INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 5, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, WES Corporation 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:
|
Plan of Correction
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of personnel records, the facility failed to document an individual training plan for each employee, with the plan being appropriate to that employee's skill level and developed annually with input from both the employee and the supervisor in three of three applicable personnel records reviewed.
Employee # 1 was hired as the project director and facility director on November 20, 2019. There was no current individual training plan documented in the personnel record at the time of the inspection. The facility did provide the 2024 - 2025 individual training plan; however, the plan was not updated for the current training year and there was no documentation indicating it was developed with input from both the employee and the supervisor.
Employee # 2 was hired as a clinical supervisor on September 10, 2023. There was no current individual training plan documented in the personnel record at the time of the inspection. The facility did provide the 2024 - 2025 individual training plan; however, the plan was not updated for the current training year and there was no documentation indicating it was developed with input from both the employee and the supervisor.
Employee # 3 was hired as a counselor on September 10, 2023. There was no current individual training plan documented in the personnel record at the time of the inspection. The facility did provide the 2024 - 2025 individual training plan; however, the plan was not updated for the current training year and there was no documentation indicating it was developed with input from both the employee and the supervisor.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director shall meet with Employees #1, #2 and #3 by 1/28/2026 to collaborate with staff to complete an individual training plan for training year 2026.
To ensure that this deficiency does not recur, The Program Director will meet to collaborate on an update to each staff member's by 12/31 of each year. Both the supervisor and staff member will sign the plan to acknowledge the plan was completed.
Additionally, WES Training Director and WES Director of Quality Management shall facilitate a Training Review meeting in the first week of January each year to discuss staff training for the current year and to confirm that confirm that individualized training plans have been completed and signed by the program director and staff. |
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.
|
Observations
Based on a review of the facility's November 2024 through November 2025 fire drill logs, the facility failed to ensure their written fire drill logs included documentation of the time of the drill and the amount of time it took for evacuation.
At the time of the inspection, the February 2025 fire drill log did not include documentation of what time the drill occurred and the amount of time it took for evacuation.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The WES Quality Management Director shall meet with the WES Facilities Director and with each facility staff by 1/23/26 to review the Fire Drill regulations.
To ensure that this deficiency does no recur, the WES Quality Management Director shall review Fire Drill logs to confirm that all required documentation is included on the log for monthly fire drills, including the time the drill occurred and the amount of time it took for evacuation. |
709.28 (c) 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.
|
Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in the client record in one of seven client records reviewed.
Client # 3 was admitted on May 14, 2025 and was still active at the time of the inspection. There was evidence of disclosures to a family member during a family counseling session conducted on May 29, 2025; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director shall review the entire client record for Client #3 to identify all disclosures and complete consents to release information for each individual they consent to disclose information to by 1/23/26.
To ensure that this deficiency does not recur, Program Director shall review regulations, policies and procedures related to consent to release of information by 1/23/26 to ensure that there is a consent to release information for each individual that the client is providing consent for.
Additionally, to ensure that this deficiency does not recur, the WES Quality Management Director shall complete a monthly random sample of charts to confirm that such releases are present in the client record. If there is not a consent to release information for each individual that the client is providing consent for, the Quality Management will immediately complete an individual corrective action plan for the Program Director. |
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.
|
Observations
Based on a review of client records, the facility failed to document the name of a person, agency, or organization to whom a disclosure would be made to on release of information forms in four of seven client records reviewed.
Client # 1 was admitted on March 6, 2025 and was active at the time of the inspection. There was a release of information form to a physician signed by the client on December 17, 2024; however, the form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.
Client # 4 was admitted on August 21, 2025 and was discharged on October 31, 2025. There was a release of information form to a family member signed by the client on August 21, 2025; however, the form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.
Client # 5 was admitted on April 16, 2025 and was discharged on October 16, 2025. There was release of information forms to a judge and an emergency contact signed by the client on April 16, 2025; however, the forms did not include documentation of the name of the person, agency, or organization to whom the disclosures would be made.
Client # 6 was admitted on February 11, 2025 and was discharged on October 29, 2025. There was release of information forms to a judge and a physician signed by the client on February 11, 2025; however, the forms did not include documentation of the name of the person, agency, or organization to whom the disclosures would be made.
This is a repeat citation from the December 6, 2023 and November 7, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
WES Program Director shall meet with all Program Staff by 1/23/26 to review all regulations, policies and procedures related to consent to release information to ensure that the name of a person, agency, or organization to whom a disclosure would be made to, is included in each consent to release information.
Program Staff shall schedule meetings with Clients #1,#4, #5, and #6 and update all consent to release information and include the name of a person, agency or organization to whom a disclosure will be made to.
Additionally, to ensure that this deficiency does not recur, the WES Quality Management Director shall complete a monthly random sample of charts by the last day of each month to confirm that all consents to release information contain the name of a person, agency or organization that the disclosure will be made to. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
|
Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on release of information forms in six of seven client records reviewed.
Client # 1 was admitted on March 6, 2025 and was active at the time of the inspection. There was a release of information form to the funding source signed by the client on December 17, 2024; however, the form did not include documentation of the purpose of the disclosure.
Client # 2 was admitted on July 17, 2025 and was active at the time of the inspection. There was a release of information form to the funding source signed by the client on July 17, 2025; however, the form did not include documentation of the purpose of the disclosure.
Client # 4 was admitted on August 21, 2025 and was discharged on October 31, 2025. There was a release of information form to the funding source signed by the client on August 21, 2025; however, the form did not include the purpose of the disclosure.
Client # 5 was admitted on April 16, 2025 and was discharged on October 16, 2025. There was a release of information form to the funding source signed by the client on April 16, 2025; however, the form did not include documentation of the purpose of the disclosure.
Client # 6 was admitted on February 11, 2025 and was discharged on October 29, 2025. There was a release of information form to the funding source signed by the client on February 11, 2025; however, the form did not include documentation of the purpose of the disclosure.
Client # 7 was admitted on November 1, 2024 and was discharged on March 17, 2025. There was a release of information form to the funding source signed by the client on January 21, 2025; however, the form did not include documentation of the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The WES Program Director shall meet with all Program staff by 1/23/26 to review regulations, policies and procedures related to consent to release information to ensure that all staff are aware that the purpose of the disclosure is required to be included on the release of information form.
Program Staff shall schedule time to meet with Clients #1 and Clients #2 by 1/23/26 to update all consents to release information and document the purpose of the disclosure on the consent to release information form.
Additionally, to ensure that this deficiency does not recur, the WES Quality Management Director shall complete a monthly random sample of charts to confirm that all consent to release information contain the purpose of the disclosure. If the purpose of disclosure is not included in a consent to release information, the Quality Management will immediately meet with the Program Director to complete a Corrective Action Plan to address this concern. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
|
Observations
Based on a review of client records, the facility failed to document, during the intake and admission process, the disclosure to the client of the criteria for admission, treatment, completion, and discharge in six of six applicable client records reviewed.
Client # 1 was admitted on March 6, 2025 and was active at the time of the inspection. There was no disclosure to the client of criteria for admission, treatment, completion and discharge documented in the record at the time of the inspection.
Client # 2 was admitted on July 17, 2025 and was active at the time of the inspection. There was no disclosure to the client of criteria for admission, treatment, completion and discharge documented in the record at the time of the inspection.
Client # 3 was admitted on May 14, 2025 and was still active at the time of the inspection. There was no disclosure to the client of criteria for admission, treatment, completion and discharge documented in the record at the time of the inspection.
Client # 4 was admitted on August 21, 2025 and was discharged on October 31, 2025. There was no disclosure to the client of criteria for admission, treatment, completion and discharge documented in the record at the time of the inspection.
Client # 5 was admitted on April 16, 2025 and was discharged on October 16, 2025. There was no disclosure to the client of criteria for admission, treatment, completion and discharge documented in the record at the time of the inspection.
Client # 6 was admitted on February 11, 2025 and was discharged on October 29, 2025. There was no disclosure to the client of criteria for admission, treatment, completion and discharge documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The WES Program Director shall meet with Program Staff by 1/23/26 to review the policy that the Program Staff that completes the initial intake contact shall disclose the criteria for admission, treatment, completion and discharge for each new client. Clients shall verify by signature that they received a program handbook that includes the criteria for admission, treatment, completion and discharge and acknowledge that their rights and responsibilities have been explained.
Program Staff shall contact clients #1, #2 and #3 by 1/23/26 to schedule a time to meet to review the criteria for program admission, treatment, completion and discharge and obtain verification by signature by the client that these were reviewed by their signature.
Additionally, to ensure that this deficiency does not recur, the WES Quality Management Director shall complete a monthly random sample of charts to confirm that all client signatures are present to document and verify such program criteria was reviewed during intake. If there is not a client signature present in the client record that verifies that such program criteria was reviewed during intake, the Quality Management Director will immediately complete an individual corrective action plan for the Program Director. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
|
Observations
Based on a review of client records, the facility failed to document, during the intake and admission process, client orientation to the project in six of six applicable client records reviewed.
Client # 1 was admitted on March 6, 2025 and was active at the time of the inspection. There was no client orientation documented in the record at the time of the inspection.
Client # 2 was admitted on July 17, 2025 and was active at the time of the inspection. There was no client orientation documented in the record at the time of the inspection.
Client # 3 was admitted on May 14, 2025 and was still active at the time of the inspection. There was no client orientation documented in the record at the time of the inspection.
Client # 4 was admitted on August 21, 2025 and was discharged on October 31, 2025. There was no client orientation documented in the record at the time of the inspection.
Client # 5 was admitted on April 16, 2025 and was discharged on October 16, 2025. There was no client orientation documented in the record at the time of the inspection.
Client # 6 was admitted on February 11, 2025 and was discharged on October 29, 2025. There was no client orientation documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director shall meet with Program Staff by 1/23/26 to review the requirement that during the admission process, client was oriented to program and that verification that this occurred is in the client record.
Program Staff shall schedule time to meet with clients #1, #2 and #3 by 1/23/26 to re-orient them to the program and obtain a verification by signature from each client that they were re-oriented to the program.
Additionally, to ensure that this deficiency does not recur, the WES Quality Management Director shall complete a monthly random sample of charts to confirm that client signatures to verify that they were oriented to the program during the intake process are present in each chart reviewed. If there is not a client signature to verify that orientation occurred during intake, the Quality Management will immediately complete an individual corrective action plan for the Program Director. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of an aftercare plan, in three of three applicable client records reviewed.
Client # 4 was admitted on August 21, 2025 and was discharged on October 31, 2025. There was no documentation of an aftercare plan in the record at the time of the inspection.
Client # 5 was admitted on April 16, 2025 and was discharged on October 16, 2025. There was no documentation of an aftercare plan in the record at the time of the inspection.
Client # 6 was admitted on February 11, 2025 and was discharged on October 29, 2025. There was no documentation of an aftercare plan in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The WES Quality Management Director will collaborate with the WES IT Department and add an After Care Plan to the electronic health record system by 1/26/26. The Program Director shall meet with all program staff by 1/28/26 to review all regulations, policies and procedures related to after care planning to ensure that the program is maintaining complete client records.
Additionally, to ensure that this deficiency does not recur, the WES Quality Management Director shall complete a monthly random sample of charts to confirm that the client records for clients who have been discharged contain an after care plan. If there is not a an aftercare plan for discharged clients, the Quality Management will immediately complete an individual corrective action plan for the Program Director.
|
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.
|
Observations
Based on an administrative review, the facility failed to comply with plans of correction that were previously approved by the Department.
Plans of correction for failing to document the name of a person, agency, or organization to whom a disclosure would be made on release of information forms were submitted and approved by the Department for the December 6 2023 and November 7, 2024 annual licensing inspections. Failing to document the name of a person, agency, or organization to whom a disclosure would be made on release of information forms was again found to be a deficiency during the December 5, 2025 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director supported by the Quality Management Department shall meet by 1/31/26 to review the current Plan Of Correction and after that shall meet on a monthly basis to review the results of the monthly Quality Management chart reviews to ensure that all elements of the Plan of Correction are being completed. During such meetings, the Quality Management Director shall modify any Program Director's existing Corrective Action Plan to further ensure that the POCs are being followed. |