INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 6, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CenterPoint Healthcare Avenue 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on an administrative review, the facility failed to present a complete plan documenting the qualifications and training of staff to Department licensing representatives at the time of the project's site visit.
At the time of the inspection, facility staff were unable to produce a fully completed Staffing Requirements Facility Summary Report. The Licensing Specialist provided technical assistance showing how to complete the staffing report at the beginning of the inspection process; however, facility staff did not submit an accurate report with the requested updates completed and corrections made prior to the conclusion of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure clinical supervisors participated in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position in one of three applicable personnel records reviewed.
Employee # 3 was hired as a clinical supervisor on May 20, 2026. There was no documentation, in the personnel record, showing monthly meetings with their supervisor for the first 6 months in the position had been completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on an administrative review and a review of the facility policy and procedure manual, the facility failed to implement and follow their staff development program policies and procedures.
The staff development program policy stated the facility will complete an assessment of staff training needs by December 15 of each year. At the time of the inspection, there was no documentation indicating an assessment of staff training needs was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on an administrative review and a review of the facility policy and procedure manual, the facility failed to implement and follow their staff development program policies and procedures.
The staff development program policy stated the facility will complete an overall training plan by December 31 of each year. At the time of the inspection, there was no documentation indicating an overall training plan was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
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 a review of personnel records, the facility failed to ensure an annual, written individual training plan was developed for each employee, with input from both the employee and the supervisor in three of three applicable personnel records reviewed.
Employee # 1 was hired as the project director on May 20, 2026. There was no individual training plan documented in the personnel record at the time of the inspection.
Employee # 2 was hired as the facility director on May 20, 2026. There was no individual training plan documented in the personnel record at the time of the inspection.
Employee # 3 was hired as the clinical supervisor on May 20, 2026. There was no individual training plan documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide a sink, a wall mirror, an operable soap dispenser and either individual paper towels or a mechanical dryer in each bathroom.
On the date of the inspection at approximately 10:00 a.m., there was no operable soap dispenser or usable soap in both first-floor bathrooms.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
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 the date of the inspection at approximately 10:00 a.m., there were space heaters found in a first-floor doctor' s office and a second-floor clinical supervisor's office.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
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 personnel records, the facility failed to instruct and document that staff were trained in the use of fire extinguishers upon staff employment in three of three applicable personnel records reviewed.
Employee # 1 was hired as the project director on May 20, 2026. There was no documentation in the personnel record indicating the employee was trained in the use of fire extinguishers upon employment as of the date of the inspection.
Employee # 2 was hired as the facility director on May 20, 2026. There was no documentation in the personnel record indicating the employee was trained in the use of fire extinguishers upon employment as of the date of the inspection.
Employee # 3 was hired as the clinical supervisor on May 20, 2026. There was no documentation in the personnel record indicating the employee was trained in the use of fire extinguishers upon employment 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
An approved Plan of Correction is not on file. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the June 2025 through March 2026 fire drill logs, the facility failed to conduct fire drills during normal staffing conditions.
The facility ' s posted hours of operation are Tuesday, Thursday, and Friday from 11:30 a.m. through 3:00 p.m. The fire drills conducted during the months of June 2025, July 2025, September 2025, October 2025, November 2025, December 2025, January 2026, and March 2026 were conducted outside of normal staffing conditions and business hours.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
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 all personnel on all shifts were trained to perform assigned tasks during emergencies in three of three applicable personnel records reviewed.
Employee # 1 was hired as the project director on May 20, 2026. There was no documentation in the personnel record indicating the employee was trained to perform assigned tasks during emergencies as of the date of the inspection.
Employee # 2 was hired as the facility director on May 20, 2026. There was no documentation in the personnel record indicating the employee was trained to perform assigned tasks during emergencies as of the date of the inspection.
Employee # 3 was hired as the clinical supervisor on May 20, 2026. There was no documentation in the personnel record indicating the employee was trained to perform assigned tasks during emergencies 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
An approved Plan of Correction is not on file. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the June 2025 through March 2026 fire drill logs, the facility failed to maintain a complete written fire drill record, which is to include the date, time, amount of time to evacuate, the exit route used, number of people in the facility, any problems encountered, and whether the fire alarm or smoke detector was operative.
Every fire drill reviewed, during the review period, did not include documentation of which exit route was used, if there were any problems encountered, and whether the fire alarm or smoke detector was operative.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the June 2025 through March 2026 fire drill logs, the facility failed to ensure a fire alarm or smoke detector was set off during each fire drill.
At the time of the inspection, there was no documentation provided indicating a fire alarm or smoke detector was set off during each fire drill conducted during the reviewed period.
This finding was reviewed with facility staff at the time of the inspection.
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Plan of Correction
An approved Plan of Correction is not on file. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of client records, the facility failed to maintain the confidentiality of client records and failed to follow procedures pertaining to how the project plans to address the security and release of electronic and paper records.
Client # 1 was admitted on May 20, 2025 and was still active at the time of the inspection. During the client record review, there was documentation pertaining to another client, who was not identified as a drug and alcohol prgram client, filed within client # 1's record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, the facility failed to secure hard copy client records within locked storage containers.
On March 6, 2026, at approximately 10:00 a.m., the identified drug and alcohol client's paper record was stored in an unlocked filing cabinet within an unlocked records storage room and there was no facility staff working in the room at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
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 a review of client records, the facility failed to obtain a written informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in one of one client record reviewed.
Client # 1 was admitted on May 20, 2025 and was still active at the time of the inspection. There was evidence of disclosures to a laboratory during the client's treatment episode; however, there was no consent to release information form documented in the client's record prior to any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that they were notified of their client rights in one of one applicable client records reviewed.
Client # 1 was admitted on May 20, 2025 and was still active at the time of the inspection. There was no written acknowledgement of all required client rights documented in the client record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review, the facility failed to maintain a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project's performance.
The facility was initially notified of the annual renewal inspection on December 29, 2025, using standard Department procedures. Per the inspection notice, facility staff was to submit requested presubmission documentation no later than January 16, 2026. The documents were not submitted by the due date, and several phone and email follow-up attempts were made and were unsuccessful until February 4, 2026 when the Licensing Specialist was informed by the facility's clinical supervisor that they were not aware of the inspection notices. At one point during the process, facility staff said they were not aware that they had a Department license.
Additionally, as early as February 5, 2026, the facility was requested to provide an active and discharged client list to the Licensing Specialist upon arrival on-site; however, facility staff did not provide the client list until approximately two hours after being requested again when the Licensing Specialist was on-site. When the client list was provided, the list included all clients of the facility, which included mental health clients and medication management clients, who should not have been and were not included in the drug and alcohol treatment program.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a recordkeeping system that allowed for the identification of clients' admissions and discharges within a specific time period.
The facility was unable to provide a list of discharged drug and alcohol program clients 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
An approved Plan of Correction is not on file. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to maintain a complete client record for clients receiving drug and alcohol services in one of one client record reviewed.
Client # 1 was admitted on May 20, 2025 and was still active at the time of the inspection. This client was the only client identified as receiving drug and alcohol services. The client record did not include the following required documentation:
to the client of admission, treatment, completion, and discharge criteria;
orientation to the project
completed medical history,
completed drug and alcohol history
completed personal history
to treatment, signed by the client
completed psychosocial evaluation
completed preliminary treatment plan
completed individual treatment and rehabilitation plan, developed with the client
to release information forms, signed and dated by the client
These findings were reviewed with facility staff during the onsite complaint investigation
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Plan of Correction
An approved Plan of Correction is not on file. |