INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 26, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Renewal Treatment Inc. 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of applicable staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in two of six staff records.
Staff #9 was hired on as a counselor on June 30, 2025 and was still in this position at the time of the inspection. TB/STD training was to be completed no later than June 30, 2026; however, this was not completed until July 2, 2026.
Staff #10 was hired on as a counselor on June 30, 2025 and was still in this position at the time of the inspection. HIV/AIDS training was to be completed no later than June 30, 2026; however, this was not completed until July 1, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action: The agency will incorporate HIV/AIDS and TB/STD training into new hire orientation. All applicable staff will be required to complete these trainings as part of the orientation process, within the required timeframe.
Monitoring: Human Resources and Clinical Leadership will monitor new hire training records to verify completion and ensure the required trainings are completed and documented.
Ongoing Compliance: Training completion will be reviewed as part of the new hire onboarding process, and any identified deficiencies will be addressed promptly through completion of the required training.
This POC will be implemented by 10.2.26
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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 applicable client record reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one record.
Client #5 was admitted on October 15, 2025 and discharged on November 7, 2025. There was no documentation in the client record notifying the client, in writing, of termination from the project.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 20, 2025 annual licensing inspection.
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Plan of Correction
Corrective Action: All Clinical Supervisors will receive retraining on DDAP requirements related to termination from services notices, including required content, documentation, and timely completion. Supervisors will be responsible for ensuring compliance with these requirements within their assigned programs.
Monitoring/Auditing: The Clinical Supervisor and/or designated clinical leadership will conduct routine audits of termination records to verify that required notices are completed and properly documented. Any deficiencies identified through the audits will be addressed promptly through corrective action and additional staff retraining as needed.
Ongoing Compliance: Audit results will be reviewed by clinical leadership to identify trends and ensure continued compliance with DDAP termination notice requirements.
This POC will be implemented by 10.2.26
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709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Based on applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in two of five applicable records. The facility policy and procedure manual indicate a case consultation to occur every thirty days.
Client #1 was admitted to inpatient on July 1, 2026 and was still active at the time of the inspection. A case consultation was due to occur no later than August 1, 2026; however, this was not completed at the time of the inspection.
Client #2 was admitted to inpatient on July 15, 2026 and was still active at the time of the inspection. A case consultation was due to occur no later than August 15, 2026; however, this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the August 20, 2025 annual licensing inspection.
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Plan of Correction
Corrective Action: Counselors will identify residents who are approaching 30 days in the program. For residents who have been in the program 20?28 days, the counselor will ensure that a case consultation is completed prior to the 30-day requirement. The case consultation will then be reviewed and discussed during clinical supervision.
Monitoring: Clinical Supervisors will track upcoming 30-day case consultations on their calendars and monitor completion during clinical supervision. Any missed or approaching deadlines will be addressed promptly with the responsible counselor.
Ongoing Compliance: This process will be incorporated into routine clinical supervision to ensure case consultations are completed timely and consistently in accordance with DDAP requirements.
This POC will be implemented by 10.9.26
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in three of three records. The policy and procedure manual indicates follow-up contact must be made within thirty days after discharge.
Client #4 was admitted inpatient on May 27, 2026 and was discharged on June 4, 2026. The follow-up contact was due to be completed no later than July 4, 2026; however, this was not completed at the time of the inspection.
Client #6 was admitted inpatient on January 30, 2026 and was discharged on March 17, 2026. The follow-up contact was due to be completed no later than April 17, 2026; however, this was not completed at the time of the inspection.
Client #7 was admitted inpatient on April 15, 2026 and was discharged on June 5, 2026. The follow-up contact was due to be completed no later than July 5, 2026; however, this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the August 20, 2025 annual licensing inspection.
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Plan of Correction
Corrective Action: The agency will develop a standardized discharge follow-up letter to be completed and mailed at the time of discharge. The letter will identify the type of discharge and provide appropriate follow-up information and resources, as applicable.
Policy Update: The agency will revise its discharge policy to clearly define follow-up expectations based on the type of discharge. Residents who return to jail or escape from the facility will be excluded from routine post-discharge follow-up due to the circumstances of their discharge. The revised policy will clearly document these exceptions and the rationale for them.
Monitoring: Clinical leadership will monitor discharge documentation to ensure the appropriate follow-up letter is completed and mailed at the time of discharge and that the type of discharge is accurately identified.
This POC with be implemented by 10.16.26
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