INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 5, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Perry Human Services, 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from January 2025 - December 2025, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the month of May 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Correction:
A fire drill was conducted following the licensing review. The fire drill log was updated.
Prevention:
The facility will conduct one unannounced fire drill each month. The Project Director or designee will complete and document each drill in a centralized log.
Monitoring:
The Project Director will review the fire drill log monthly to ensure compliance.
Responsible Person(s):
Project Director/Designee
Date of Compliance:
3/12/2026 |
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 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 four out of seven records reviewed.
Client #2 was admitted on September 11, 2025 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
Client #3 was admitted on November 17, 2025 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. Additionally, there was no documentation that the facility obtained an informed and voluntary consent for the prison and there was documentation in the client record of contact between the prison and the facility.
Client #6 was admitted on February 13, 2025 and discharged on July 17, 2025. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
Client #7 was admitted on October 14, 2025 and was discharged on April 9, 2025. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Correction:
The facility reviewed the identified records. Active clients have had appropriate consents obtained. Staff were instructed to obtain consent prior to releasing or billing any information.
Prevention:
The facility will obtain informed and voluntary consent prior to any release of client information, including billing to funding sources and communication with external entities. The Project Director or designee will ensure consents are completed at admission and maintained in the client record.
Monitoring:
The Project Director will conduct monthly chart reviews to ensure required consents are present and completed prior to release of information.
Responsible Person(s):
Project Director/Designee
Date of Compliance:
3/26/2026 |
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 a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client and shall include written documentation of the type and frequency of treatment and rehabilitation services in two out of six applicable client records reviewed.
Client #1 was admitted on November 5, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 21, 2025, that did not include a specific type and frequency of treatment and rehabilitation services.
Client #5 was admitted on March 10, 2025 and discharged on November 14, 2025. A comprehensive treatment plan was developed on March 24, 2025, that did not include a specific type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Correction:
The identified records were reviewed. Active client treatment plans have been updated to include the type and frequency of services. Staff were instructed on required documentation elements.
Prevention:
The facility will ensure all treatment plans include the type and frequency of treatment and rehabilitation services at the time of development. The Project Director or designee will review treatment plans for completeness prior to finalization.
Monitoring:
The Project Director will conduct monthly chart reviews to ensure treatment plans include required elements.
Responsible Person(s):
Project Director/Designee
Date of Compliance:
3/19/2026 |
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 client records, the facility failed to develop an individual treatment and rehabilitation plan with a client that included written documentation of the proposed type of support service in two out of six applicable records reviewed.
Client #1 was admitted on November 5, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 21, 2025, that did not include proposed type of supportive services.
Client #5 was admitted on March 10, 2025 and discharged on November 14, 2025. A comprehensive treatment plan was developed on March 24, 2025, that did not include proposed type of supportive services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Correction:
The identified records were reviewed. Active client treatment plans have been updated to include the proposed type of supportive services. Staff were instructed on required documentation elements.
Prevention:
The facility will ensure all treatment plans include the proposed type of supportive services at the time of development. The Project Director or designee will review treatment plans for completeness prior to finalization.
Monitoring:
The Project Director will conduct monthly chart reviews to ensure treatment plans include all required elements.
Responsible Person(s):
Project Director/Designee
Date of Compliance:
3/19/2026 |
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 a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven records reviewed.
Client #2 was admitted on September 11, 2025 and was still active at the time of the inspection. A treatment plan was completed on September 11, 2025, and the next update was due no later than November 10, 2025; however, the next update was completed on November 13, 2025.
Client #5 was admitted on March 10, 2025 and was discharged on November 14, 2025. A treatment plan was completed on April 24, 2025, and the next update was due no later than June 23, 2025; however, it was completed on July 8, 2025. The next treatment plan update was due no later than September 6, 2025; however, it was completed on September 12, 2025.
Client #6 was admitted on February 13, 2025 and discharged on July 17, 2025. A treatment plan was completed on April 1, 2025, and the next update was due no later than May 31, 2025; however, it was completed on June 4, 2025.
This is a repeat citation from December 20, 2023, and February 18, 2025, licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Correction:
The identified client records were reviewed. All current treatment plans have been updated and documented in accordance with regulatory requirements. Staff were immediately re-educated on the requirement to complete treatment plan updates within the required timeframe.
Prevention / Systemic Change:
The facility implemented a treatment plan tracking system to monitor due dates for updates.
Staff will complete treatment plan updates within the regulatory timeframe.
Staff training on treatment plan requirements will occur annually and for all new hires.
The Project Director or designee will review treatment plans for timeliness prior to submission and address any delays immediately.
Monitoring:
Monthly chart reviews by the Project Director will verify treatment plan updates are completed on time.
Any overdue updates will be documented and corrective action taken.
Compliance will also be reviewed quarterly during internal quality assurance meetings to ensure sustainability.
Responsible Person(s):
Project Director/Designee
Date of Compliance:
3/18/2026 |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of six applicable records reviewed.
Client #2 was admitted on September 11, 2025 and was still active at the time of the inspection. The treatment plans dated September 11, 2025, and November 13, 2025, indicated two individual counseling sessions a month. There was documentation that the client only received one counseling session in the months of November and December 2025.
Client #4 was admitted on July 29, 2025 and was discharged on February 26, 2026. The treatment plan dated December 9, 2025, indicated individual sessions occurring two times a week. There was no documentation that the client received two individual sessions the weeks of December 15, 22, and 29, 2025 and January 5 and 12, 2026.
Client #6 was admitted on February 13, 2025 and was discharged on July 17, 2025. The treatment plans dated February 27, April 1 and June 4, 2025, indicated one individual counseling session a week. There was no documentation that the client received individual counseling the weeks of March 3, 24, April 14, 28, May 12, 26, June 2, 9, 23, 30 and July 7, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Correction:
The identified client records were reviewed. Missing sessions have been addressed where possible, and staff were re-instructed to provide counseling services according to each client's treatment plan.
Prevention / Systemic Change:
Staff have been re-educated on the requirement to deliver counseling services according to the individual treatment plan.
The facility will implement a weekly counseling schedule tracker to ensure services are provided as documented.
The Project Director or designee will review counseling logs weekly to verify that services match the treatment plan.
Monitoring:
Weekly review of counseling logs by the Project Director will ensure services are provided according to the plan.
Any missed sessions will be documented, and corrective action will be taken immediately.
Compliance will also be reviewed monthly as part of quality assurance.
Responsible Person(s):
Project Director/Designee
Date of Compliance:
3/23/2026 |
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 the review of client records, the facility failed to document case consultations every sixty days, per the facility ' s policy and procedures manual in five out seven records reviewed.
Client #2 was admitted on September 11, 2025 and still active at the time of the inspection. A case consultation was due no later than November 10, 2025 and January 12, 2026; however, there was no documentation that they were completed.
Client #3 was admitted on November 17, 2025 and was still active at the time of the inspection. A case consultation was due no later than January 16, 2026; however, there is no documentation that one was completed.
Client #4 was admitted on July 29, 2025 and discharged on February 26, 2026. A case consultation was due no later than September 27, 2025; however, there was no documentation that one was completed.
Client #5 was admitted on March 10, 2025 and discharged on November 14, 2025. A case consultation was completed on April 9, 2025, and the next one was due no later than June 8, 2025; however, it was not completed until July 1, 2025. The next case consultation was due no later than August 30, 2025; however, it was not completed until September 12, 2025.
Client #6 was admitted on February 13, 2025 and discharged on July 17, 2025. A case consultation was completed on April 1, 2025, and the next one was due no later than May 31, 2025; however, it was not completed until June 4, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Correction:
The identified client records were reviewed. Missing case consultations have been completed where possible. Staff were re-instructed on the requirement to complete case consultations every sixty days as outlined in the facility's policy and procedures.
Prevention / Systemic Change:
Staff have been re-educated on timely case consultations.
The facility implemented a case consultation tracking system to monitor due dates for all active clients.
The Project Director or designee will review case consultation logs monthly to ensure timely completion.
Monitoring:
Monthly review of case consultation logs by the Project Director will verify completion within sixty-day intervals.
Any overdue consultations will be documented, and corrective action taken immediately.
Compliance will also be reviewed quarterly as part of the facility's quality assurance process.
Responsible Person(s):
Project Director/Designee
Date of Compliance:
3/30/2026 |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting treatment plan updates were submitted and approved by the Department for the December 20, 2023, and February 18, 2025, annual licensing inspections. Completing and documenting treatment plan updates was again found to be a deficiency in the March 5, 2026, licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Correction:
The facility has reviewed all previously approved plans of correction. Staff were re-instructed on the requirement to implement all approved plans fully and timely, as submitted and approved by the Department.
Prevention / Systemic Change:
The facility will maintain a centralized tracking system for all approved plans of correction.
The Project Director or designee will oversee implementation of all plans of correction and ensure each is completed according to the approved timeline.
Staff responsible for executing plans of correction will be informed of their responsibilities and provided ongoing supervision and guidance.
Monitoring:
The Project Director or designee will review the status of all approved plans of correction monthly.
Any delays or deficiencies in implementing a plan of correction will be addressed immediately, documented, and communicated to staff.
Quarterly reviews will evaluate overall compliance with all plans of correction and identify any opportunities for process improvement.
Responsible Person(s):
Project Director/Designee
Date of Compliance:
3/26/2026 |