INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 24, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Bucks County Treatment Solutions 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(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.
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Observations
Based on a review of personnel records, the facility failed to ensure a written individual training plan was developed for each employee, with input from both the employee and the supervisor, in one of one personnel record reviewed.
Employee # 1 was hired as the project director and facility director on January 1, 2024. There was no individual training plan, for the current training year, documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and Director of Operations have examined this citation. The Director of Operations will ensure that individual training plans are updated on an annual basis. Training plans will be stored in employee file and reviewed by Human Resources. Individual training plan will be completed with employee #1. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, the facility failed to provide adequate CPR certification and first aid training to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operations.
There was no documentation provided indicating any facility staff members had a current CPR certification and first aid training at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and Director of Operations have examined this citation. The Director of Operations and Human Resources will ensure that CPR certifications and first aid certifications are updated on an annual basis. Certifications will be stored in employee file and reviewed by Human Resources. Human resources will ensure that There will be at least one staff member with a current CPR certification at all times. |
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 ensure the project director and facility director completed at least 12 clock hours of annual training during the facility's January 1, 2024 through December 31, 2024 training year.
Employee #1 was hired as the Project Director and Facility Director on January 1, 2024. The personnel record documented 0 hours of training during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and Director of Operations have examined this citation. The Director of Operations will ensure that individual training hours and certifications are updated on an annual basis. Training certifications and hours will be stored in employee file and reviewed by Human Resources. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's September 2024 through January 2025 fire drill logs, the facility failed to ensure that unannounced fire drills were conducted at least once a month.
At the time of the inspection, there were no monthly fire drills documented during any of the months of the reviewed period.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and Director of Operations have examined this citation. The Director of Operations will ensure that fire drills are conducted monthly and stored on site for review. |
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 the review of personnel records, the facility failed to ensure an annual written individual staff performance evaluation was completed and reviewed and signed by the employee in one of one applicable personnel record reviewed.
Employee # 1 was hired as the project director and facility director on January 1, 2024. There was no annual performance evaluation documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and Director of Operations have examined this citation. The Director of Operations will ensure that performance evaluations are updated on an annual basis. Performance evaluations will be stored in employee file on site and reviewed by Human Resources. The performance evaluation was completed for employee #1, reviewed, signed and added to employee file. |
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 complete an informed and voluntary consent to release information form prior to the disclosure of information in one of four applicable client records reviewed.
Client # 5 was admitted to the partial hospitalization activity on August 31, 2024 and was discharged on September 5, 2025. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, along with the Director of Operations, has reviewed this citation. The Project Director will conduct weekly chart audits to assess voluntary consents and make necessary updates to ensure compliance. |
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).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on a release of information form in one of four applicable client records reviewed.
Client # 8 was admitted to the outpatient activity on September 10, 2024 and was discharged on September 16, 2024. The release of information form to the funding source was signed and dated by the witness on September 11, 2024, but the form did not include the dated signature of the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, along with the Director of Operations, has reviewed this citation. The Project Director will conduct weekly chart audits to assess voluntary consents and make necessary updates to ensure compliance. |
709.34 (c) (3) 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:
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
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Observations
Based on a review of the facility's September 2024 through January 2025 unusual incident logs and a discussion with facility staff, the facility failed to file a written unusual incident report with the Department within 3 business days following a significant disruption of services due to a disaster such as fire, storm, flood, or other occurrence that results in the closure of the facility for more than 1 day.
The facility discharged/referred all active clients and ceased operations as of September 20, 2024. There was no unusual incident report regarding the facility closure filed with the Department as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, in collaboration with the Director of Operations, has examined this citation. The Project Director will guarantee that all incidents are reported to the department within the regulatory timeframes by utilizing the incident portal for submissions. |
709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, a medical history of the client in two of two applicable client records reviewed.
Client # 4 was admitted to the partial hospitalization activity on August 29, 2024 and was discharged on September 5, 2024. There was no medical history documented in the record at the time of the inspection.
Client # 5 was admitted to the partial hospitalization activity on August 31, 2024 and was discharged on September 5, 2024. There was no medical history documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, in collaboration with the Director of Operations, has examined this citation. To ensure compliance, the Project Director will perform weekly chart audits for both active and discharged clients and request the needed documents. |
709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, a drug and alcohol history of the client in one of two applicable client records reviewed.
Client # 5 was admitted to the partial hospitalization activity on August 31, 2024 and was discharged on September 5, 2024. There was no documentation of a drug and alcohol history in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, in collaboration with the Director of Operations, has examined this citation. To ensure compliance, the Project Director will perform weekly chart audits for both active and discharged clients. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, a personal history of the client in two of two applicable client records reviewed.
Client # 4 was admitted to the partial hospitalization activity on August 29, 2024 and was discharged on September 5, 2024. There was no documentation of a personal history in the record at the time of the inspection.
Client # 5 was admitted to the partial hospitalization activity on August 31, 2024 and was discharged on September 5, 2024. There was no documentation of a personal history in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, in collaboration with the Director of Operations, has examined this citation. To ensure compliance, the Project Director will perform weekly chart audits for both active and discharged clients. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake process, a psychosocial evaluation of the client in one of two applicable client records reviewed.
Client # 5 was admitted to the partial hospitalization activity on August 31, 2024 and was discharged on September 5, 2024. There was no documentation of a psychosocial evaluation in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, in collaboration with the Director of Operations, has examined this citation. To ensure compliance, the Project Director will perform weekly chart audits for both active and discharged clients. |
709.83(a)(11) LICENSURE Client records
709.83. 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 document a complete client record, which is to include documentation of follow-up information, in three of five applicable client records reviewed.
Client # 3 was admitted to the partial hospitalization activity on July 31, 2024 and was discharged on September 6, 2024. There was no follow-up information documented in the record at the time of the inspection.
Client # 4 was admitted to the partial hospitalization activity on August 29, 2024 and was discharged on September 5, 2024. There was no follow-up information documented in the record at the time of the inspection.
Client # 5 was admitted to the partial hospitalization activity on August 31, 2024 and was discharged on September 5, 2024. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, in collaboration with the Director of Operations, has examined this citation. To ensure compliance, the Project Director will perform weekly chart audits for both active and discharged clients. Project Director will assign designee to complete the follow up with each discharged client. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, a psychosocial evaluation of the client in one of three applicable client records reviewed.
Client # 8 was admitted to the outpatient activity on September 10, 2024 and was discharged on September 16, 2024. There was no documentation of a psychosocial evaluation in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, in collaboration with the Director of Operations, has examined this citation. To ensure compliance, the Project Director will perform weekly chart audits for both active and discharged clients. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
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Observations
Based on a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client in one of three applicable client records reviewed.
Client # 6 was admitted to the outpatient activity on September 6, 2024 and was discharged on September 20, 2024. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, in conjunction with the Director of Operations, has reviewed this citation. To guarantee adherence to standards, the Project Director will conduct weekly chart audits for both current and discharged clients. Additionally, the Project Director will verify that each client has an established treatment plan tailored to their specific treatment requirements. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include documentation of case consultation notes, in two of two applicable client records reviewed.
Client # 6 was admitted to the outpatient activity on September 6, 2024 and was discharged on September 20, 2024. There were no case consultation notes in the record at the time of the inspection.
Client # 7 was admitted to the outpatient activity on September 10, 2024 and was discharged on September 20, 2024. There were no case consultation notes in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, in collaboration with the Director of Operations, has evaluated this citation. To ensure compliance with standards, the Project Director will perform weekly chart audits for both active and discharged clients. Furthermore, the Project Director will oversee case consultations for every client experiencing a change in their level of care.
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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 document a complete client record, which is to documentation of follow-up information, in six of six applicable client records reviewed.
Every outpatient client record reviewed was discharged and there was no documentation of follow-up information in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, in conjunction with the Director of Operations, has assessed this citation. To maintain adherence to standards, the Project Director will conduct weekly chart audits for both current and discharged clients. Additionally, the Project Director will designate an individual to carry out follow-up for each discharged client.
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