INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 27, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Behavioral Wellness Center at Girard Torre De La Raza 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:
|
Plan of Correction
|
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in five of ten client records reviewed.Client # 2 was admitted on July 30, 2026 and was discharged on August 25, 2026. There was a release of information form to a probation and parole office signed and dated by the client on July 30, 2026; however, the name of the person, agency, or organization to whom the disclosure was to be made was not documented on the form. Additionally, there was a release of information form to an emergency contact signed and dated by the client on August 13, 2026; however, the name of the person, agency, or organization to whom the disclosure was to be made was not documented on the form. Client # 3 was admitted on July 21, 2026 and was active at the time of inspection. There was a release of information form to a probation and parole office signed and dated by the client on July 21, 2026; however, the name of the person, agency, or organization to whom the disclosure was to be made was not documented on the form.Client # 4 was admitted on August 5, 2026 and was active at the time of inspection. There was a release of information form to a probation and parole office signed and dated by the client on August 5, 2026; however, the name of the person, agency, or organization to whom the disclosure was to be made was not documented on the form.Client # 6 was admitted on August 13, 2026 and was active at the time of inspection. There was a release of information form to a probation and parole office signed and dated by the client on August 13, 2026; however, the name of the person, agency, or organization to whom the disclosure was to be made was not documented on the form.Client # 7 was admitted on August 19, 2026 and was active at the time of inspection. There was a release of information form to an emergency contact signed and dated by the client on August 20, 2026; however, the name of the person, agency, or organization to whom the disclosure was to be made was not documented on the form.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Intake and other respective assigned staff will be re-trained on the proper completion of consent/release of information forms to ensure that the forms are completed in their entirety without blank areas.
Training will cover required authorization elements, acceptable identification of recipients, handling incomplete forms, and documentation of disclosures. Competency will be validated through a post-test.
Responsible Party:
Clinical Supervisor, Intake Workers and Counselors
Completion Date: 10/3/26
The Clinical Supervisor will conduct a focused review of 100% of consent/release-of-information forms for four (4) weeks to verify that each form is properly completed. Any deficiency will be corrected promptly and addressed with the responsible staff member through documented coaching and retraining, up to and including progressive disciplinary action when warranted. Thereafter, the Clinical Supervisor will review five (5) charts per month for three months to monitor ongoing compliance.
Responsible Party: Clinical Supervisor
Completion Date: 12/31/2026
|
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.
|
Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent to release information form was offered to the client in one of ten client records reviewed.Client # 7 was admitted on August 19, 2026 and was active at the time of inspection. There was a release of information form to an emergency contact signed and dated by the client on August 20, 2026; however, there was no documentation in the record indicating a copy of the release form was offered to the client. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Intake and other respective assigned staff who obtain consent/release of information forms will be re-trained to ensure that they offered a copy of the signed consent/release of information forms to the client and acknowledgement will be indicated in the client's medical record.
Responsible Party: Clinical Supervisor,
Intake Workers and Counselors
Completion Date: 10/9/26
The Clinical Supervisor will conduct a focused review of 100% of consent/release-of-information forms for four (4) weeks to verify that each form is properly completed. Any deficiency will be corrected promptly and addressed with the responsible staff member through coaching and retraining, up to and including progressive disciplinary action when warranted. Thereafter, the Clinical Supervisor will review five (5) charts per month for three months to monitor ongoing compliance.
Responsible Party: Clinical Supervisor
Completion Date: 12/31/2026
|
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.
|
Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, which is to also include the reason for termination, in one of one applicable client record reviewed.Client # 9 was admitted on April 10, 2026 and administratively discharged on June 6, 2026. There was no documentation in the record indicating the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project. This is a repeat citation from the August 7, 2025 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Counseling staff and or clinical supervisor will provide written notice of any decision to involuntarily terminate treatment to a client. The notice will state the specific reason for termination. A copy of the notice will be scanned into the client's electronic record.
All applicable staff will receive re training on the involuntary termination process and required elements of the written notice.
Responsible Party: Counselors and Clinical Supervisor
Completion Date: 10/9/26
Clinical Supervisor will conduct focus review of 100% or 5 charts of clients who are involuntarily terminated from treatment during a 3-month period to ensure that the client received written notice of the decision to terminate treatment. Any deficiency will be corrected promptly and addressed with the responsible staff member through documented coaching and retraining, up to and including progressive disciplinary action when warranted.
Responsible Party:
Clinical Supervisor
Completion Date: 12/31/2026
|
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
|
Observations
Based on a review of client records, the facility failed to ensure the client was given an opportunity to request reconsideration of a decision terminating treatment in one of one applicable client record reviewed.Client # 9 was admitted on April 10, 2026 and was administratively discharged on June 6, 2026. There was no documentation in the record indicating the client was provided the opportunity to request reconsideration of the decision to terminate treatment. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Counseling staff and or clinical supervisor will explain to the clients that they can request reconsideration of a decision terminating treatment. Prior to giving the client, the involuntary termination notice, the counselor and or clinical supervisor will ensure that the client understand that they can request reconsideration of the decision.
Counseling staff will receive re-training on the involuntary termination process, required elements of the written notice and the client's reconsideration rights.
Responsible Party: Clinical Supervisor and Counselors
Completion Date: 10/9/26
Clinical Supervisor will conduct focus review of 100% or 5 charts of clients who are involuntarily terminated from treatment during a 3-month period to ensure that the client was given the opportunity to request reconsideration of the decision to terminate treatment.
Non-compliance will be addressed with the responsible staff member through coaching and retraining, up to and including progressive disciplinary action when warranted.
Responsible Party: Clinical Supervisor Completion Date: 12/31/2026
|
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on a review of client records, the facility failed to ensure a physical examination was completed, as a part of the facility's intake and admission process, in three of ten client records reviewed.The facility's policy and procedure manual stated the physical examination of a client will be completed within 7 days of admission. Client # 1 was admitted on July 21, 2026 and was discharged on August 21, 2026. The physical examination was due to be completed no later than July 28, 2026; however, the exam was not completed until July 30, 2026. Client # 4 was admitted on August 5, 2026 and was active at the time of the inspection. The physical examination was due to be completed no later than August 12, 2026; however, the exam was not completed until August 14, 2026.Client # 5 was admitted on August 18, 2026 and was active at the time of the inspection. The physical examination was due to be completed no later than August 25, 2026; however, the exam was not completed until August 26, 2026.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Clients admitted into treatment will receive a physical examination within seven (7) days of admission. The program will work with our medical provider to coordinate and ensure that physical examinations are completed within seven (7) days. The medical provider will provide the program with "block times" for the completion of client's physical examination.
Responsible Party:
Clinical supervisor, nurse
Completion Date: 10/9/26
Clinical Supervisor will conduct focus chart review of 100% of admissions during a 3-month period to ensure timely completion of physical examinations. Noncompliance will be discussed with the medical provider, and additional actions to ensure 100% compliance will be discussed with the medical team.
Responsible Party:
Clinical Supervisor and Director of Recovery Services
Completion Date: 12/31/2026
|
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to ensure a psychosocial evaluation was completed, as a part of the facility's intake and admission process, in six of ten client records reviewed.The facility's policy and procedure manual stated the biopsychosocial evaluation of a client will be completed within 72 hours of admission. Client # 1 was admitted on July 21, 2026 and was discharged on August 21, 2026. The psychosocial evaluation was due to be completed no later than July 24, 2026; however, the evaluation was not completed prior to discharge. Client # 3 was admitted on July 21, 2026 and was active at the time of the inspection. The psychosocial evaluation was due to be completed no later than July 24, 2026; however, the evaluation was not completed until July 30, 2026. Client # 4 was admitted on August 5, 2026 and was active at the time of the inspection. The psychosocial evaluation was due to be completed no later than August 8, 2026; however, the evaluation was not completed until August 21, 2026. Client # 8 was admitted on October 1, 2025 and was discharged on November 23, 2025. The psychosocial evaluation was due to be completed no later than October 4, 2025; however, the evaluation was not completed until October 9, 2025.Client # 9 was admitted on April 10, 2026 and was discharged on June 6, 2026. The psychosocial evaluation was due to be completed no later than April 7, 2026; however, the evaluation was not completed until May 4, 2026. Client # 10 was admitted on December 23, 2025 and was discharged on February 20, 2026. The psychosocial evaluation was due to be completed on December 26, 2025; however, the evaluation was not completed until January 7, 2026. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Psychosocial evaluation will be completed within three days (72 hours) of each client's admission. Counselors will receive reminders during supervision regarding this requirement and the importance of timely completion. If the assigned counselor is unable to complete the evaluation within the required timeframe, the Clinical Supervisor shall assume responsibility for completing the psychosocial evaluation within 72 hours of admission.
Responsible Party:
Counselors and Clinical Supervisor
The Clinical Supervisor will conduct focused chart review of 100% of admissions for a period of three (3) months to verify timely completion of each psychosocial evaluation. Any identified noncompliance will be addressed through progressive corrective action, beginning with coaching and retraining and, when warranted, advancing to formal progressive discipline.
Responsible Party:
Clinical Supervisor and Director of Recovery Services
Completion Date: 12/31/2026
|
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
|
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 eight of ten client records reviewed. The facility's policy and procedure manual states that the comprehensive (individual) treatment plan will be completed within 7 days of admission. Client # 1 was admitted on July 21, 2026 and was discharged on August 21, 2026. The individual treatment and rehabilitation plan was due to be completed no later than July 28, 2026; however, the plan was not completed until July 30, 2026. Client # 3 was admitted on July 21, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than July 28, 2026; however, the plan was not completed until July 30, 2026. Client # 4 was admitted on August 5, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than August 12, 2026; however, the plan was not completed until August 26, 2026. Client # 5 was admitted on August 18, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than August 25, 2026; however, the plan was not completed as of the date of the inspection. Client # 6 was admitted on August 13, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than August 20, 2026; however, the plan was not completed as of the date of the inspection. Client # 7 was admitted on August 19, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than August 26, 2026; however, the plan was not completed as of the date of the inspection. Client # 9 was admitted on April 10, 2026 and was discharged on June 6, 2026. The individual treatment and rehabilitation plan was due to be completed no later than April 17, 2026; however, the plan was not completed until April 20, 2026. Client # 10 was admitted on December 23, 2025 and was discharged on February 2, 2026. The individual treatment and rehabilitation plan was due to be completed no later than December 30, 2025; however, the plan was not completed until January 8, 2026. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The clinical supervisor will re-educate counseling staff regarding the requirement to develop and document each client's individualized comprehensive treatment and rehabilitation plan within seven (7) days of admission. Counselors will complete and document treatment plans within the required timeframe. If the assigned counselor is unavailable, the clinical supervisor will complete the client's individualized comprehensive treatment and rehabilitation plan.
Responsible Party: Counselors and Clinical Supervisor.
Completion Date 10/3/26
The Clinical Supervisor or Director of Recovery Services will conduct focused audits of 100% of newly admitted clients for three (3) months to verify compliance with the seven-day treatment-planning requirement.
Responsible Party: Clinical Supervisor and Director of Recovery Services.
Completion Date 12/31/26
|
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in two of three applicable client records reviewed.Client # 8 was admitted on October 1, 2025 and was discharged on November 23, 2025. The individual treatment and rehabilitation plan was completed on October 8, 2025, and the first update was due to be completed no later than November 7, 2025; however, the update was completed on November 18, 2025.Client # 10 was admitted on December 23, 2025 and was discharged on February 20, 2026. The individual treatment and rehabilitation plan was completed on January 8, 2025, and the first update was due to be completed no later than February 7, 2026; however, the update was not completed prior to discharge.This is a repeat citation from the August 7, 2025 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Counselors will receive reminders during clinical supervision of the requirement to review and update each client's individualized treatment and rehabilitation plan at least every thirty (30) days.
Counselors will complete and document treatment plan updates within the required timeframe. If the assigned counselor is unable to complete the treatment plan update in the required timeframe, the clinical supervisor will review and update the client's individualized treatment and rehabilitation plan.
Responsible Party:
Counselors and Clinical Supervisor
Clinical Supervisor or Director of Recovery Services will conduct focused audit on 100% of treatment plan updates for a 3-month period to ensure compliance. Noncompliance will be addressed through coaching, retraining and when warranted, progressive disciplinary.
Responsible Party:
Clinical Supervisor and Director of Recovery Services
Completion Date: 12/31/2026
|
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to ensure that counseling services were being provided according to the individual treatment and rehabilitation plan in two of six applicable client records reviewed. Client # 3 was admitted on July 21, 2026 and was active at the time of inspection. The individual treatment and rehabilitation plan, completed on July 30, 2026, indicated the client was to receive weekly individual counseling sessions. There was no documentation in the record of individual counseling sessions occurring during the weeks of August 9, 2026 through August 22, 2026.Client # 8 was admitted on October 1, 2025 and was discharged on November 23, 2025. The individual treatment and rehabilitation plan, completed on October 8, 2025, indicated the client was to receive weekly individual counseling sessions. There was no documentation in the record of individual counseling sessions occurring during the weeks of October 12, 2025 through October 18, 2025 and October 26, 2025 through November 15, 2025. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All counseling services will be provided in accordance with each client's individual treatment and rehabilitation plan, including the type and frequency of services identified in the plan. Counselors will be re-educated during their clinical supervision as to importance of ensuring that the services provided are in accordance with each client's individual treatment and rehabilitation plan.
Responsible Party:
Counselors and Clinical Supervisor
Clinical Supervisor or Director of Recovery Services will conduct focused audit on 100% of all clients' treatment and rehabilitation plan updates for three (3) months to ensure compliance.
Noncompliance will be addressed with the responsible staff member through coaching and retraining, up to and including progressive disciplinary action when warranted.
Responsible Party: Clinical Supervisor and Director of Recovery Services
Completion Date: 12/31/2026
|
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.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in one of three applicable client records reviewed.Client # 9 was admitted on April 10, 2026 and was discharged on June 6, 2026. There was no follow-up information documented in the record at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Counselors will receive reminders during clinical supervision of the importance of following up with clients within seven (7) and thirty (30) days following the client's discharge. Counselor will document each follow-up attempt and outcome in the client record.
Responsible Party: Counselors and Clinical Supervisor
Clinical Supervisor will conduct focus review of 5 charts per month of discharged clients for a period of 3 months to ensure compliance. Noncompliance will be addressed with the responsible staff member through coaching and retraining, up to and including progressive disciplinary action when warranted.
Responsible Party: Clinical Supervisor and Director of Recovery Services
Completion Date: 12/31/2026
|