D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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TRADITION HOUSE
1311 13TH STREET
ALTOONA, PA 16601

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Survey conducted on 07/23/2025

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on July 23, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Tradition House 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
705.10 (d) (5) LICENSURE Fire safety. 705.10. Fire safety. (d) Fire drills. The residential facility shall: (5) Conduct a fire drill during sleeping hours at least every 6 months.
Observations Based on review of fire drill logs from September 2024-June 2024, the facility failed to document a fire drill during sleep hours every six months. This finding was reviewed with facility staff during the licensing process.	Plan of Correction Executive Driector reviewed this with the maintenance team and risk team during our monthly meeting on 8/12/25. Staff were retrained on fire drill protocol and proper documentation. Executive Director reviewed policy on documenting drills every 6 months during sleep hours. We reviewed sleep hours, to ensure they are not occurring during MAT med pass times. Executive Director and Safety Leader will monitor monthly fire drills for compliance and will address any ongoing areas of concern.
709.28 (c) (2) 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: (2) Specific information disclosed.
Observations Based on review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which contained the specific information disclosed in three out seven records reviewed. Client #2 was admitted on May 22, 2025 and was still active at the time of the inspection. A release form for a dentist was signed and dated May 22, 2025; however, it did not include the specific information to be disclosed. Client #3 was admitted on March 20, 2025 and was still active at the time of the inspection. A release form for an eye doctor, was signed and dated March 20, 2025; however, it did not include the specific information to be disclosed. Client #6 was admitted on January 31, 2025 and was discharged on May 02, 2025. A release form for a doctor, dentist, and eye doctor, was signed and dated January 31, 2025; however, they did not include the specific information to be disclosed. These findings were reviewed with facility staff during the licensing process.	Plan of Correction Executive Director and Clinical Supervisor reviewed ROI accuracy and compliance on 8/12/2025. ED and Clinical Supervisor reviewed ensuring documentation of what is authorized for disclosure. This staffing included our clinical, admin, and medical staff. This re-education is documented in the meeting minutes/notes. All active charts reviewed during this audit have been updated to reflect these changes. These were all updated by 8/29/2025. In order to monitor compliance with our plan of correction, the Clinical Supervisor will be responsible for weekly supervision with direct care staff to ensure compliance. ED and Clinical Supervisor will complete random chart audits monthly, reviewing ROI complaince.
709.28 (c) (4) 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: (4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
Observations Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the dated signature of the client in one out of seven records reviewed. Client #3 was admitted on March 20, 2025, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information contained in the client record dated March 31, 2025, for the emergency contact had a witness signature, but did not include the dated signature of the client. This finding was reviewed with facility staff during the licensing process.	Plan of Correction Executive Director will meet with nursing staff, clinical staff, and admission staff on 8/12/25 during staff meeting to review ROI's and appropriate information to be disclosed. Clinical Supervisor will review ROI complaince for all admissions and monitor compliance through monthly chart audits.All active client ROI's will be updated by 8/25/2025.
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.
Observations Based on a review of the 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 seven out of seven records reviewed. Client #1 was admitted on May 02, 2025 and was still active at the time of the inspection. There was no documentation that a copy of the informed and voluntary consent to release form for a funding source dated May 02, 2025, was offered to the client. Client #2 was admitted on May 22, 2025 and was still active at the time of the inspection. There was no documentation that a copy of the informed and voluntary consent to release form for a funding source dated May 22, 2025, was offered to the client. Client #3 was admitted on March 20, 2025 and was still active at the time of the inspection. There was no documentation that a copy of the informed and voluntary consent to release form for a funding source dated March 20, 2025, was offered to the client. Client #4 was admitted on February 17, 2025 and discharged on May 23, 2025. There was no documentation that a copy of the informed and voluntary consent to release form for a funding source dated February 17, 2025, was offered to the client. Client #5 was admitted on December 31, 2024 and discharged on March 10, 2025. There was no documentation that a copy of the informed and voluntary consent to release form for a funding source dated December 31, 2024, was offered to the client. Client #6 was admitted on January 31, 2025 and discharged on May 02, 2025. There was no documentation that a copy of the informed and voluntary consent to release form for a funding source dated January 31, 2025, was offered to the client. Client #7 was admitted on November 25, 2024 and discharged on April 17, 2025. There was no documentation that a copy of the informed and voluntary consent to release form for a funding source dated November 25, 2024, was offered to the client. These findings were reviewed with facility staff during the licensing process.	Plan of Correction Pyramid Healthcare has submitted a ticket into its health records system to add an enhancement. This enhancement will denote that a copy of the Consent for Treatment, Payment and Healthcare Operations consent is offered to the client and will be memorialized and maintained in the client record. This denote will be a required field at the bottom of the document. As a result, staff will be unable to move forward to complete the document without the review and acknowledgement of whether a copy was offered to the client or not. Compliance monitors on a monthly basis the completion of the Consent for Treatment, Payment and Healthcare Operations consent for all clients active in treatment. The monitoring information is shared with the facilities operations and clinical leadership team through a scorecard to review and identify if any client receiving care may be missing one. If clients are determined to be missing a document, Clinical Supervisor will be responsible for ensuring completion of the Consent for Treatment, Payment and Healthcare Operations consent with those clients and offering a copy. Executive Director and Clinical Sueprvisor will re-educate staff on the expectation to offer a copy of the Treatment, Payment and Healthcare Operations consent to each client and document that offering on the updated consent form in our clinical meeting on 8/12/25. This re-education will be recorded in the meeting minutes/notes. In order to monitor compliance with our plan of correction, the Clinical Supervisor will be responsible for weekly supervision with direct care staff to ensure compliance. Executive Director will supervise the Clinical Supervisor weekly to monitor the plan of correction. Executive Director will provide updates to the Regional Director bi-weekly to ensure compliance with plan of correction.
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:
Observations Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan within 72 hours of admission, per facility policy, in five of seven records reviewed. Client #1 was admitted on May 02, 2025 and was still active at the time of the inspection. The individual treatment plan was due no later than May 05, 2025; however it was not completed until May 08, 2025. Client #4 was admitted on February 17, 2025 and discharged on May 23, 2025. The individual treatment plan was due no later than February 20, 2025; however, it was not completed until March 06, 2025. Client #5 was admitted on December 31, 2024 and discharged on March 10, 2025. The individual treatment plan was due no later than January 03, 2025; however it was not completed until January 14, 2025. Client #6 was admitted on January 31, 2025 and discharged on May 02, 2025. The individual treatment plan was due no later than February 03, 2025; however, it was not completed until February 24, 2025. Client #7 was admitted on November 25, 2024 and discharged on April 17, 2025. The individual treatment plan was due no later than November 28, 2024; however, it was not completed until December 27, 2024. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the August 23, 2024 licensing inspection.	Plan of Correction Clinical Supervisor will review timelines for treatment plan completion during next clinical meeting on 8/19/25. Clinical Supervisor will monitor treatment plans weekly for the next month, to ensure complaince. Clinical Supervisor will then continue to monitor compliance during monthly chart audits and will address any ongoing issues during individual monthly supervision.
709.53(a)(5) LICENSURE Progress Notes 709.53. 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: (5) Progress notes.
Observations Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed within 24 hours after therapy sessions, in seven of seven records reviewed. Client #1 was admitted on May 02, 2025 and still active at the time of the inspection. The record contained progress notes for individual sessions occurring May 02, 2025, May 08, 2025, May 22, 2025, and June 26, 2025; that were not completed until May 07, 2025, May 14, 2025, May 26, 2025, and July 01, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on June 30, 2025, and July 09, 2025, that were not completed until July 08, 2025 and July 13, 2025, respectively. Client #2 was admitted on May 22, 2025 and still active at the time of the inspection. The record contained progress notes for an individual session occurring on July 02, 2025, that was not completed until July 08, 2025; additionally, there was an individual session on July 16, 2025, that was not documented at the time of the inspection. The record also contained progress notes for group sessions occurring on June 18, 2025, June 30, 2025, July 01, 2025, July, 04, 2025, July 09, 2025, July 13, 2025, July 14, 2025, and July 17, 2025, that were not completed until June 20, 2025, July 15, 2025, July 15, 2025, July 06, 2025, July 13, 2025, July 15, 2025, July 20, 2025, and July 20, 2025 respectively. Client #3 was admitted on March 20, 2025 and still active at the time of the inspection. The record contained progress notes for individual sessions occurring on May 09, 2025, June 12, 2025, June 26, 2025, and July 21, 2025, that were not completed until May 14, 2025, June 18, 2025, July 01, 2025, and July 23, 2025, respectively. Client #4 was admitted on February 17, 2025 and discharged on May 23, 2025. The record contained a progress note for an individual session occurring on April 29, 2025, that was not completed until May 04, 2025. Client #5 was admitted on December 31, 2024 and discharged on March 10, 2025. The record contained a progress note for an individual session occurring on January 01, 2025, that was not completed until January 06, 2025. Additionally, the record contained progress notes for group sessions occurring on January 02, 2025, January 03, 2025, January 07, 2025, January 08, 2025, January 09, 2025, January 10, 2025, and January 13, 2025, that were not completed until January 06, 2025, January 06, 2025, January 17, 2025, February 01, 2025, January 14, 2025, January 17, 2025, and January 17, 2025, respectively. Client #6 was admitted on January 31, 2025 and discharged on May 02, 2025. The record contained progress notes for individual sessions occurring on February 03, 2025, and March 14, 2025, that were not completed until February 06, 2025 and March 17, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on February 03, 2025, February 05, 2025, February 10, 2025, and February 26, 2025, that were not completed until February 06, 2025, February 07, 2025, February 12, 2025 and March 03, 2025, respectively. Client #7 was admitted on November 25, 2024 and discharged on April 17, 2025. The record contained progress notes for individual sessions occurring on January 08, 2025, January 10, 2025, and March 17, 2025, that were not completed until January 13, 2025, January 17, 2025, and March 19, 2025. Additionally, the record contained progress notes for group sessions occurring on December 23, 2024, December 26, 2024, December 30, 2024, January 01, 2025, January 07, 2025, January 08, 2025, January 13, 2025, January 27, 2025, that were not completed until December 26, 2024, February 01, 2025, January 02, 2025, January 14, 2025, January 17, 2025, February 01, 2025, January 17, 2025, and January 30, 2025, respectively. These findings were reviewed with facility staff during the licensing process.	Plan of Correction Clinical Supervisor will review timelines for treatment notes to be completed during next clinical meeting on 8/19/25. Clinical Supervisor will continue to monitor compliance during monthly chart audits and will address any ongoing issues during individual monthly supervision.