INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 23, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, TPALS 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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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the facility director.
Employee # 1 has been in the position of facility director since January 1, 2016. The facility's training year that was reviewed was from January 1, 2025 through December 31, 2025. Employee # 1's personnel record only documented 8 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Faility Director has enrolled in and scheduled the required training hours to meet the annual requirement for the current training year. Documentation of the completed training will be submitted to the personnel file upon completion. Employee number one completed 4 hours of training, and it was recorded in his employee chart before all of his training hours for that year were completed by 2/13/2026. Any staff who is not staying on schedule throughout the year with their required hours will be coached or written up at the Facility Director's discretion.
To ensure ongoing compliance with 704.11(d)(2): The clinical supervisor will maintain a training tracking log for all staff, including the project/facility director. The log will include: Required annual hours, completed hours, due dates, and verification of certificates. The Facility Director will meet quarterly with the Clinical Supervisor to review the training process and ensure all required hours are on track for completion. The Clinical Supervisor is responsible for tracking, auditing, and documenting. The facility Director will ensure the timely completion of training hours. This will be implemented on 2.13.2026. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that personnel records contained an annual written performance evaluation that was reviewed and signed by the employee in one of six applicable records reviewed.
Employee # 3 has been in the position of counselor since May 14, 2024 and is current in that position. The annual written staff performance evaluation documented in the record May 9, 2025, was not signed by the employee.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction for 709.26(B)(3): Corrective Action Plan: A standardized Annual Evaluation Template has been created to ensure consistent documentation. The clinical supervisor will review this template monthly to ensure all employee reviews are signed by staff member and clinical supervisor. The Clinical Supervisor will maintain a compliance calendar that includes the annual evaluation due date. Facility Director will review employee reviews on a monthly basis with Clinical Supervisor. Responsible parties are Clinical Supervisor reviewing employee reviews on a monthly basis to ensure everything is signed. Facility Director will oversee the documents with Clinical Supervisor monthly basis. This goes into effective into effect on 2/13/2026. |
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.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in three out of seven records reviewed.
Client #3 was admitted to the outpatient level of care on November 21,2025 and is currently active at time of licensing process. There was documentation that information was disclosed to Lackawanna County Probation Officer on December 19, 2025, and again January 16, 2026, however the record did not contain documentation that the client signed a release of information form for Lackawanna County Probation. Additionally, there was documentation that information was disclosed to a funding source, however the record did not contain documentation that the client signed a release of information form for funding source.
Client #4 was admitted to the outpatient level of care on February 5, 2025 and discharged May 21, 2025. There was documentation that information was disclosed to Lackawanna County Probation Officer on February 6, 2025, however the record did not contain documentation that the client signed a release of information form for Lackawanna County Probation until February 10, 2025.
Client #7 was admitted to outpatient level of care on July 9, 2025 and discharged January 19, 2026. There was documentation that information was disclosed to funding source, however the record did not contain documentation that the client signed a release of information form for funding source.
This is a repeat citation from the December 18, 2024 annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Corrective Action Taken 709.28(C): A Consent Verification Step has been added to our system. Before any phone call, email, written communication, or electronic communication, staff must verify that a valid, signed consent form is in the chart. Staff must document in the contact log that they verified the ROI before speaking to the other party. Staff Retraining: All clinical and administrative staff will have completed a mandatory Confidentiality @ ROI Compliance Training covering 709.28(C), 42 CFR Part 2, HIPAA minimum necessary standards, and proper documentation of disclosures. The Clinical Supervisor will review all new LOC/A on a weekly basis. The clinical Supervisor will review the ROI of all client charts monthly. The Facility Director will review confidentiality compliance quarterly and report findings to the Clinical Supervisor. The ROI and confidentiality policies will be reviewed annually and updated as needed. The Clinical Supervisor is responsible for monitoring and corrective action plan. Facility Director's monthly compliance review and policy. Client number three's ROI was signed on 2/3/2026. This will be implemented on 2/13/2026. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project, in one of one applicable record reviewed.
Client # 4 was admitted to outpatient level of care on February 5, 2025 and was involuntarily discharged on May 21, 2025. The record did not contain documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction for 709.33(a): An Involuntary Termination Notice has been completed for Client #4 and placed in the client record. Staff involved in the discharge have been re-educated on the requirement to provide written notice prior to or at time of involuntary termination. A mandatory step has been added to the discharge process requiring all staff to: Provide written notice to to the client chart. he client and upload the file. We will hold a refresher training on 709.33(a), documentation for all involuntary discharges and that they are uploaded. Clinical Supervisor is responsible to audit 100% of discharges monthly to verify the notice is present. Facility Director will review termination procedures quarterly to ensure compliance and updated policies when needed. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of client records and discussion with facility staff, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel.
Client #4 discharge summary documents the presence of ambulance and police personnel on May 21, 2025; however, there was no documentation that written unusual incident reports were ever filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Corrective Plan of Action for 709.34(C)(4) A reportable incident was reported to DDAP on 2/26/2026.
The incident has been logged in the facility's internal incident tracking system. Staff involved has left our facility. Staff Training is mandatory on 709.34(C) reporting requirements, Identifying reportable incidents, timelines, and document standards, and confidentiality considerations when reporting. We created two binders, one for non-reportable incidents and one for reportable incidents. The Clinical Supervisor will monitor these logs monthly and report any reportable incidents to DDAP. The clinical Supervisor will report the incident to DDAP within 3 days. The Facility Director will monitor the logs quarterly and address any patterns of noncompliance. This will be effective as of 2/13/2026. |
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 client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in two of two applicable records reviewed.
Client #4 was admitted to outpatient program February 5, 2025 and discharged May 21, 2025. The record did not contain documentation of follow-up information.
Client # 6 was admitted to outpatient program February 20, 2025 and discharged October 24, 2025. The record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction for 709.93(A)(11)Follow‑up attempts for Client #4 and Client #6 were completed on 2/13/2026, and documentation of the follow‑up attempts?including date, method, and outcome?was added to each client record. If the client could not be reached, the attempt and outcome were documented in accordance with DDAP requirements. A standardized Follow‑Up Procedure was implemented on 2/13/2026, requiring staff to complete and document a follow‑up attempt within 7 days of discharge.
A Follow‑Up Documentation Form and EHR template field were added to ensure consistent documentation of:
Date of follow‑up attempt
Method of contact
Outcome of the attempt
Staff completing the attempt
All clinical staff were trained on the updated follow‑up procedure on 2/13/2026. Training included expectations for documentation and examples of compliant entries. A sign‑in sheet is maintained. The Clinical Supervisor will conduct a monthly audit of all discharged client charts to ensure discharge is completed. Facility Director will ensure the policy is being followed by reviewing random discharged charts every three months. This went in effect as of 2/13/2026 |