INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 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, Avise Wellness 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 all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of four applicable personnel records reviewed.
Employee # 5 was hired as a counselor on January 13, 2025 and was due to have TB/STD training no later than January 13, 2026; however, the TB/STD training was not completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee # 5 was on a few waitlists during the year and was finally registered to take the course on 12/19/2025 but had a family emergency and was unable to attend. She registered for the next available training which was 2/24/26 and this has been completed and certificate is in her HR file.
Going forward, the facility will develop an internal TB/STD training so in the event of an external circumstance preventing attendance, all staff will be able to do this training at the facility prior to their year anniversary. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure each clinical supervisor completed at least 12 clock hours of training annually during the facility's January 1, 2025 through December 31, 2025 training year in one of one applicable personnel record reviewed.
Employee # 2 was hired as a clinical supervisor on January 2, 2024. The personnel record documented 6 hours of training received during the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward, the Clinical Supervisor as well as all admin staff will have their 12 hours of training completed within the facility training year.
Our Office Manager will be reviewing all training plans every month in order to check on compliance with training requirements and ensure that all trainings are scheduled.
Facility Director will follow up once per quarter to ensure all staff are on schedule to comply with training requirements. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure all facility heaters were permanently mounted or installed.
On February 27, 2026, at approximately 2:25 p.m., there was a space heater found in a counseling office.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The agency does not use portable facility heaters. A brand new staff member who started four days prior to the inspection and was still in her training week, brought one into the office and turned it on.
As a part of the training plan, all staff are informed that space heaters are not permitted at the facility. This will continue to be re-iterated during regular staff meetings throughout the year. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in fourteen of fourteen client records reviewed.
In each client record reviewed, there was a release of information form to the laboratory and each release form did not include the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Avise Wellness has rectified the lab release not having specific information to be disclosed. The lab release now states two areas of disclosure; urine drug screening results and insurance coverage or limitations between Avise Wellness and the respective labs.
At the conclusion of each week, all new assessments will be reviewed by Senior Clinical Admin staff to ensure all new clients being entered into the EHR have the correct forms added to their profile.
In addition, all charts will undergo monthly QA checks to ensure that all releases follow DDAP regulations and have the information that will be released explicitly indicated.
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709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on a release of information form in one of fourteen client records reviewed.
Client # 12 was admitted to the outpatient activity on April 21, 2025 and was discharged on October 17, 2025. A release of information form to a family member was signed by a witness on September 9, 2025, but the consent form did not include the dated signature of the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately all forms will be signed by the client and no consent forms will be signed via telehealth.
All staff were notified of this following the DDAP inspection on 2/27/26 via email and all staff were trained on this during an assessment training 3/4/26.
The Facility Director will continue to review all documents and forms that are in the EHR for compliance to ensure ROIs have a dated client signature as well as a witness signature. |