INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 14, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Warren General Hospital 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director met the qualifications for their position in one record reviewed.
Staff #1 was promoted to project director on April 5, 2026. The facility was unable to provide verification of the project director ' s education during the licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Warren General Hospital will obtain credentials and appropriate documentation upon hire of a Facility Director. Unit Manager will be in charge of obtaining the aforementioned documentation at the time of hire. This will be reviewed on an annual basis at the time of the Facility Director's annual review, appropriate education will be provided at this time as well. If the annual review falls after the DDAP inspection, this will be reviewed prior to the inspection to ensure proper documentation is provided. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel information, the facility failed to document a mechanism for collecting feedback on completed training in two of two records reviewed.
A mechanism to collect feedback on completed training was not documented for any staff members for the July 2024 to June 2025 training year.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the June 25, 2024 and the June 25, 2025 annual licensure inspection.
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Plan of Correction
Counselors will submit training certificates with accompanying training feedback forms upon completion of each training to the unit supervisor. This will be reviewed on a quarterly basis to ensure proper documentation is completed and submitted. Counselors are responsible for completing and ensuring the appropriate credit hours are completed and submitting documentation to the unit supervisor and the unit supervisor is responsible for compiling these documents for DDAP annual licensure inspection. |
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 the counselor complete at least 25 clock hours of annual training in one of one records.
Employee #3 was hired as a counselor on February 4, 2022 and still employed. Employee #3 documented 13 hours of training for the July 1, 2024 to June 30, 2025 training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Unit supervisor will be responsible for monitoring that Counselors will complete a minimum of 6 clock hours of annual training per quarter and submit the certifications and feedback forms to the unit supervisor to accomplish the required 25 minimum hours of annual training. These hours will be tracked by each individual Counselor to ensure the required training hours are met in adequate time to meet the requirements of DDAP annual licensing and will be completed by May of each year in total. |
710.22(c) LICENSURE Patient Management Services
§ 710.22. Patient management services.
(c) The service staff shall develop a written patient follow-up policy.
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Observations
Based on a review of client records, the facility failed to document an attempt to notify the emergency contact within twelve hours of leaving against medical advice in one of two applicable records.
Agency policy and procedure states an attempt to contact emergency contact will be documented within 12 hours of AMA discharge.
Client #7 was admitted February 19, 2026 and discharged February 24, 2026 against medical advice. There was no documentation of the facility attempting to contact the emergency contact on file within 12 hours of discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon AMA discharge, Counselor or Nursing Staff will call the patient's emergency contact to notify them of the AMA discharge. This will be documented in the Discharge Checklist upon completion of the phone call. The discharge section for elopement and AMA has been updated to require documentation that the emergency contact was notified before the provider or RN can complete the discharge paperwork. Therefore the emergency contact will be contacted as soon as the patient leaves AMA or elopes and the chart cannot be closed until this step is completed. The telephone contacts will be monitored by the unit supervisor for occurrence, consistency and oversight of the procedure. |