INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 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, PA Treatment & Healing 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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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 fire drill records from September 2025 through July 2026, the facility failed to maintain a written fire drill record that documented any problems encountered during the fire drills in eleven of eleven fire drill records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On August 27, 2026, the Project Director conducted a staff meeting during which the deficiency identified during the licensing inspection was reviewed and addressed with applicable facility staff. Staff were specifically educated regarding the documentation requirements contained within 705.28(d)(4) and were informed that all required components of the fire drill record must be completed for every fire drill conducted.
Staff were instructed that each fire drill record must document, at minimum:
Date of the fire drill;
Time of the fire drill;
Amount of time required to complete the evacuation;
Exit route used;
Number of persons present in the facility at the time of the drill;
Any problems encountered during the drill; and
Whether the fire alarm and/or smoke detector was operative.
Specific attention was given to the deficiency identified during the licensing review regarding the failure to document problems encountered. Staff were instructed that this section may not be left blank. If no problems are encountered during a fire drill, the individual completing the record will specifically document "None" or "No problems encountered." If a problem is identified, the specific issue will be documented along with any corrective action taken or needed.
The Facility Director/designee will be responsible for implementing this Plan of Correction and ensuring that staff responsible for conducting and documenting fire drills understand the requirements of 705.28(d)(4).
Effective August 27, 2026, the Facility Director/designee will ensure that the facility's fire drill documentation is reviewed following each fire drill to verify that all required elements have been completed before the record is filed.
Staff responsible for conducting the fire drill will be responsible for completing the fire drill record in its entirety immediately following the drill and submitting it to the Facility Director/designee for review.
The Facility Director/designee will monitor compliance on an ongoing basis by reviewing 100% of fire drill records following each monthly fire drill to ensure that all required information is documented, including whether any problems were encountered.
The Facility Director/designee will verify that:
No required section of the fire drill record has been left blank;
"None" or "No problems encountered" is documented when applicable;
Any problems identified during the drill are clearly documented;
Corrective action is documented when a problem requires follow-up; and
All other elements required by 705.28(d)(4) are present and complete.
Any incomplete fire drill record will be returned immediately to the responsible staff member for correction. If monitoring identifies that a staff member has failed to appropriately complete the required documentation, that employee will receive additional instruction and documented retraining regarding the fire drill documentation requirements.
Repeated failure to comply with the established documentation requirements will be addressed through PATH's corrective/disciplinary process in accordance with agency policy.
To prevent recurrence of this deficiency, fire drill documentation requirements will remain part of the facility's ongoing compliance monitoring process. The Facility Director/designee will continue reviewing each monthly fire drill record for completeness and regulatory compliance.
Additionally, applicable newly hired staff will receive instruction regarding fire drill procedures and documentation requirements as part of their facility-specific orientation prior to assuming responsibility for conducting or documenting a fire drill.
Through staff education, completion requirements, supervisory review of 100% of monthly fire drill records, immediate correction of identified deficiencies, and retraining when necessary, PATH will ensure continued compliance with 705.28(d)(4). |
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 obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two out of eight records reviewed.
Client #3 was admitted on February 6, 2026, and was still active at the time of the inspection. There was documentation in the client record that the facility had contact with a legal entity on January 7 and 30, 2026; however, there was no documentation that the facility obtained an informed and voluntary consent for the legal entity.
Client #5 was admitted on April 28, 2026, and discharged on July 31, 2026. There was documentation in the client record that the facility had contact with a legal entity on May 8 and 11, 2026; however, there is no documentation that the facility obtained an informed and voluntary consent for the legal entity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On **September 3, 2026**, the **Project Director reviewed this deficiency with staff** and provided education regarding the requirements for obtaining an informed and voluntary written consent prior to disclosing client information to an outside individual, agency, legal entity, or other third party, except when disclosure is otherwise specifically permitted or required by applicable law.
During the review, staff were reminded that the existence of a referral, court involvement, probation involvement, treatment court participation, or another legal relationship does not, by itself, replace the requirement to ensure that appropriate authorization for disclosure is present when required.
Staff were instructed that **prior to communicating protected client information to a legal entity or other outside party, the client's record must be reviewed to verify that a current and appropriately completed informed and voluntary consent authorizing the specific disclosure is present.**
Staff were further instructed that the consent must be completed in its entirety and contain all required information before disclosure occurs. Staff may not assume that another employee previously obtained the necessary consent.
The deficiencies identified for Clients #3 and #5 were utilized as examples during the September 3, 2026 review to reinforce the importance of verifying consent documentation prior to disclosure.
The consent deficiency identified for **Client #3 will be corrected individually and promptly.** The clinician assigned to Client #3 will contact the client and arrange for the client to review and sign a **corrected, fully completed informed and voluntary consent**.
The corrected consent must be obtained **at Client #3's next scheduled appointment or within five (5) business days, whichever occurs first.** The clinician will ensure that the corrected consent contains all required elements, accurately identifies the individual, agency, legal entity, or other third party authorized to receive information, and appropriately identifies the information that may be disclosed and the purpose of the disclosure.
Once completed, the corrected consent will be maintained in Client #3's record in accordance with PATH's documentation and confidentiality requirements.
The **Project Director will be responsible for directly following up with the assigned clinician to verify that the corrected consent for Client #3 has been obtained within the required timeframe and properly maintained in the client record.** The Project Director will document or otherwise verify completion of this corrective action.
If the assigned clinician fails to contact Client #3, obtain the corrected consent within the required timeframe, or appropriately document the corrected consent in the client record, **disciplinary action will be taken in accordance with PATH's corrective and/or progressive disciplinary policies.**
Effective **September 3, 2026**, all clinical and applicable administrative staff are required to verify the presence and validity of the appropriate informed and voluntary consent prior to releasing or communicating protected client information to an outside party.
The staff member making the disclosure will be responsible for confirming that:
1. An appropriate informed and voluntary consent is present in the client record;
2. The consent authorizes communication with the specific individual, agency, or entity receiving the information;
3. The consent permits disclosure of the information being communicated;
4. The consent remains valid and has not expired or been revoked; and
5. The disclosure is consistent with the scope and purpose of the authorization.
If staff are uncertain whether an existing consent permits a proposed disclosure, **no disclosure will occur until the matter has been reviewed with the Project Director, Facility Director, Clinical Supervisor, or other designated supervisory staff.**
The **Project Director will be responsible for overseeing implementation of this Plan of Correction.** Facility Directors and/or Clinical Supervisors will assist with ongoing monitoring at the facility level.
To verify continued compliance, supervisory staff will conduct **monthly random reviews of active client records** to ensure that disclosures documented within the record are supported by appropriate informed and voluntary consent documentation when required.
The review will specifically compare documentation of external communications?including communication with courts, probation, attorneys, treatment court personnel, Children & Youth agencies, referral sources, and other outside entities?with the consents maintained within the client record.
Any identified disclosure for which required consent documentation cannot be verified will be immediately brought to the attention of the Project Director and/or appropriate supervisor for review and corrective action.
The Project Director will periodically review the results of these monitoring activities to identify recurring deficiencies, staff-training needs, or systemic concerns requiring additional corrective action.
If monitoring identifies that a staff member communicated protected client information without first verifying that an appropriate consent was present when required, the staff member will receive **documented retraining regarding confidentiality, informed consent, and disclosure requirements**.
Following retraining, the employee's documentation will be subject to additional supervisory monitoring to verify competency and compliance.
Repeated failure to follow the agency's confidentiality and consent requirements will be addressed through PATH's corrective and/or progressive disciplinary process in accordance with agency policy.
To prevent recurrence, confidentiality and informed-consent requirements will also be reviewed with applicable newly hired staff as part of their orientation and training process.
New staff will be instructed that protected client information may not be disclosed solely because an outside agency or legal entity requests information. Staff must first determine whether the disclosure is appropriately authorized or otherwise permitted by applicable confidentiality requirements.
Supervisory staff will be available to provide guidance whenever an employee is uncertain whether information may appropriately be released.
PATH will prevent recurrence of this deficiency through:
* Staff education completed by the Project Director on September 3, 2026;
* **Immediate correction of Client #3's deficient consent at the client's next appointment or within five business days, whichever occurs first;**
* **Direct Project Director follow-up to verify completion of Client #3's corrected consent;**
* **Disciplinary action if the assigned clinician fails to complete the required Client #3 corrective action within the established timeframe;**
* Mandatory verification of appropriate consent prior to disclosure;
* Supervisory consultation when the permissibility of a disclosure is unclear;
* Monthly random record reviews comparing documented external communications with corresponding consent documentation;
* Documented retraining when deficiencies are identified;
* Increased monitoring following identified noncompliance; and
* Inclusion of confidentiality and informed-consent requirements in applicable new-employee training.
These corrective measures are intended to ensure that the specific deficiency identified for Client #3 is corrected promptly, that staff consistently verify that an appropriate informed and voluntary consent is present prior to disclosing protected client information when such consent is required, and that PATH maintains ongoing compliance with applicable confidentiality requirements.
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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 the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in two out of eight client records reviewed.
Client #2 was admitted on April 7, 2026, and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information forms for two funding sources, and one emergency contact dated April 2, 2026, was offered to the client.
Client #8 was admitted on January 15, 2026, and discharged on April 10, 2026. There was no documentation that a copy of an informed and voluntary consent to release information form for a medical provider dated March 30, 2026, was offered to the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On **September 3, 2026**, the **Project Director reviewed this deficiency with staff** and provided education regarding the requirements for completion and documentation of informed and voluntary consent forms.
Staff were specifically instructed that when an informed and voluntary consent to release information is completed, **a copy of the completed consent must be offered to the client and documentation must reflect that the copy was offered. A copy of the completed consent must also be maintained in the client's record.**
The Project Director reviewed the findings identified during the licensing process and reinforced that completing and signing the consent form alone is not sufficient if the record does not also demonstrate that the client was offered a copy as required.
Staff were instructed that the requirement applies to applicable consent forms regardless of the type of entity involved, including funding sources, emergency contacts, medical providers, legal entities, referral sources, and other individuals or organizations for whom an informed and voluntary consent is required.
The consent deficiency identified for **Client #2 will be corrected individually and promptly.** The clinician assigned to Client #2 will contact the client and arrange for the client to review and sign a **corrected, fully completed informed and voluntary consent** that includes appropriate documentation that a copy of the completed consent was offered to the client.
The corrected consent must be obtained **at Client #2's next scheduled appointment or within five (5) business days, whichever occurs first.**
At the time the corrected consent is completed, the clinician will ensure that:
1. The informed and voluntary consent is completed in its entirety;
2. All required information, signatures, and dates are present;
3. A copy of the completed consent is offered to Client #2;
4. The consent documentation clearly reflects that a copy was offered;
5. If Client #2 declines the copy, the record documents that the copy was offered and declined; and
6. A completed copy of the corrected consent is maintained in Client #2's record.
The **Project Director will be responsible for directly following up with the assigned clinician to verify that the corrected consent for Client #2 has been completed within the required timeframe and is appropriately maintained in the client record.** The Project Director will verify completion of this corrective action.
If the assigned clinician fails to contact Client #2, obtain the corrected consent within the required timeframe, document that a copy was offered to the client, or appropriately maintain the corrected consent in the client record, **disciplinary action will be taken in accordance with PATH's corrective and/or progressive disciplinary policies.**
Effective **September 3, 2026**, all clinical and applicable administrative staff responsible for obtaining informed and voluntary consents will ensure that the consent process is completed in its entirety.
The staff member obtaining the consent will be responsible for verifying that:
1. The informed and voluntary consent is completed in its entirety;
2. All required signatures, dates, and information are present;
3. A copy of the completed consent is **offered to the client**;
4. The record clearly documents that the client was offered a copy of the consent; and
5. A completed copy of the consent is maintained in the client's record.
If the client declines a copy, staff will document that the copy was offered and declined rather than leaving the applicable documentation incomplete or blank.
Staff were advised that this requirement applies to **each individual consent completed** and that they are responsible for reviewing the consent for completeness before finalizing or filing the document.
The **Project Director will be responsible for overseeing implementation of this Plan of Correction.** The Facility Director and/or Clinical Supervisor will assist with ongoing monitoring at the facility level.
To ensure continued compliance, supervisory staff will conduct **monthly random reviews of active client records**. During these reviews, informed and voluntary consent forms will be examined to verify that:
* The consent has been completed appropriately;
* Required signatures and dates are present;
* Documentation confirms that a copy of the consent was offered to the client; and
* A completed copy of the consent is maintained within the client record.
Any consent identified as incomplete will be addressed immediately. When clinically and administratively appropriate, staff will obtain or correct the required documentation. The responsible staff member will also receive instruction regarding the identified deficiency.
The **Project Director will monitor the results of the monthly record reviews** to determine whether the corrective measures remain effective and whether additional staff education, monitoring, or procedural changes are necessary.
Any staff member identified as failing to properly complete the consent process or document that a copy was offered to the client will receive **documented retraining** regarding informed and voluntary consent requirements.
Following retraining, supervisory staff will conduct additional monitoring of the employee's documentation to verify that the employee demonstrates continued competency and compliance.
Repeated failure to comply with the established consent documentation requirements will be addressed through PATH's corrective and/or progressive disciplinary process in accordance with agency policy.
To prevent recurrence, the requirements for obtaining, completing, and documenting informed and voluntary consents will be incorporated into applicable new-employee orientation and training.
Prior to independently completing client consent documentation, applicable new staff will be instructed regarding the requirement to offer the client a copy of each completed consent, document that the copy was offered, and maintain the completed consent within the client record.
The Facility Director, Clinical Supervisor, and/or designated supervisory staff will verify that applicable new employees have received this instruction before independently assuming responsibility for client consent documentation.
PATH will prevent recurrence of this deficiency through:
* Staff education completed by the Project Director on **September 3, 2026**;
* **Immediate correction of Client #2's deficient consent at the client's next appointment or within five business days, whichever occurs first;**
* **Direct Project Director follow-up to verify completion of Client #2's corrected consent;**
* **Verification that Client #2 was offered a copy of the corrected consent and that this was documented in the record;**
* **Disciplinary action if the assigned clinician fails to complete the required Client #2 corrective action within the established timeframe;**
* Standardized expectations for completion of informed and voluntary consent documentation;
* Monthly supervisory record reviews;
* Immediate correction of subsequently identified deficiencies when appropriate;
* Documented retraining when noncompliance is identified;
* Increased supervisory monitoring following identified noncompliance; and
* Inclusion of informed and voluntary consent requirements in applicable new-employee orientation and training.
These corrective measures will ensure that the specific deficiency identified for Client #2 is corrected within the established timeframe, that clients are consistently offered a copy of each applicable informed and voluntary consent, that the offer is appropriately documented, and that completed consent documentation is maintained within the client record. The Project Director will maintain oversight of implementation and ongoing compliance.
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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 document that a comprehensive treatment plan was developed with the client within thirty days of admission, per the facility ' s policy, in five out of eight records reviewed.
Client #1 was admitted on May 16, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than June 15, 2026; however, it was completed on July 1, 2026, and there was no documentation that it was developed with the client.
Client #2 was admitted on April 7, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than May 7, 2026; however, it was completed on May 18, 2026.
Client #4 was admitted on October 8, 2025, and discharged on April 29, 2026. A comprehensive treatment plan was completed on November 8, 2025; however, there is no documentation that it was completed with the client.
Client #6 was admitted on May 14, 2026, and discharged on August 17, 2026. A comprehensive treatment plan was due no later than June 13, 2026; however, it was completed on July 10, 2026.
Client #7 was admitted on April 23, 026 and discharged on May 29, 2026. A comprehensive treatment plan was due no later than May 23, 2026; however, there was no documentation that the comprehensive treatment plan was completed due to the client only attending the initial session.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On **September 3, 2026**, the **Project Director reviewed this deficiency with staff** and provided education regarding PATH's requirement that a comprehensive treatment plan be developed with the client within thirty (30) days of admission.
The Project Director reviewed the findings identified during the licensing process and emphasized that staff are responsible for both **timely completion of the comprehensive treatment plan and documentation demonstrating the client's participation in its development**.
Staff were instructed that the comprehensive treatment plan must be individualized and developed collaboratively with the client. Documentation must clearly demonstrate the client's involvement in identifying treatment needs, goals, objectives, and interventions. The client's participation will be evidenced through the appropriate documentation and client signature when required.
Staff were further instructed that a client's inconsistent attendance, missed appointments, or failure to return for services does not eliminate the need to document efforts made to complete the comprehensive treatment plan. When a treatment plan cannot be completed within the required timeframe because the client fails to attend or otherwise does not participate, staff must document the circumstances, attempts to contact and engage the client, scheduled or missed appointments, and efforts made to obtain the client's participation.
Effective **September 3, 2026**, clinical staff will be responsible for monitoring the treatment-plan due dates of clients assigned to their caseloads and ensuring that comprehensive treatment plans are developed with clients within thirty (30) days of admission.
Counselors will begin treatment-planning discussions sufficiently in advance of the due date to allow adequate time for collaborative development and completion of the comprehensive treatment plan.
Clinical staff will ensure that:
1. The comprehensive treatment plan is completed within thirty (30) days of the client's admission;
2. The treatment plan is individualized according to the client's assessed needs;
3. The client actively participates in developing treatment goals, objectives, and interventions;
4. The client's participation is clearly documented in the client record;
5. Required client and staff signatures and dates are obtained and documented;
6. Treatment-plan due dates are monitored so that plans are not permitted to become overdue; and
7. When the client does not attend or is otherwise unavailable to participate, all attempts to engage the client and complete the treatment plan are documented in the client record.
Staff were instructed to notify their **Clinical Supervisor and/or Facility Director prior to the treatment plan becoming overdue** if barriers exist that may prevent timely completion so that the issue can be addressed before the thirty-day deadline whenever possible.
The **Project Director will be responsible for overseeing implementation of this Plan of Correction.** The Clinical Supervisor and/or Facility Director will be responsible for routine monitoring of treatment-plan compliance at the facility level.
To prevent treatment plans from becoming overdue, the **Clinical Supervisor and/or Facility Director will review treatment-plan due dates on a weekly basis** for active clients. This review will identify treatment plans approaching the thirty-day deadline and allow supervisory staff to intervene before a plan becomes delinquent.
In addition, supervisory staff will conduct **monthly random client-record reviews** to verify that comprehensive treatment plans:
* Were completed within thirty (30) days of admission;
* Demonstrate that the client participated in treatment-plan development;
* Contain required signatures and dates;
* Include individualized goals, objectives, and interventions; and
* Contain appropriate documentation of outreach and barriers when the client was unavailable or failed to attend scheduled services.
Any treatment plan identified as approaching its due date without completion will be immediately brought to the attention of the assigned counselor and Clinical Supervisor. Any overdue or otherwise deficient treatment plan identified through monitoring will be addressed promptly, and corrective action will be initiated as appropriate.
The **Project Director will monitor the results of these reviews** to ensure that the corrective measures remain effective and to identify any patterns requiring additional training, supervision, or procedural changes.
Any staff member who fails to complete a comprehensive treatment plan within the required timeframe, fails to appropriately involve and document the client's participation, or fails to document barriers and attempts to engage a non-attending client will receive **documented retraining and supervisory guidance** regarding treatment-planning requirements.
Following retraining, the employee's treatment-plan documentation will be subject to increased supervisory review to verify continued compliance.
Repeated failure to comply with treatment-planning requirements will be addressed through PATH's corrective and/or progressive disciplinary process in accordance with agency policy.
To prevent recurrence, applicable newly hired clinical staff will receive training regarding comprehensive treatment-plan requirements as part of their orientation and clinical onboarding.
Prior to independently assuming responsibility for a clinical caseload, new clinical staff will be educated regarding the thirty-day treatment-plan requirement, expectations for client participation, required signatures and documentation, procedures for monitoring due dates, and documentation requirements when a client fails to attend or participate.
The Clinical Supervisor and/or Facility Director will verify completion of this training before the employee independently assumes responsibility for treatment planning.
PATH will prevent recurrence of this deficiency through staff education completed by the Project Director on **September 3, 2026**, counselor monitoring of individual treatment-plan due dates, weekly supervisory review of upcoming treatment-plan deadlines, monthly random record reviews, documented retraining when deficiencies are identified, and increased supervisory monitoring when necessary.
These corrective measures will ensure that comprehensive treatment plans are developed collaboratively with clients within thirty (30) days of admission, that client participation is appropriately documented, and that circumstances preventing timely completion are clearly documented and addressed.
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