INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 18, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Penn Presbyterian Medical Center 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 personnel records, the facility failed to ensure that one applicable employee received a minimum of 4 hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee # 3 has been in the position of counselor since June 26, 2023. Employee # 3 was due to have the communicable disease trainings no later than June 26, 2024; however, the TB/STD training was not completed as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Responsible Party: Program Director or designee
The Program Director conducted a review of staff training files and confirmed that all were in compliance, with the exception of Employee #3. While Employee #3 completed the required 6 hours of DDAP-approved HIV/AIDS training, they have not yet fulfilled the 4-hour requirement of tuberculosis, sexually transmitted diseases, and other health-related topics. Ensuring staff completion of these trainings has been challenging due to the limited availability and capacity of sponsored courses. The Program Director is now actively engaging more with staff to help overcome barriers to scheduling approved mandatory training programs.
- Employee #3 is registered to attend the required training session scheduled for November 21, 2025, from 9:00 AM to 1:00 PM. The Program Director will monitor the employee's attendance and ensure that documentation of successful completion is promptly filed in the employee's training record as evidence of compliance.
- The Program Director or designee will conduct monthly audits of staff training records to review compliance with DDAP requirements for 6 months until compliance is achieved and every 6 months thereafter as new employees are added. Specifically, staff must complete a minimum of 6 hours of DDAP-approved HIV/AIDS training and at least 4 hours covering tuberculosis, sexually transmitted diseases, and other health-related topics?within the first two years of employment for general staff, and within one year for counselors.
- To support ongoing Quality Assurance and Performance Improvement (QAPI), audit results will be reported during the Clinical Effectiveness Quality Improvement (CEQI) Committee meetings. The Program Director will proactively identify and address any barriers to staff enrollment in DDAP-approved training programs to assist and prevent recurrence of non-compliance and promote sustained adherence to regulatory standards.
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection on August 18, 2025, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room, as an individual session in office 2-123 could be heard clearly in office 2-124, the room next door, at 03:00 p.m. on August 18, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Responsible Party:
Program Director or designee
Plan of Correction:
Action:
- Program Director reviewed § 705.23 (3) Counseling or activity areas and office space with other leaders and Privacy experts at Penn Medicine to comply with the standard. Program policies were determined to be sufficient to promote compliance.
- Staff were educated on the finding and were instructed that the office was out of use until inspection of how the office could be brought into compliance with building improvements was completed. On August 28, 2025, counselors were instructed to confirm that white noise machines are on the inside and outside their offices during program hours to reduce the possibility of noise from sessions would be carried outside of the session. Completion of the instruction and attendance at the meeting is documented in staff's weekly counselor clinical group record.
- Upon notification from the surveyor and as an immediate plan of correction, the Program Director immediately prohibited the office from being used for any patient care interactions to prevent a breach in confidentiality until measures could be implemented to comply with privacy/confidentiality standards.
- To comply with the standard, the Program Director has obtained and installed additional white noise machines to actively operate both inside and outside every counseling office and group therapy space. This enhancement provides an added layer of sound masking to protect patient confidentiality by minimizing the risk of conversations being overheard outside of clinical sessions. Installation of the remaining equipment in all clinical areas will be completed by September 12, 2025. Upon notification from the surveyor on August 18, 2025, the Program Director promptly engaged building management to assess the clinical space with the goal of identifying potential modifications that are reasonable and feasible that would enhance soundproofing and further safeguard patient confidentiality during clinical sessions.
- Program Director or designee will conduct daily rounding through the program to ensure white noise machines are on and operable during program hours on an ongoing basis to ensure compliance.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of five personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one record reviewed.
Employee # 5 has been in the position of counselor since March 31, 2025 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as completed until April 10, 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Responsible Party:
Program Director or designee
Plan of Correction:
The Program Director conducted a review of staff training files and confirmed that all were in compliance, except Employee #5. While Employee #5 completed the required fire extinguisher, it was not completed within the required timeframe. Ensuring staff completion of these trainings has been challenging due to the limited availability and capacity of sponsored courses. The Program Director is now actively engaging more with staff to help overcome barriers to scheduling approved mandatory training programs.
- The Program Director will monitor the employee's attendance and ensure that documentation of successful completion is promptly filed in the employee's training record as evidence of compliance.
- The Program Director or designee will conduct monthly audits of staff training records to review compliance with DDAP requirements for 6 months until compliance is achieved and every 6 months thereafter as new employees are added.
- To support ongoing Quality Assurance and Performance Improvement (QAPI), audit results will be reported during the Clinical Effectiveness Quality Improvement (CEQI) Committee meetings. The Program Director will proactively identify and address any barriers to staff enrollment in required training to assist and prevent recurrence of non-compliance and promote sustained adherence to regulatory standards.
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711.92(a)(3) LICENSURE Mngt of Treatment Services
711.92. Treatment and rehabilitation services.
(a) The project shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the development, approval and ongoing management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility's policy and procedure manual and a discussion with the Facility Director, the facility was not following their guidelines for discharging clients with a pattern of program non-attendance. The policy and procedure manual stated, "If an individual has two consecutive unexcused absences from scheduled sessions or if they present a chronic pattern of missing sessions periodically (e.g. missing one out of every three scheduled appointments), then they must be discharged from the program." In practice, the Facility Director reported that the counselors are to attempt to contact clients three times within a 30-day period to attempt reengagement. The facility failed to discharge clients due to lack of engagement or document three attempts of contact within a 30-day period in six of seven records reviewed. Due to the facility not discharging those clients or documenting outreach according to the policy, those clients were considered active and therefore missing required documentation for a period of the treatment episode.
Client # 1 was admitted on October 11, 2024 and was discharged on February 7, 2025. The client last attended a treatment session on December 26, 2024 and the record did not contain documentation of three attempts to reengage the client within a 30-day period.
Client # 2 was admitted on October 23, 2024 and was discharged on April 30, 2025. The client last attended a treatment session on February 18, 2025 and the record did not contain documentation of three attempts to reengage the client within a 30-day period.
Client # 3 was admitted on October 18, 2024 and was discharged on May 28, 2025. The client attended one treatment session between February 25, 2025 and the date of discharge, and the record did not contain documentation of three attempts to reengage the client within a 30-day period.
Client # 4 was admitted on January 8, 2025 and was discharged on July 9, 2025. The client last attended a treatment session on April 4, 2025 and the record did not contain documentation of three attempts to reengage the client within a 30-day period.
Client # 5 was admitted on December 23, 2024 and was active at the time of the inspection. The client attended one treatment session between April 28, 2025 and July 23, 2025, and the record did not contain documentation of three attempts to reengage the client within a 30-day period.
Client # 6 was admitted on January 30, 2025 and was active at the time of the inspection. The client last attended a treatment session on March 5, 2025 and the record did not contain documentation of three attempts to reengage the client within a 30-day period.
This is a repeat citation from the June 27, 2024 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Responsible Party: Program Director or designee
Plan of Correction:
Action:
- To improve compliance with §711.92(a)(3) ? Management of Treatment Services, the Program Director has revised the department's coordination plan for client treatment and rehabilitation services. The updated plan includes clearly defined written procedures for the development, approval, and ongoing management of individualized treatment and rehabilitation services. These procedures are designed to promote consistent, high-quality care and regulatory compliance across clinical operations of the program.
To strengthen adherence to discharge protocols for clients demonstrating a pattern of non-attendance, the Program Director has revised the policy and procedure manual. The updated guidelines state:
"If a client has two unexcused absences within a 30-day period, the counselor must initiate outreach efforts to re-engage the individual in their treatment plan. If two outreach attempts?via phone or engagement letter?are unsuccessful, the client will be discharged from the program."
In accordance with this policy, counselors are required to document two outreach attempts (via phone and/or engagement letter), including notice of potential discharge. If the client does not respond, discharge procedures must be initiated and documented accordingly.
- To reinforce staff understanding of the revised discharge policy, the Program Director conducted in-person education by rounding with program staff on August 28, 2025. This direct engagement provided an opportunity to inform members of the updated procedures and expectations regarding client non-attendance and discharge protocols. Completion of the retraining and attendance at the training is documented in staff weekly counselor clinical group record.
- The Program Director assigned chart auditing responsibilities to counselors, requiring them to present cases of patients scheduled for discharge due to attendance non-compliance during weekly clinical rounding meetings with the program's medical and clinical directors. Counselors must demonstrate at least documented outreach attempts in the patient's chart ? via phone and/or engagement letter ? prior to initiating discharge.
- Weekly chart reviews will help verify consistent application of discharge standards and reinforce accountability in managing patient engagement and compliance.
- Self-auditing of patient charts has been formally established as a core responsibility of each counselor. By August 28, 2025, counselors signed an acknowledgement confirming their understanding of this expectation. To support this process, Counselors have been provided access to a tracking tool within the secure system, enabling monitoring of both active and discharged patients. The Behavioral Health Coordinator and Practice Manager will oversee the application of the tool to verify its accuracy and effectiveness in monitoring compliance.
- In addition to weekly chart reviews conducted in clinical-medical rounding, the Program Director or approved designee will audit 20 discharged patient charts/month to verify compliance with discharge protocols. This targeted auditing process will continue until six consecutive months of compliance is achieved, ensuring sustained adherence to the program standards and regulatory requirements.
- The Program Director or designee will report audit findings to the Clinical Effectiveness and Quality Improvement (CEQI) Committee as part of the Facility's ongoing quality assurance and performance improvement activities. The Committee will evaluate the data, provide feedback to staff, and recommend further process improvements or additional audits as needed to support sustained compliance and enhanced patient care practices.
- Client #1, Client #2, Client #3 & Client #4 records noted in findings were discharged from the program at the time of review, and no further action could be taken on the charts to meet preexisting missed timeframes outlined in discharge procedures.
- Client #5 and Client #6 charts have been updated with additional outreach that aligns with program policies and procedures at the time of the occurrences for contact before discharge and DDAP regulation 711.92(a)(3). These 2 occurrences were assigned to the same counselor and completed on August 29, 2025.
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711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in four of four applicable records reviewed.
Client # 1 was admitted on October 11, 2024 and was discharged on February 7, 2025. There was no documentation of follow-up information in the record.
Client # 2 was admitted on October 23, 2024 and was discharged on April 30, 2025. There was no documentation of follow-up information in the record.
Client # 3 was admitted on October 18, 2024 and was discharged on May 28, 2025. There was no documentation of follow-up information in the record.
Client # 4 was admitted on January 8, 2025 and was discharged on July 9, 2025. There was no documentation of follow-up information in the record.
This is a repeat citation from the June 27, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Responsible Party: Program Director or designee
Plan of Correction:
Action:
- Program Director reviewed Pennsylvania Code Title 28 - HEALTH AND SAFETY
Part V - Department of Drug and Alcohol Programs, Chapter 711 - STANDARDS FOR CERTIFICATION OF TREATMENT ACTIVITIES WHICH ARE A PART OF A HEALTH CARE FACILITY, Subchapter H - STANDARDS FOR OUTPATIENT ACTIVITIES, Section 711.93 - Client records (28 PA Code § 711.93) (a)(7) Follow-up Information for a full understanding of the requirement. The review revealed an opportunity to re-educate staff on the regulatory requirement and related program policy.
- The program Director reviewed the standard with the team to review and re-educate on the content and intent of the regulation. The director rounded with staff on August 28, 2025, to reinforce the importance of documenting follow-up information in client records. Completion of the retraining and attendance at the training is documented in staff weekly counselor clinical group record.
- The Program Director assigned counselors chart auditing responsibilities, which required them to review all active client charts and any closed charts within the past 30 days to ensure adherence to standards for all of their assigned patients.
- Self-auditing of charts by counselors was outlined as an expectation of the counselor's role and responsibilities, which counselors acknowledged in writing on August 28, 2025.
- Active charts and discharged charts from the past 30 days were reviewed and brought into compliance by September 5, 2025, as needed. In cases where follow-up could not be completed due to lack of contact information, this was documented in the chart under the Phone Notes section, not in Case Management Notes.
- The program Director or designee will audit for compliance to verify a complete client record includes information relative to the client's involvement with the project, to include follow-up information
- The sample size will include 20 records: 10 current and 10 discharged charts permonth will be audited for verification of follow-up protocol compliance until six months of sustained compliance at 100% is achieved.
- The Program Director or designee will perform chart audits to ensure the counselors adhere to their weekly chart audit responsibilities. Results from chart audits will be recorded and reported out monthly in PPMC Clinical Effectiveness and Quality Improvement (CEQI) Committee meetings.
- The Program Director or designee of the Program Director will report results to the PPMC CEQI Committee as part of the Facility's quality assurance and performance improvement activities. The Committee will evaluate the results and implement any further process changes and audits, as needed.
- Client #1, Client #2, Client #3, and Client #4 have been updated to show attempted outreach by counselor for follow-up after discharge; however, no further action can be taken on the charts to meet the preexisting missed timeframe of follow-up within 30 days of discharge outlined in follow-up procedures.
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711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in six of seven records reviewed.
Client # 2 was admitted on October 23, 2024 and was discharged on April 30, 2025. Per a discussion with the Facility Director, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on October 23, 2024, did not allow for the release of that information.
Client # 3 was admitted on October 18, 2024 and was discharged on May 28, 2025. Per a discussion with the Facility Director, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on October 19, 2024, did not allow for the release of that information.
Client # 4 was admitted on January 8, 2025 and was discharged on July 9, 2025. Per a discussion with the Facility Director, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on January 8, 2025, did not allow for the release of that information.
Client # 5 was admitted on December 23, 2024 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on December 23, 2024, did not allow for the release of that information.
Client # 6 was admitted on January 30, 2025 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on January 30, 2025, did not allow for the release of that information.
Client # 7 was admitted on February 19, 2025 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on February 19, 2025, did not allow for the release of that information.
This is a repeat citation from the June 27, 2024 annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Responsible Party: Program Director or designee
Plan of Correction:
Action:
- Program Director reviewed § 709.28. Confidentiality, § 711.93, 4 Pa. Code § 255.5, LICENSING ALERT 04-2024 Consent to Release Information-Informed & Voluntary: Client records: (c) Confidentiality. The review revealed an opportunity to re-educate staff on the regulatory requirement and related program policy developments..
- The program Director reviewed the applicable policy with the team and found no changes to thecurrent policy were required to meet the intent of the regulation. In the time after Client #2, Client #3, Client #4, Client #5, Client #6 and Client #7 consents were completed, a program consent to release information form and associated policies and procedures had been updated. Reflecting updates to 42 CFR Part 2 regulations, a single consent for Treatment, Payment and Operations (TPO) purposes is now completed by patients during the initial intake process. This consent form provides a more streamlined and straightforward consent process. The TPO consent to release information form, and updated policy and procedures were presented to surveyor at the time of survey and after.
- The director reeducated staff on the use of the the newer Treatment, Payment and Operations consent to release information form available in EMR system, the supplemental ad hoc consent to release information form, as well as policy and procedures when rounding with staff on August 28, 2025 to reinforce critical aspects of the policy and procedure to facilitate compliance.
- Consent to release information to funding sources is now completed by admission staff upon initial intake and admission to program. This was reviewed in rounding with admission team members who signed off on understanding on August 29,2025.
- The Program Director assigned counselors chart auditing responsibilities, which required them to review active client charts to review adherence to consent requirements for their assigned patients.
- Self-auditing of charts by counselors for consents will be outlined as an expectation of the counselor's role and responsibilities, which counselors acknowledged in writing on August 28, 2025.
- Active charts were reviewed and brought into compliance by September 5, 2025, as needed. The program Director or designee will audit for compliance.
- 20 active charts per month will be audited for verification of consent protocol compliance until six months of sustained compliance at 100% is achieved.
- The Program Director or designee will perform chart audits to ensure the counselors adhere to their weekly chart audit responsibilities.
- The Program Director or designee of the Program Director will report results to the PPMC Clinical Effectiveness and Quality Improvement (CEQI) Committee as part of the Facility's quality assurance and performance improvement activities. The Committee will evaluate the results and implement any further process changes and audits as needed.
- Client #2, Client #3 and Client #4 charts were discharged at the time of review, and an update could not be made to the closed chart to obtain a release information to the funding source to meet preexisting missed timeframes outlined in procedures.
- Client #5, #6 and Client #7 charts were active at the time of review, and an updated consent to release information to the funding source has been completed.
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