INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 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, Spark Wellness 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(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 training during the facility's January 1, 2025 through December 31, 2025 training year in one of one applicable personnel record reviewed.
Employee #1 was hired as the project director and facility director on January 3, 2024. The personnel record documented 9 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
As of 3/10/26, the Clinical Director will ensure that all employees are made aware of their required training hours each year. In addition, Clinical Director will check monthly to remind employees/stay up to date with tracking their hours of training. |
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 facility's March 2025 through December 2025 fire drill logs, the facility failed to maintain a written fire drill record, which is to include the documentation of the exit route used during the drill.
At the time of the inspection, the March 2025 and October 2025 fire drill records did not have the exit route used during the fire drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/10/2026, the Facility Director will double check all the relevant information is included after each fire drill. It will also be shared with Clinical Director to check as well to make sure all relevant information is included. |
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 eleven client records reviewed.
Client # 10 was admitted to the outpatient activity on March 31, 2025 and was discharged on June 17, 2025. There was evidence of disclosures to the funding source during the client's treatment episode; however, the consent to release information form was not signed by the client until their discharge date of June 17, 2025.
This is a repeat citation from the February 21, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/10/2026, the Clinical Director will check all intake paperwork within 72 hours of admission to ensure all consents are completed with all required signatures. If a consent is found to be missing a signature, Clinical Director will reach out to the primary counselor to have client sign the document. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in one of two applicable client records reviewed.
Client #1 was admitted to the partial hospitalization activity on January 5, 2026 and was discharged on February 23, 2026. The individual treatment and rehabilitation plan, dated January 8, 2026, indicated the client was to receive two individual counseling sessions per week. The client's record of service and progress notes indicated the client had received one individual counseling session per week from January 11, 2026 through January 31, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/10/26, Clinical Director will complete weekly chart check audits of clinical paperwork. Included in the chart check template is acknowledgment of whether a PHP client has 2 sessions in a week or documentation of client not wanting sessions in the week.
Clients will be encouraged to attend their scheduled individual sessions per the timelines of the program they are in.
If clients are not able to maintain that level, the treatment plan will be amended to correctly reflect the clients level of involvement in their interventions. |
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 individual treatment and rehabilitation plans were developed with the client, per the facility policy, in three of seven client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plan will be completed within 30 days of admission.
Client # 4 was admitted to the outpatient activity on October 1, 2025 and was still active at the time of the inspection. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
Client # 5 was admitted to the outpatient activity on November 28, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than December 28, 2025; however, the treatment plan was not completed until January 7, 2026.
Client # 7 was admitted to the outpatient activity on April 8, 2025 and was discharged on August 27, 2025. The individual treatment and rehabilitation plan was due to be completed no later than May 8, 2025; however, the treatment plan was not completed until July 2, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/10/26, the Clinical Director will complete weekly chart checks for clinician's caseloads. On the chart check template is a notice of master treatment plans and their due dates along with treatment plan updates from the time of treatment plan.
In the chart checks, Clinical Director will let staff know if a treatment plan is late but also when an upcoming treatment plan will be due by.
As to the clients listed, their treatment plans will be completed by 3/13/26 and verified by chart checks done by Clinical Director. |