INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on April 21, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mind Dojo LLC 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 staff records, the facility failed to ensure that staff members received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics in two of four applicable records. Staff #3 was hired to the position of counselor on December 18, 2024 and was in this position at the time of review. Staff # 3 was due to complete 6 hours of HIV/AIDS training and 4 hours of TB/STD training no later than December 18, 2025. However, staff #3 completed 6 hours of HIV/AIDS training on April 16, 2026 and 4 hours of TB/STD training on April 15, 2026.Staff #4 was hired to the position of counselor on December 18, 2024 and was in this position at the time of review. Staff # 4 was due to complete 6 hours of HIV/AIDS training no later than December 18, 2025. However, staff #4 completed 6 hours of HIV/AIDS training on April 21, 2026.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the April 16, 2025 annual licensing inspection.
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Plan of Correction
Clinical Director and Office Manager will change Staff Trainings requirement to address all new hires complete the HIV/AIDS within 30 days of hire and TB/STD/ Other health related will be addressed for all staff in July 2026 and will be avilable to all staff after July 2026 on their first 30 days of hire. Clinical Director will audit staff training on a quarterly basis |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of staff records, the facility failed to ensure all counselors completed at least 25 hours of training annually in two of three applicable records. Staff #3 was hired to the position of counselor on December 18, 2024 and was in this position at the time of review. Staff # 3 completed 20 hours of training during the January 1, 2025 through December 31, 2025 training year. Staff #4 was hired to the position of counselor on December 18, 2024 and was in this position at the time of review. Staff # 4 completed 16 hours of training during the January 1, 2025 through December 31, 2025 training year. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Staff Trainings will be organized to a 30 day hire and quarterly due dates to be easily tracked for compliance by Facility Director and will be auditted quarterly to make sure all hours are accounted for. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on an inspection of the physical plant and staff interview, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. A fire extinguisher was found at the entrance of the facility that was labeled as being inspected in January of 2026. However, there was no record that the fire extinguisher was inspected by a local fire department or fire extinguisher company.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Local Fire Department has already been contacted by Office Manager to obtain a fully inspected fire estingisher and will be replaces prior to 5/8/2026. The Company replacing the fire estingisher will also be used to inspect yearly moving forward to ensure compliance |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in four of four applicable records. Client #1 was admitted to the outpatient level of care on August 18, 2025 and was active at the time of review. Client #1 had a treatment plan completed October 6, 2025. The next update was due no later than December 6, 2025. No further updates were found in the client record. Client #3 was admitted to the outpatient level of care on April 3, 2025 and was active at the time of review. Client #3 had a treatment plan completed January 6, 2026. The next update was due no later than March 6, 2026. The next treatment plan update for client #3 was completed April 13, 2026.Client #4 was admitted to the outpatient level of care on January 6, 2025 and was discharged October 9, 2025. Client #4 had a treatment plan completed on May 1, 2025. The next update was due no later than July 1, 2025. No further updates were found in the client record.Client #5 was admitted to the outpatient level of care on January 29, 2025 and was discharged September 15, 2025. Client #5 had a treatment plan completed on March 17, 2025. The next update was due no later than May 17, 2025. The next treatment plan update for client #5 was completed August 4, 2025. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the April 17, 2024 and the April 16, 2025 annual licensing inspection.
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Plan of Correction
Additional Staff Training regarding treatment plan reviews was facilitated on 4/26/2026 by Facility Director and surveys were sent to all counselors to explore barriers to this practice. Additional training will take place based on survey results and monthly chart audits will continue by Facility 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.
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Observations
Based on a review of client records, the facility failed to complete an aftercare plan in one of one applicable records. Client #6 was admitted to the outpatient level of care on March 27, 2025 and was discharged July 9, 2025. No aftercare plan was completed for client #6.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the April 17, 2024 and the April 16, 2025 annual licensing inspection.
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Plan of Correction
Facility Director trained staff on 5/1/2026 addressing Aftercare plans and process of completing Discharge Progress Note that includes Aftercare plan for last session of all Successful Discharges. Facility Director will do discharge audit quarterly to ensure compliance.
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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 failing to complete aftercare plans was submitted and approved by the Department for the April 17, 2024 and April 16, 2025 annual licensing inspections. Completing aftercare plans was again found to be a deficiency in the April 21, 2026 licensing inspection.A plan of correction for failing to update treatment plans at least every sixty days was submitted and approved by the Department for the April 17, 2024 and April 16, 2025 annual licensing inspections. Updating treatment plans at least every sixty days was again found to be a deficiency in the April 21, 2026 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director updated workflows and SOPs regarding Plan of Correction. These were introduced to all Staff on 4/29/2026. Quarterly reviews of POC and continued education will be given to all clinical staff during weekly clinical meeting.
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