INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Familylinks, Inc. 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(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 a review of staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in one of four applicable staff records.Staff #8 was hired as a support staff on March 7, 2023 and was still in this position at the time of the inspection. The HIV/AIDs and TB/STD trainings were to be completed by March 7, 2025; however, these were not completed at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon Hire, the staff member will complete and sign a training plan. That training plan will be reviewed, approved and signed off on by Associate Director of Behavioral Health. All newly hired staff will be required to complete HIV/AIDS training within 6 months of their start date and will sign up for TB/STD training within 30 days of hire to ensure that it is completed within 365 days of hire. Staff #8 completed the HIV Training on 4-3-26. Staff#8 is registered for TB/STD training on 4-29-26. The training will be completed and the survey will be completed by 4-30-26. Both certificates will be emailed to the DDAP auditor by 5-1-26 to verify completion. Associate Director of Behavioral Health will review all training plans quarterly and annually with all staff members to ensure that all required trainings are completed each year.
Person Responsible: Associate Director of Behavioral Health |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the personnel training records, the facility failed to have counselors complete at least twenty-five clock hours of annual training in one of two applicable records. Staff #4 was hired as a counselor on October 3, 2023 and was still in this position at the time of the inspection. Staff #4 had documented 23.4 hours of training for the January 1, 2025 through December 31, 2025 training year.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The annual training requirements for DDAP will be reviewed with all staff during the 4-10-26 outpatient staff meeting. This will also be reviewed during individual supervisions occurring during the month of April with all individual reviews occurring by 4-30-26. The overall training plan and implementation will be monitored monthly and quarterly by the Associate Director of Behavioral Health to assure that all trainings and hours of trainings are completed within the required time frames. The Associate Director of Behavioral Health will provide a report to the Director of Behavioral Health quarterly to ensure the plan is followed and completed. The plan will be completed by December 31st of each training year.
Persons Responsible: Associate Director of Behavioral Health, Director of Behavioral Health
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709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include short- and long-term goals for treatment in seven of seven records. Client #1 was admitted to outpatient on September 3, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on September 11, 2025; however, there was no documentation of short-term goals.Client #2 was admitted to outpatient on January 8, 2026 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on January 8, 2026; however, there was no documentation of short-term goals.Client #3 was admitted to outpatient on August 11, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on August 20, 2025; however, there was no documentation of short-term goals.Client #4 was admitted to outpatient on August 25, 2025 and was discharged on November 19, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on August 27, 2025; however, there was no documentation of short-term goals.Client #5 was admitted to outpatient on May 1, 2025 and was discharged on August 6, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on May 8, 2025; however, there was no documentation of short-term goals.Client #6 was admitted to outpatient on October 22, 2025 and was discharged on February 26, 2026. A comprehensive treatment and rehabilitation plan was developed with the client on October 23, 2025; however, there was no documentation of short-term goals.Client #7 was admitted to outpatient on September 15, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on September 22, 2025; however, there was no documentation of short-term goals.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment planning in Welligent EHR will be reviewed with all staff at the 4-10-26 staff meeting. Long term goals (Problems) and short-term goals (Objectives) will be reviewed with staff and a demonstration will occur that will review how to put target dates in the EHR for both of these. After the review at the staff meeting, this will be reviewed individually with each staff during regular supervision during the month of April with all individual reviews occurring by 4-30-26. This process will be implemented beginning 5-1-26.
Person Responsible: Therapist, Associate Director of Behavioral Health
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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 applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services in seven of seven records. Client #1 was admitted to outpatient on September 3, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on September 11, 2025; there was no documentation of type and frequency of services.Client #2 was admitted to outpatient on January 8, 2026 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on January 8, 2026; however, there was no documentation of type and frequency of services.Client #3 was admitted to outpatient on August 11, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on August 20, 2025; however, there was no documentation of type and frequency of services.Client #4 was admitted to outpatient on August 25, 2025 and was discharged on November 19, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on August 27, 2025; however, there was no documentation of type and frequency of services.Client #5 was admitted to outpatient on May 1, 2025 and was discharged on August 6, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on May 8, 2025; however, there was no documentation of type and frequency of services.Client #6 was admitted to outpatient on October 22, 2025 and was discharged on February 26, 2026. A comprehensive treatment and rehabilitation plan was developed with the client on October 23, 2025; however, there was no documentation of type and frequency of services.Client #7 was admitted to outpatient on September 15, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on September 22, 2025; however, there was no documentation of type and frequency of services.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the February 4, 2025 annual licensing inspection.
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Plan of Correction
A function was created within the treatment plan in the Welligent electronic health record. Under this function, the therapist will be able to add the type and frequency of treatment to the treatment plan. This process will be reviewed and demonstrated with staff at the 4-10-26 staff meeting. After the review at the staff meeting, this will also be reviewed individually with each staff during regular supervision during the month of April with all individual reviews occurring by 4-30-26. This process will be implemented beginning 5-1-26.
Persons Responsible: Associate Director of Behavioral Health, Director of Behavioral Health
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of applicable client records, the facility failed to document proposed type of support service on individual treatment plans in seven of seven records.Client #1 was admitted to outpatient on September 3, 2025 and was still active at the time of the inspection.A comprehensive treatment and rehabilitation plan was developed with the client on September 11, 2025; there was no documentation of proposed type of support service.Client #2 was admitted to outpatient on January 8, 2026 and was still active at the time of the inspection.A comprehensive treatment and rehabilitation plan was developed with the client on January 8, 2026; however, there was no documentation of proposed type of support service.Client #3 was admitted to outpatient on August 11, 2025 and was still active at the time of the inspection.A comprehensive treatment and rehabilitation plan was developed with the client on August 20, 2025; however, there was no documentation of proposed type of support service.Client #4 was admitted to outpatient on August 25, 2025 and was discharged on November 19, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on August 27, 2025; however, there was no documentation of proposed type of support service.Client #5 was admitted to outpatient on May 1, 2025 and was discharged on August 6, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on May 8, 2025; however, there was no documentation of proposed type of support service.Client #6 was admitted to outpatient on October 22, 2025 and was discharged on February 26, 2026. A comprehensive treatment and rehabilitation plan was developed with the client on October 23, 2025; however, there was no documentation of proposed type of support service.Client #7 was admitted to outpatient on September 15, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on September 22, 2025; however, there was no documentation of proposed type of support service.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A review of including Support Services that assist the client in completing their goals in the treatment plan will be reviewed at 4-10-26 outpatient team meeting with staff. This will also be reviewed during individual supervisions occurring during the month of April with all individual reviews occurring by 4-30-26.
Responsible person: Therapist, Associate Director of Behavioral Health
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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 client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in five of seven applicable records.Client #3 was admitted to outpatient on August 11, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on August 20, 2025. A treatment and rehabilitation plan update was due no later than October 20, 2025; however, this was not completed until November 6, 2025.Client #4 was admitted to outpatient on August 25, 2025 and was discharged on November 19, 2025. A treatment and rehabilitation plan was developed on August 27, 2025. A treatment and rehabilitation plan update was due no later than October 27, 2025; however, this was not completed until October 29, 2025.Client #5 was admitted to outpatient on May 1, 2025 and was discharged on August 6, 2025. A treatment and rehabilitation plan was developed on May 8, 2025. A treatment and rehabilitation plan update was due no later than July 8, 2025; however, this was not completed until July 24, 2025.Client #6 was admitted to outpatient on October 22, 2025 and was discharged on February 26, 2026. A treatment and rehabilitation plan was developed on October 23, 2025. A treatment and rehabilitation plan update was due no later than December 23, 2025; however, this was not completed prior to discharge.Client #7 was admitted to outpatient on September 15, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on November 19, 2025. A treatment and rehabilitation plan update was due no later than January 19, 2026; however, this was not completed until January 21, 2026.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The review of the timeline for initial treatment planning and on-going treatment planning will be reviewed at the 4-10-26 outpatient staff meeting. This will also be reviewed during individual supervisions occurring during the month of April with all individual reviews occurring by 4-30-26. Client charts will be reviewed monthly for the next six months or until consistently completed per agency policy and DDAP regulation.
Responsible Person: Associate Director of Behavioral Health
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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 client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in three of three applicable records. The facility policy and procedure manual indicate a case consultation to occur prior to client discharge.Client #4 was admitted to outpatient on August 25, 2025 and was discharged on November 19, 2025. A case consultation was due to occur no later than November 19, 2025; however, this was not completed at the time of the inspection.Client #5 was admitted to outpatient on May 1, 2025 and was discharged on August 6, 2025. A case consultation was due to occur no later than August 6, 2025; however, this was not completed at the time of the inspection.Client #6 was admitted to outpatient on October 22, 2025 and was discharged on February 26, 2026. A case consultation was to occur no later than February 26, 2026; however, this was not completed until March 6, 2026.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The review of timelines for case consultations will be reviewed at the 4-10-26 staff meetings. The review of timelines will also be reviewed during individual supervision meetings during the month of April. Associate Director of Behavioral Health will review charts monthly to ensure documentation is completed per the agency's timeline.
Responsible Person: Therapist, Associate director of Behavioral Health.
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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 applicable client records reviewed, the facility failed to complete an aftercare plan in accordance with the facility policy and procedure manual in one of one record. The facility policy and procedure manual indicated an aftercare plan will be completed with the client for all planned discharges. Client #5 was admitted to outpatient on May 1, 2025 and was discharged on August 6, 2025. An aftercare plan was not completed at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon discharge from the program, a client will be provided a letter that outlines their aftercare plan. A copy of the letter and a corresponding coordination care note will be placed in the EHR as verification that the plan was provided to the client. This process will be updated in the Aftercare policy and reviewed at the 4-10-26 outpatient meeting. This will also be reviewed during individual supervisions occurring during the month of April with all individual reviews occurring by 4-30-26. Client discharges will be reviewed monthly for the next six months or until consistently completed per agency policy and DDAP regulation.
Responsible Person: Associate Director of Behavioral Health, Therapists
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in three of three records. The policy and procedure manual indicates follow-up contact must be made within seven days of discharge.Client #4 was admitted to outpatient on August 25, 2025 and was discharged on November 19, 2025. Follow-up contact was due to occur no later than November 26, 2025; however, this was not completed at the time of the inspection.Client #5 was admitted to outpatient on May 1, 2025 and was discharged on August 6, 2025. Follow-up contact was due to occur no later than August 13, 2025; however, this was not completed at the time of the inspection.Client #6 was admitted to outpatient on October 22, 2025 and was discharged on February 26, 2026. Follow-up contact was due to occur no later than March 5, 2026; however, this was not completed at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon discharge from the program, a client will be provided a letter that provides follow up information. A copy of the letter and a corresponding coordination care note will be placed in the EHR as verification that follow up was provided to the client. This process will be updated in the Aftercare policy and reviewed at the 4-10-26 outpatient meeting. This will also be reviewed during individual supervisions occurring during the month of April with all individual reviews occurring by 4-30-26. Client discharges will be reviewed monthly for the next six months or until consistently completed per agency policy and DDAP regulation.
Person Responsible: Therapists, Associate Director of Behavioral Health |