INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection. The physical plant inspection was conducted on August 13, 2026, and the client record review was conducted on August 27, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Tradition House 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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709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on a review of client records, the facility failed to record medication errors in the client record in two of seven records reviewed.
Client #4 was admitted on December 22, 2025, and discharged on March 23, 2026. The client was prescribed Sofoslvelpat Tab 400-100, one tablet at bedtime. The medication administration records showed that the medication was not given on January 16 or 24, 2026. There was no additional documentation included indicating a reason why the medication was not given as prescribed.
The client was prescribed Carvedelol Tab 12.5 mg one tablet in the morning and one in the evening. The medication administration records showed that the medication was not given on January 24, 2026. There was no additional documentation included indicating a reason why the medication was not given as prescribed.
The client was prescribed Flutic-Salen 250-50 mcg Aer, one puff orally two times a day. The medication administration records showed that the medication was not given in the evening on January 16 or 24, 2026. There was no additional documentation included indicating a reason why the medication was not given as prescribed.
Client # 6 was admitted on March 23, 2026, and discharged on July 16, 2026. The client was prescribed Trazadone 100 mg one tablet at bedtime. The medication administration records showed that the medication was not given on April 14 or 20, 2026. There was no additional documentation included indicating a reason why the medication was not given as prescribed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility nurse will provide all BHT staff retraining on meds, addressing proper documentation by September 30, 2026. ED and medical department will monitor ongoing compliance through monthly chart audits. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within seven days of admission, per facility policy, in four out of seven records reviewed.
Client #2 was admitted on July 17, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than July 24, 2026; however, it was not completed until August 10, 2026.
Client #3 was admitted on July 7, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than July 14, 2026; however, it was not completed until July 26, 2026.
Client #4 was admitted on December 22, 2025, and discharged on March 23, 2026. A comprehensive treatment plan was due no later than December 30, 2025; however, it was not completed until January 5, 2026.
This is a repeat citation from the July 23, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Ed and clinical supervisor reviewed policy for completing comprehensive treatment plan on 9/01/2026 during clinical team meeting. Addressed the importance of completion within the required time frames. Clinical supervisor will review ongoing compliance through monthly charts audits and will address any ongoing areas of concern during monthly individual supervision. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 within seven days of admission, per facility policy, in four out seven records reviewed.
Client #2 was admitted on July 17, 2026, and was still active at the time of the inspection. A case consultation was due no later than July 24, 2026; however, there was no documentation that one was completed.
Client #3 was admitted on July 7, 2026, and was still active at the time of the inspection. A case consultation was due no later than July 14, 2026; however, there was no documentation that one was completed.
Client #5 was admitted on May 21, 2026, and was discharged on June 10, 2026. A case consultation was due no later than May 28, 2026; however, it was not completed until June 7, 2026.
Client #7 was admitted on Apil 24, 2026 and discharged on July 31, 2026. A case consultation was due no later than May 1, 2026; however, it was not completed until May 15, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ED and clinical supervisor reviewed policy for completion of case consults during the clinical team meeting on 9/01/2026. Clinical team will review case consultation weekly during clinical team meetings and document within the proper time frames. ED and Clinical supervisor will monitor ongoing compliance through chart audits and weekly clinical team meetings. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 a review of client records, the facility failed to provide a complete client record, which is to include follow-up information for clients within seven days of discharge, per facility policy, in two out of four applicable records reviewed.
Client #6 was admitted on March 23, 2026, and discharged on July 16, 2026. A follow up was due no later than July 23, 2026; however, there was no documentation that one was completed.
Client #7 was admitted on April 24, 2026, and discharged on July 31, 2026. A follow up was due no later than August 7, 2026; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ED re-educated clinical and administrative staff on the policy for aftercare follow up and timelines for completion during the weekly clinical team meeting on 9/01/26. ED and clinical supervisor will review compliance with aftercare follow up through monthly chart audits. |