INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 2026 and July 9, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Amwell Recovery of Wayne 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 annually, appropriate to the employee ' s skill level, and with input from both the employee and the supervisor in eight of eleven applicable personnel records reviewed.
Employee # 1 was hired as the project director and facility director on February 24, 2025 and was still in the position. The individual training plan, completed on July 6, 2026, had no documentation indicating the plan was developed with input from the supervisor.
Employee # 2 was hired as the clinical supervisor on May 27, 2025 and was still in the position. The training plan, completed on July 9, 2026, was not individualized as the plan was a basic template used for the clinical supervisor position. There was no other documentation in the personnel record indicating an individual training plan was completed for the facility's current training year.
Employee # 3 was hired as a counselor on August 25, 2025 and was still in the position. The training plan, completed on April 26, 2026, was not individualized as the plan was a basic template used for the counselor position and there was no documentation indicating there was any input from the supervisor. There was no other documentation in the personnel record indicating an individual training plan was completed for the facility's current training year.
Employee # 6 was hired as a counselor on February 1, 2026 and was still in the position. The training plan, completed on February 16, 2026, was not individualized as the plan was a basic template used for the counselor position. There was no other documentation in the personnel record indicating an individual training plan was completed for the facility's current training year.
Employee # 7 was hired as a counselor on May 1, 2026 and was still in the position. The training plan, completed on May 29, 2026, was not individualized as the plan was a basic template used for the counselor position. There was no other documentation in the personnel record indicating an individual training plan was completed for the facility's current training year.
Employee # 8 was hired as a counselor on January 20, 2025 and was still in the position. There was no documentation in the personnel record indicating an individual training plan was completed for the facility's current training year.
Employee # 9 was hired as a counselor on May 7, 2026 and was still in the position. The training plan, completed on May 11, 2026, was not individualized as the plan was a basic template used for the counselor position. There was no other documentation indicating an individual training plan was completed for the facility's current training year.
Employee # 11 was hired as a counselor on November 3, 2025 and was still in the position. The training plan, completed on November 22, 2025, was not individualized as the plan was a basic template used for the counselor position. There was no other documentation indicating an individual training plan was completed for the facility's current training year.
This is a repeat citation from the June 26, 2024 and July 2, 2025 annual licensing renewal inspections.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Operation Director will create and implement tool for annual staff training plans by 8/31/26. These annual training plans will be issued on 12/1 each year and completed by 12/31 by staff for the following and upcoming year. Direct supervisor will then comment and add necessary and recommended training.
HR Compliance has created a grid with current staffing to track ongoing and to add future employees.
Operation Director and HR Compliance will work in tandem to ensure training plan is completed and given prior to start date. |
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 the review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in two of five applicable personnel record reviewed.
Employee # 3 was hired as a counselor on May 1, 2024 and was due to have both communicable disease trainings completed no later than May 1, 2025; however, there was no documentation indicating the TB/STD training was completed as of the date of the inspection.
Employee # 8 was hired as a counselor on January 20, 2025 and was due to have both communicable disease trainings completed no later than January 20, 2026; however, there was no documentation indicating the TB/STD training was completed as of the date of the inspection. Additionally, the documentation of the HIV/AIDS training indicated it was completed on February 9, 2026.
This is a repeat citation from the July 2, 2025 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff are signed up for the necessary trainings and enrolled but are taking he trainings late.
Moving forward HR representative will create a training grid to outline the required and necessary first year/ new hire trainings and will track complete. Operation Director will review for completion and Clinical supervisor will review at individual supervisions to check on progress. |
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 July 1, 2025 through June 30, 2026 training year, in one of one applicable personnel record reviewed.
Employee # 1 was hired as the project director and facility director on February 24, 2025 and was still in the position. At the time of the inspection, the personnel record documented 5 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
This Operation/ Facility Director will need to work to carve out time and will utilize internal training tool and other online resources to ensure 12 hours is completed annual. HR representative will keep track of hours and certificates to ensure compliance. This will be done monthly and tracked. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in five of six applicable records reviewed.
Employee # 4 was hired as a counselor on May 18, 2026. The fire extinguisher training was not completed until June 9, 2026.
Employee # 6 was hired as a counselor on February 1, 2026. The fire extinguisher training was not completed until February 10, 2026.
Employee # 7 was hired as a counselor on May 1, 2026. The fire extinguisher training was not completed until May 13, 2026.
Employee # 10 was hired as a counselor on April 8, 2026. The fire extinguisher training was not completed until June 12, 2026.
Employee # 11 was hired as a counselor on November 3, 2025. The fire extinguisher training was not completed until December 17. 2025.
This is a repeat citation from the June 26, 2024 and July 2, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Operation director With ensure that any staff that are uncompleted will be done by 8/30.
Hiring manager will set up and send out training platform before the new hire starts. This will be sent in advance and trainings will be completed prior to start date. This will be implemented immediately.
Hiring manager will ensure this is completed prior to start date.
HR representative will not allow start until these trainings are completed and obtained.
HR will track completion via Staffing Grid. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies in five of six applicable records
Employee # 4 was hired as a counselor on May 18, 2026. The training to perform assigned tasks during emergencies was not completed until June 9, 2026.
Employee # 6 was hired as a counselor on February 1, 2026. The training to perform assigned tasks during emergencies was not completed until February 18, 2026.
Employee # 7 was hired as a counselor on May 1, 2026. The training to perform assigned tasks during emergencies was not completed until May 13, 2026.
Employee # 10 was hired as a counselor on April 8, 2026. The training to perform assigned tasks during emergencies was not completed until June 12, 2026.
Employee # 11 was hired as a counselor on November 3, 2025. The training to perform assigned tasks during emergencies was not completed until December 17, 2025.
This is a repeat citation from the June 26, 2024 and July 2, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Operation Director and HR representative will send out training platform prior to start date. Emergency Protocol and Fire Safety and Procedure training will be completed prior to start date via virtual platform. HR representative will review onboarding to ensure this is completed prior to starting. This will be implemented immediately.HR will track completion and add to staffing grid to ensure this is done prior to start date. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the July 2025 through June 2026 fire drill logs, the facility failed to maintain on their written fire drill record the exit route used and the number of persons in the facility at the time of the drill.
At the time of the inspection, there was no documentation on the drill log indicating the exit route used for the drills conducted during the months of July 2025, September 2025, October 2025, November 2025, January 2026, and February 2026. Additionally, there was no documentation on the drill log indicating the number of persons in the facility at the time of the drill for the drill conducted during the month of May 2026.
This is a repeat citation from the June 26, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 8/10/2026 The fire drill log has been edited and adjusted and the templated recreated to incorporate alternative exits and entries. This will be effective as of 8/10/26.
The updated log will equally include a space for number of participants.
Admin staff will submit and scan and send to Operations director to ensure correct and accurate completion.
Operation director will review monthly in Fire Drill binder. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's July 2025 through June 2026 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
At the time of the inspection, the facility's posted hours of operation was Monday through Friday from 9 A.M to 8 P.M. None of the fire drills conducted during the reviewed period were completed after 2:30 P.M.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Operations Director will conduct training on 8/30 to review the need for different times to conduct the fire drills with the administrative team. This training will be logged and recorded. Operations director will ensure 1 fire drill is conducted monthly in the evening during operations hours for night programming. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for the completion of an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles and including a reference to the drug and alcohol treatment activities, for the project's fiscal year ending December 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Operations director filed for an exemption, and this was approved pending our ability to provide tax returns. Tax returns will need to be provided next year. Or ownership will need to hire a CPA to complete the annual fiscal and financial audit.
Ownership will seek out CPA for next fiscal year and provide both sets of tax returns for 2025/ 2026.
Operations Director will reach out to ownership. |
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.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a consent to release information form was offered to the client in fourteen of fourteen client records reviewed.
In each client record, there was no documentation indicating a copy of the client-signed release of information form to the funding source was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This has since been corrected. A check box is now visible and useable on the form. Clinical supervisor will review admission paper work to ensure completion. |
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 maintain a complete client record on an individual, which is to include documentation of follow-up information, in two of two applicable records reviewed.
Client # 12 was admitted on October 3, 2025 and discharged on October 23, 2025. At the time of the inspection, there was no follow-up information documented in the record.
Client # 13 was admitted on November 12, 2025 and was discharged on December 15, 2025. At the time of the inspection, there was no follow-up information documented in the record.
This is a repeat citation from the July 2, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This operation director is sending weekly reporting to case manager to ensure follow up is completed and recorded. Clinical supervisor will review and ensure follow up is notated prior to closing the record. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in two of six applicable records reviewed.
Client # 2 was admitted on May 1, 2026 and was active at the time of inspection. The individual treatment plan was completed on June 7, 2026; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services the client was to receive.
Client # 3 was admitted on September 19, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on September 23, 2025; however, the plan did not include documentation of the frequency of treatment and rehabilitation services the client was to receive.
This is a repeat citation from the June 26, 2024 and July 2, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Operations director is working with EMR team to update the treatment plans and add widgets to notate the type and frequency of services. This will be completed by 8/31/26.
Operations Director will review with team at supervision on 8/31.
Clinical Director will review treatment plans for ongoing compliance via chart audit tool and system monthly.
Peer audits equally will check for 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 ensure treatment and rehabilitation plans were updated at least every 60 days in three of five applicable records reviewed.
Client # 1 was admitted on December 2, 2025 and was active at the time of inspection. A treatment plan update was completed on April 2, 2026, and the next update was due no later than June 2, 2026; however, there were no additional treatment plan updates completed as of the date of the inspection.
Client # 3 was admitted on September 19, 2025 and was active at the time of inspection. A treatment plan update was completed on October 30, 2025, and the next update was due no later than December 30, 2025; however, the update was not completed until April 7, 2026.
Client # 7 was admitted on January 16, 2026 and was discharged on June 5, 2026. The individual treatment and rehabilitation plan was completed on March 31, 2026, and the first update was due no later than May 31, 2026; however, the update was completed on June 15, 2026.
This is a repeat citation from the July 2, 2025 annual licensing renewal inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Clinical supervisor will continue to pull weekly reporting. Compliance Manager was hired to ensure and to review timely documentation and treatment plan compliance. Charts are reviewed daily and compliance officer is emailing the staff member to fix compliance issues. Clinical supervisor will review in individual supervision. Treatment plan update will occur before 8/30/2026 |
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 and the facility's policy and procedure manual, the facility failed to maintain a complete client record on an individual, which is to include the documentation of case consultation notes, in two of five applicable records reviewed.
The facility policy and procedure manual stated that case consultations will be completed at level of care changes and at discharge.
Client # 2 admitted on May 1, 2026 and was still active at the time of inspection. The client stepped down from the partial hospitalization activity; however, there were no case consultation notes documented in the record at the time of the inspection.
Client # 6 was admitted on January 20, 2026 and was discharged on February 19, 2026. There were no case consultation notes documented in the record at the time of the inspection.
This is a repeat citation from the June 26, 2024 and July 2, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Case consults will be completed at Clinical Supervision meetings for step down and discharge. Clinical supervisor will sign off. Transfer of care summary will be completed upon step down. This will be implemented immediately. Clinical Supervisor and Operation and UR will review for compliance. |
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 maintain a complete client record on an individual, which is to include the documentation of an aftercare plan, in one of one applicable record reviewed.
Client # 7 was admitted on January 16, 2026 and was discharged on June 5, 2026. At the time of the inspection, there was no documentation in the record indicating an aftercare plan was completed.
This is a repeat citation from the July 2, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Compliance manager will aid with chart audits to ensure aftercare plans are completed. As client is stepping down and moving to discharge Clinical supervisor will review to ensure aftercare plan is completed. This will be implemented immediately prior to closing the chart. |
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 maintain a complete client record, which is to include the documentation of follow-up information, in two of four applicable records reviewed.
Client # 5 was admitted on October 20, 2025 and was discharged on October 24, 2025. At the time of the inspection, there was no follow-up information documented in the record.
Client # 6 was admitted on January 20, 2026 and discharged on February 19, 2026. At the time of the inspection, there was no follow-up information documented in the record.
This is a repeat citation from the June 26, 2024 and July 2, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Operations Director will send out weekly reports of clients who were discharged. Case manager and admin team will reach out to discharge clients and document follow up in the clinical record and notate attempts. This will begin immediately. Operation Director will check weekly in charts to ensure a discharge follow up note is documented in the chart. |
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 ensure all staff were instructed in the use of the fire extinguishers upon employment was submitted and approved by the Department for the June 26, 2024 and July 2, 2025 annual licensing inspections. Failing to complete the fire extinguisher instruction upon employment was again found to be a deficiency in the July 9, 2026 licensing inspection.
A plan of correction for failing to ensure all staff were trained to perform assigned tasks during emergencies was submitted and approved by the Department for the June 26, 2024 and July 2, 2025 annual licensing inspections. Failing to complete the emergency-assigned task training was again found to be a deficiency in the July 9, 2026 licensing inspection.
A plan of correction for failing to document the type and frequency of outpatient services on the individual treatment plan was submitted and approved by the Department for the June 26, 2024 and July 2, 2025 annual licensing inspections. Failing to document the type and frequency of outpatient services on the individual treatment plan was again found to be a deficiency in the July 9, 2026 licensing inspection.
A plan of correction for failing to document outpatient case consultation notes was submitted and approved by the Department for the June 26, 2024 and July 2, 2025 annual licensing inspections. Failing to document outpatient case consultation notes was again found to be a deficiency in the July 9, 2026 licensing inspection.
A plan of correction for failing to document outpatient follow-up information was submitted and approved by the Department for the June 26, 2024 and July 2, 2025 annual licensing inspections. Failing to document outpatient follow-up information was again found to be a deficiency in the July 9, 2026 licensing inspection.
A plan of correction for failing to document individual training plans for each staff was submitted and approved by the Department for the June 26, 2024 and July 2, 2025 annual licensing inspections. Failing to document individual training plans for each staff was again found to be a deficiency in the July 9, 2026 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon new hire training this operation director will implement in new hire orientation training on how to use the fire extinguishers prior to start. This will be notated and documented in the new hire training plans starting immediately. Additionally with new hire orientation this operations director will review fire exits, fire extinguisher safety, and demonstrate the locations. Operations Director will be responsible party to ensure compliance of fire safety upon hire.
Sited staff will review at supervision on 8/26/2026
Operations Director has updated the treatment plans as of 8/26 to include type and frequency. This will be monitored by Clinical Supervisor at chart audit.
Staff will receive training on 8/24 to review case consultation at step down, discharge and every 90 days. Clinical Supervisor will review for compliance.
Case Manager is responsible for follow up after discharge. Clinical Supervisor will confirm notes in the chart. |