INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, AWJW1, LLC dba Sobriety Solutions Pennsylvania 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records and the projects policies and procedure manual, the project failed to document a written initial individual training plan for each employee within thirty days of their hire date and yearly in the month of December, that is appropriate to that employee's skill level with input from both the employee and the supervisor in one out of six records reviewed.
Employee #3 was hired as a counselor on July 21, 2025 and was currently in that position at the time of the inspection. An individual training plan was to be documented in the personnel record no later than August 21, 2025; however, an individual training plan was not documented in the personnel record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The facility reviewed the cited personnel file and completed the missing individual training plan for Employee #3. A full audit of all personnel files was completed to ensure required training plans were present and up to date. Project Director implemented a tracking and reminder system to ensure timely completion of initial (within 30 days) and annual (each December) training plans. Monthly audits and an updated onboarding checklist will ensure continued compliance. Project Director will meet with Chief Clinical Officer monthly to review findings. |
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 project failed to ensure that one of six employees received a minimum of six hours of HIV/AIDS and four hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee # 6 was hired as a contracted counselor on May 28, 2024 and was currently in that position at the time of the inspection. Employee #6 was due to have the communicable disease training no later than May 28, 2025. Documentation showed that this employee did not receive the six hours of HIV/AID training until October 23, 2025 and there was no documentation that the employee received the four hours of TB/STD training at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Pursuant to DDAP regulation 704.11(c)(1), new hires will be trained with at least 4 hours of TB/STD and at least 6 hours of HIV/AIDS when hired or will be asked to provide these trainings upon start date. If a new hire has not been trained or does not having training documentation, the new employee will be required to complete these trainings. During weekly clinical meetings with Clinical Director and Chief Clinical officer, CD will identify any new staff members and have them complete these required trainings if these have not already been completed. Leadership Team will meet monthly and review new hires' training needs to ensure that all new staff have been trained. Staff TB/STD trainings and HIV/AIDS training requirements will be on the monthly leadership meeting agenda in effort to ensure compliance for regulation 704.11(c)(1) |
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 the review of personnel records and staff training records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment in three of six records reviewed.
Employee #3 was hired as a counselor on July 21, 2025 and was currently in that position at the time of the inspection. The employee was to be instructed in the use of the fire extinguisher upon employment; however, the employee did not receive this training as of the date of the licensing inspection.
Employee #4 was hired as a counselor intern on September 2, 2025 and was currently in that position at the time of the inspection. The employee was to be instructed in the use of the fire extinguisher upon employment; however, the employee did not receive this training as of the date of the licensing inspection.
Employee #5 was hired as a counselor intern on September 2, 2025 and was currently in that position at the time of the inspection. The employee was to be instructed in the use of the fire extinguisher upon employment; however, the employee did not receive this training as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pursuant to 705.28 (c) (4), employees #3, #4, #5 completed use of fire extinguisher training by 12/12/2025. Leadership reviewed onboarding documentation and have included Fire Extinguisher Training in new hire orientation documentation packet. Clinical Director added Fire Extinguisher Training to new hire orientation checklist. This will be completed with new hired staff conducted by Clinical Director. Chief Clinical Officer, Clinical Director and Clinical Supervisor will continue to meet weekly for Clinical Supervisor supervision team meeting and review any new staff hired to ensure compliance to regulation 705.28(c)(4). |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records and staff training records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in three of six records reviewed.
Employee #3 was hired as a counselor on July 21, 2025 and was currently in that position at the time of the inspection. The employee was to be trained to perform assigned tasks during emergencies prior to working a shift; however, the employee did not receive this as of the date of the inspection.
Employee #4 was hired as a counselor intern on September 2, 2025 and was currently in that position at the time of the inspection. The employee was to be trained to perform assigned tasks during emergencies prior to working a shift; however, the employee did not receive this as of the date of the inspection.
Employee #5 was hired as a counselor intern on September 2, 2025 and was currently in that position at the time of the inspection. The employee was to be trained to perform assigned tasks during emergencies prior to working a shift; however, the employee did not receive this as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pursuant to 705.28 (d) (3), it was found that employees #3, #4 & #5 were not trained upon hire. This training was completed for employees #3, #4 & #5 by 12/12/2025 Leadership reviewed onboarding documentation and have included Fire Safety Training including Fire Drills in new hire orientation documentation packet to ensure new staff are trained to perform assigned tasks during emergencies. Clinical Director added Fire Safety Training to new hire orientation checklist. This will be completed with new hired staff conducted by Clinical Director. Chief Clinical Officer, Clinical Director and Clinical Supervisor will continue to meet weekly for Clinical Supervisor supervision team meeting and review any new staff hired to ensure compliance to regulation 705.28(d)(3). |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
The CEO and CFO have secured a certified public accounting firm to complete annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities as the annual audit for fiscal year 2024 had not been completed at the time of annual survey which was still in process. The selected independent certified public accounting firm or any future independent certified public accounting firm will be contractually engaged to prepare annual audits within six months of the conclusion of the previous fiscal year.
The CFO will ensure that the annual financial audit is completed for the fiscal year of 2025 within 6 months of the conclusion of the fiscal year. CFO and CEO have added update and status of the fiscal audit to the monthly leadership agenda to ensure compliance of regulation 709.25. Field work for the 2024 audit has been completed, the audit draft is now under review and expected to be finalized by 1/31/2026.
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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of fourteen client records reviewed.
Client #5 was admitted on July 21, 2025 and discharged on August 18, 2025. The facility failed to document a release of information for the funding source until July 29, 2025; however, documentation indicated that the funding source was contacted on July 21, 2025, for authorization purposes.
Client #11 was admitted on December 30, 2024 and discharged on January 28, 2025. The facility failed to document a release of information for the emergency contact until January 9, 2025; however, documentation indicated that the emergency contact was contacted by staff on December 31, 2024.
This is a repeat citation from the October 24, 2024 annual licensing renewal inspections.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
The facility reviewed the cited records and obtained and documented required consents. All active client charts were audited, and Project Director immediately reviewed confidentiality and consent requirements with staff during weekly Clinical Meeting. A mandatory admission checklist and EMR safeguards were implemented to prevent disclosures without documented consent. Project Directors will conduct weekly chart reviews, and the Compliance Officer will complete monthly audits with corrective feedback. Project Director will meet with Chief Clinical Officer monthly to review findings. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on the review of the unusual incident log, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the death or serious injury of a client due to trauma, suicide, medication error or unusual circumstances.
Project staff were notified of two separate client deaths on April 19, 2025, and April 21, 2025. Written unusual incident reports were not filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The facility failed to submit required unusual incident reports for the cited events and audited all incident records for accuracy. Staff received immediate retraining on DDAP reporting requirements. Project Director will notify Chief Clinical Officer and initiate DDAP reporting within 24 hours of incident. A tracking system with deadlines and quarterly reviews by Chief Clinical Officer will ensure adherence. Project Director will meet with Chief Clinical Officer monthly to review findings and monitor timelines and documentation. Both unusual incidents were reported to DDAP on 12/30/2025. |
709.83(a)(11) LICENSURE Client records
709.83. 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 the review of client records, the facility failed to document a complete client record on an individual that included follow-up contact within seven days post discharge, per the project policy, in three of four applicable records reviewed.
Client #4 was admitted to the partial hospitalization level of care on March 26, 2025 and was discharged on May 14, 2025. There was no follow-up contact information documented in the client record seven days post discharge.
Client # 6 was admitted to the partial hospitalization level of care on April 11, 2025 and was discharged on May 13, 2025. There was no follow-up contact information documented in the client record seven days post discharge.
Client # 7 was admitted to the partial hospitalization level of care on April 25, 2025 and was discharged on May 22, 2025. There was no follow-up contact information documented in the client record seven days post discharge.
This is a repeat citation from the October 24, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pursuant to regulation 709.83(a)(11), it was found that follow up contact was not documented for clients #4, #6 & #7 discharged from Partial Hospitalization Program.
Leadership team met and designated that all follow up contacts in CRM to be completed by Alumni Coordinator overseen by Program and Business Development Manager.
Program and Business Development Manager will review all partial hospitalization discharges weekly and audit CRM of partial hospitalization discharged clients to ensure follow up contacts are made by Alumni Coordinator. Program and Business Development Manager will report weekly CRM audit reports to Chief Clinical Officer to safeguard that facility is within compliance of regulation 709.83(a)(11).
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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 the review of outpatient client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in two of five applicable records reviewed.
Client #8 was admitted on June 10, 2025, and was active at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on July 9, 2025, with the next update due no later than September 9, 2025; however, there were no updated treatment and rehabilitation plans documented in the client record until November 17, 2025.
Client #9 was admitted on July 7, 2025, and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan was documented in the record on August 6, 2025, with the updated treatment and rehabilitation plans due no later than October 6, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Updated treatment plans for Clients #8 and #9 were completed, and all active outpatient charts were audited for compliance. Staff were retrained on treatment-plan timelines. Project Director will utilize a tracking system to ensure Clinical Team is aware of upcoming due dates and timelines. Project Director will review timelines weekly, and monthly audits will verify compliance. Project Director will meet with Chief Clinical Officer monthly to review findings. |
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 the review of client records, the facility failed to document a complete client record on an individual that included follow-up contact information within seven days post discharge, per the project policy, in four of four applicable records reviewed.
Client #11 was admitted to the outpatient level of care on December 30, 2024 and was discharged on January 28, 2025. There was no follow-up contact information documented in the client record seven days post discharge.
Client # 12 was admitted to the outpatient level of care on August 18, 2025 and was discharged on October 13, 2025. There was no follow-up contact information documented in the client record seven days post discharge.
Client #13 was admitted to the outpatient level of care on June 19, 2025 and was discharged on August 8, 2025. There was no follow-up contact information documented in the client record seven days post discharge.
Client #14 was admitted to the outpatient level of care on February 25, 2025 and was discharged on July 15, 2025. There was no follow-up contact information documented in the client record seven days post discharge.
This is a repeat citation from the October 24, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pursuant to regulation 709.93(a)(11), it was found that follow up contact was not documented for clients #11, #12, #13 & #14 discharged from the program.
Leadership team met and designated that all follow up contacts in CRM to be completed by Alumni Coordinator overseen by Program and Business Development Manager.
Program and Business Development Manager will review all discharges weekly and audit CRM of discharged clients to ensure follow up contacts are made by Alumni Coordinator. Program and Business Development Manager will report weekly CRM audit reports to Chief Clinical Officer to safeguard that facility is within compliance of regulation 709.93(a)(11).
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