clinical Supervisor will conduct focus review of 90% or 5 charts of clients who leave the facility AMA/AFA during a 2-month period to ensure that the client emergency contact was notified.
a). Responsible Party:
Clinical Supervisor and Director of Recovery Services
b). Completion Date: 12/31/2026
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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 document the name of the person, agency, or organization to whom a disclosure was to be made to on a release of information form in one of seven client records reviewed.Client # 1 was admitted on July 23, 2026 and was active at the time of inspection. There was a release of information form to a probation and parole office signed and dated by the client on July 23, 2026; however, the name of the person, agency, or organization to whom the disclosure was to be made was not documented on the release form.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake and other respective assigned staff will be re-trained on the proper completion of consent/release of information forms to ensure that the forms are completed in their entirety without blank areas.
Training will cover required authorization elements, acceptable identification of recipients, handling incomplete forms, and documentation of disclosures. Competency will be validated through a post-test.
Clinical supervisor will provide coaching for any deficiency identified through chart audits.
a). Responsible Party:
Clinical Supervisor, Intake Workers and Counselors
b). Completion Date: 10/16/26
The Clinical Supervisor will conduct a focused review of 100% of consent/
release-of-information forms for four (4) weeks to verify that each form is properly completed. Thereafter, the Clinical Supervisor will review five (5) charts per month for a period of 3 months to monitor ongoing compliance.
a). Responsible Party: Clinical Supervisor
b). Completion Date: 1/31/202
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to ensure a psychosocial evaluation was completed, as a part of the facility's intake and admission process, in three of six applicable client records reviewed.The facility's policy and procedure manual stated the biopsychosocial evaluation of a client will be completed within 72 hours of admission. Client # 1 was admitted on July 23, 2026 and was active at the time of the inspection. The psychosocial evaluation was due to be completed no later than July 26, 2026; however, the evaluation was not completed as of the date of the inspection.Client # 2 was admitted on July 21, 2026 and was active at the time of the inspection. The psychosocial evaluation was due to be completed no later than July 24, 2026; however, the evaluation was not completed until July 29, 2026.Client # 6 was admitted on December 9, 2025 and was discharged on December 26, 2025. The psychosocial evaluation was due to be completed no later than December 12, 2025; however, the evaluation was not completed prior to discharge. This is a repeat citation from the August 15, 2024 and August 7, 2025 annual licensing renewal inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Psychosocial evaluation will be completed within three days (72 hours) of each client's admission. Counselors will receive reminders during supervision regarding this requirement and the importance of timely completion. If the assigned counselor is unable to complete the evaluation within the required timeframe, the Clinical Supervisor shall assume responsibility for completing the psychosocial evaluation within 72 hours of admission.
Responsible Party:
Counselors and Clinical Supervisor
The Clinical Supervisor will conduct focused chart review of 100% of admissions for a period of three (3) months to verify timely completion of each psychosocial evaluation. Any identified noncompliance will be addressed through progressive corrective action, beginning with coaching and retraining and, when warranted, advancing to formal progressive discipline.
Responsible Party:
Clinical Supervisor and Director of Recovery Services
Completion Date: 12/31/2026
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 client records, the facility failed to develop the individual's comprehensive treatment and rehabilitation plan with the client in five of six applicable client records reviewed.The facility's policy and procedure manual states that the comprehensive treatment plan will be completed within 7 days of admission. Client # 1 was admitted on July 23, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than July 30, 2026; however, it was not completed until August 13, 2026.Client # 2 was admitted on July 21, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than July 28, 2026; however, it was not completed until August 25, 2026.Client # 3 was admitted on July 18, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than July 25, 2026; however, it was not completed until August 3, 2026.Client # 4 was admitted on January 6, 2026 and was discharged on April 8, 2026. The individual treatment and rehabilitation plan was due to be completed no later than January 13, 2026; however, it was not completed until January 28, 2026.Client # 5 was admitted on October 29, 2025 and was discharged on December 18, 2025. The individual treatment and rehabilitation plan was due to be completed no later than November 5, 2025; however, it was not completed until November 17, 2025.This is a repeat citation from the August 7, 2025 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will re-educate counseling staff regarding the requirement to develop and document each client's individualized comprehensive treatment and rehabilitation plan within seven (7) days of admission. Counselors will complete and document treatment plans within the required timeframe. If the assigned counselor is unavailable, the clinical supervisor will complete the client's individualized comprehensive treatment and rehabilitation plan.
Responsible Party: Counselors and Clinical Supervisor.
Completion Date 10/16/26
The Clinical Supervisor or Director of Recovery Services will conduct focused audits of 100% of newly admitted clients for three (3) months to verify compliance with the seven-day treatment-planning requirement.
Responsible Party: Clinical Supervisor and Director of Recovery Services.
Completion Date 12/31/26
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 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 thirty days in one of two applicable client records reviewed.Client # 4 was admitted on January 6, 2026 and was discharged on April 8, 2026. The individual treatment and rehabilitation plan was completed on January 28, 2025, and the first update was due to be completed no later than February 27, 2026; however, the update was not completed until March 10, 2026.This is a repeat citation from the August 7, 2025 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will re-educate counseling staff regarding the requirement to review and update each client's individualized treatment and rehabilitation plan at least every thirty (30) days. Counselors will complete and document treatment plan updates within the required timeframe. If the assigned counselor is unavailable, the clinical supervisor will review and update the client's individualized treatment and rehabilitation plan.
Responsible Party:
Counselors and Clinical Supervisor
Clinical Supervisor or Director of Recovery Services will conduct focused audit on 100% of treatment plan updates for three (3) months to ensure compliance. Noncompliance will be addressed through coaching, retraining and when warranted, progressive disciplinary.
Responsible Party:
Clinical Supervisor and Director of Recovery Services
Completion Date: 12/31/2026
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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 client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for not completing the psychosocial evaluation was submitted and approved by the Department for the August 14, 2024 and August 7, 2025 annual licensing inspections. Failing to complete psychosocial evaluation was again found to be a deficiency in the August 28, 2026, annual licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility acknowledges that plans of correction addressing incomplete psychosocial evaluations were submitted to and approved by the Department on 8/24/24 and 8/7/25, and that the same deficiency was identified again on 8/28/26. The Clinical Supervisor
will re-educate all counseling staff regarding the requirement to complete and document psychosocial evaluations within the timeframe established by regulation and facility policy. The training will address required elements, documentation standards, due-date tracking, and escalation procedures when the assigned counselor is unavailable. The Clinical Supervisor will verify staff competency through a post-test.
The Clinical Supervisor will assign another qualified staff member to complete the evaluation or will complete the evaluation when staffing or workflow barriers place timely completion at risk.
Responsible Parties: Counselors, Clinical Supervisor, and Director of Recovery Services
The Clinical Supervisor or Director of Recovery Services will review 100% of new admissions each week for four (4) weeks to verify the timely completion and documentation of psychosocial evaluations. Any deficiency will be corrected promptly and addressed with the responsible staff member through documented coaching and retraining, up to and including progressive disciplinary action when warranted. After four consecutive weeks of full compliance, the Clinical Supervisor will review five (5) randomly selected records of newly admitted clients each month for an additional three (3) months to ensure ongoing compliance. Audit findings will be reviewed by the Program's Vice President and reported to the Performance Improvement Committee. Any recurrence will result in renewed 100% monitoring and additional corrective action.
Responsible Parties: Clinical Supervisor, Director of Recovery Services, and Vice President
b). Completion Date: 12/31/26
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