This report is a result of an on-site complaint investigation 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 investigation, St. Joseph Institute, 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 investigation:
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Plan of Correction
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Observations
Based on a review of facility personnel records, personnel policies and staff interviews, the facility failed to implement project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include but not be limited to supervision of staff. The facility's "Corrective Action" Policy notes "...in some instances, in addressing performance issues, the Company may elect to place the Team Member on a Performance Improvement Plan specifying steps to be taken to correct the performance failure. The steps may include additional training and monitoring to assist the Team Member to bring their performance to an acceptable level." Staff #1, a Behavioral Health Tech, was placed on a "Performance Improvement Plan" on December 27, 2024, that included the requirement that a "Supervisor will meet with Staff #1 weekly for "touchpoints" to review any challenges that arise and offer supports." The facility was unable to provide any documentation that these meetings occurred.
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Plan of Correction
The Director of Human Resources will implement and maintain a shared tracking document for all staff members placed on a Performance Improvement Plan (PIP). This will be implemented by 10/1/2026. The applicable department manager will utilize the tracking document to monitor and document the employee's performance throughout the PIP, including required supervision dates, performance updates, and relevant notes.
Through December 31, 2026, the Director of Human Resources will conduct a weekly review of the tracking document to monitor completion of required staff supervisions and ensure department managers are meeting the requirements outlined in each PIP. Beginning January 1, 2027, this monitoring will transition to a monthly review.
All PIP-related staff supervisions and supporting documentation will be appropriately documented and maintained in the employee's personnel file. Upon completion of a PIP, the Director of Human Resources will ensure that the completed PIP and all required supporting documentation are accurately recorded and maintained in the employee's personnel file.
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