INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Treatment and Healing 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) (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 a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one out of three records reviewed.
Employee #3 was hired as a counselor on June 8, 2026, and was current in that position at the time of the licensing inspection. Employee #3 was to be trained to perform assigned tasks during emergencies prior to working a shift; however, there was no documentation the training had been completed.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the August 27, 2025 licensing inspection.
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Plan of Correction
On August 20, 2026, PATH conducted a team meeting during which the agency's emergency preparedness procedures were reviewed with all staff. As part of this review, each staff member was assigned specific duties and responsibilities to be carried out in the event of an emergency. Staff received instruction regarding their assigned roles and were provided an opportunity to ask questions and obtain clarification regarding expectations.
Following completion of the training, each staff member signed an attestation confirming that they had been informed of, trained on, and understood their assigned emergency preparedness responsibilities. Signed attestations will be maintained in each employee's personnel file as documentation of completed training.
**Effective immediately, all newly hired staff will receive emergency preparedness training prior to working their first shift or assuming any independent client-care responsibilities.** Emergency preparedness training will be incorporated into PATH's new-hire orientation process and will include review of the agency's emergency preparedness procedures, the employee's specific duties and responsibilities during an emergency, evacuation and emergency-response expectations, and any responsibilities specific to the employee's assigned facility and position. New employees will be provided an opportunity to ask questions and obtain clarification regarding their responsibilities before beginning their first shift.
Upon completion of the training, each new employee will sign an attestation acknowledging that the emergency preparedness procedures and their assigned responsibilities have been reviewed with them and that they understand the expectations associated with their role. **The Facility Director, or an appropriately designated supervisory staff member in the Facility Director's absence, will be responsible for ensuring that this training is completed and documented prior to the employee's first shift.** The employee will not be permitted to begin independent work responsibilities until the required emergency preparedness training has been completed and documented.
**The Facility Director will monitor ongoing compliance with this requirement** by reviewing new-hire training documentation and personnel files to verify that emergency preparedness training and the signed attestation were completed within the required timeframe. The Facility Director will also ensure that emergency preparedness responsibilities are reviewed whenever staffing assignments, job responsibilities, facility operations, or emergency procedures change. Agency leadership may conduct additional periodic personnel-file reviews to verify continued compliance with the pre-service training requirement.
To ensure ongoing compliance and staff competency, PATH will conduct monthly unannounced/random emergency preparedness drills. The Facility Director and/or designated supervisory staff will monitor staff performance during these drills to verify that employees understand and can appropriately carry out their assigned responsibilities. Drill participation, observations, identified deficiencies, and any corrective actions or retraining will be documented. Emergency preparedness assignments will also be reviewed and modified as necessary when staffing changes occur or when drill results identify opportunities for improvement.
Any staff member who is unable to identify or appropriately perform their assigned responsibilities during an emergency preparedness drill will receive documented retraining. The Facility Director or designated supervisor will be responsible for ensuring that the retraining occurs and for subsequently verifying the employee's competency. Continued failure to demonstrate competency following retraining will be addressed through PATH's progressive disciplinary process, consistent with agency policy.
Through the implementation of mandatory emergency preparedness training prior to an employee's first shift, signed training attestations, supervisory verification, ongoing monitoring, monthly emergency drills, and documented retraining when deficiencies are identified, PATH will ensure that all staff are appropriately trained and able to demonstrate competency regarding their assigned emergency preparedness responsibilities.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent that included the name of the person, agency or organization to whom the disclosure is made in one out of seven records reviewed.
Client #1 was admitted on October 17, 2025, and was discharged November 24, 2025. A release of information form was signed and dated by the client on October 17, 2025, that did not include the name of the person, agency or organization to whom the disclosure is made.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 27, 2025, licensing inspection.
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Plan of Correction
On August 20, 2026, all clinical staff received retraining regarding the proper completion and documentation of client consent forms. The training specifically addressed the requirement that all required elements must be completed accurately to ensure that each consent is valid and compliant with agency policy and applicable regulatory requirements.
To ensure ongoing compliance, the Site Supervisor will conduct monthly random chart audits. The audit will include three randomly selected client records from each clinician for each level of care in which the clinician provides services. Consent documentation will be reviewed for completeness, accuracy, and validity, including documentation of whether the client accepted or declined a copy.
If an incomplete or otherwise invalid consent is identified during an audit, the responsible clinician will be notified and provided seven calendar days to contact the client and correct the identified deficiency. The Site Supervisor will re-review the affected record within 10 calendar days of the initial finding to verify that the required correction has been completed.
If the consent remains incomplete or invalid upon re-review, the clinician will receive individualized one-on-one retraining regarding consent requirements and proper documentation procedures. Repeated noncompliance, defined as three or more identified occurrences, will result in corrective or disciplinary action in accordance with agency policy. |
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 a review of client records, the facility failed to have a complete client record on an individual which included information relative to the client's involvement with the project that included case consultation notes at admission and at discharge, per facility policy, in seven of seven records reviewed.
There was no documentation of any case consultation notes in the client records reviewed during licensing inspection.
These findings were reviewed with facility staff during their licensing process.
This is a repeat citation from the August 7, 2023, August 28, 2024, and August 27, 2025 licensing inspections.
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Plan of Correction
On August 27, 2026, a team meeting was conducted during which PATH's policy and procedures regarding case consultation were reviewed with all applicable clinical staff. The review included the required components of case consultation, expectations for timely completion, and requirements for documenting case consultation within the client record.
Effective August 27, 2026, weekly clinical case consultation meetings will be conducted via Zoom. During these meetings, all new admissions and discharges will be reviewed, along with other cases requiring clinical consultation as appropriate. Required case consultation information will be documented and maintained in the applicable client record in accordance with agency policy and DDAP requirements.
To monitor ongoing compliance, the Clinical Supervisor and/or Project Director will conduct monthly random chart audits. The audit sample will consist of three randomly selected client records from each applicable level of care and from each clinician. Records will be reviewed to verify that required case consultations have occurred and that documentation contains all required components.
If an audit identifies a missing case consultation or incomplete case consultation documentation, the responsible clinician will be notified and provided 72 hours to correct the identified deficiency. The clinician will also receive retraining regarding case consultation requirements and documentation expectations. The corrected record will be reviewed by the Clinical Supervisor or Project Director to verify completion and compliance.
If subsequent monitoring identifies repeated noncompliance following retraining, the matter will be addressed through PATH's progressive disciplinary process in accordance with agency personnel policies. |
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.
Plan of corrections for case consultations were submitted and approved by the Department for the August 7, 2023, August 28, 2024, and August 27, 2025, annual licensing inspections. Case consultations were again found to be a deficiency in the August 11, 2026, licensing inspection.
These findings were reviewed with facility staff during their licensing process.
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Plan of Correction
The Project Manager will monitor plans of correction by implementing a monthly time on the calendar to review the previous deficiencies and ensure all of the identified plans of correction are still being monitored.
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