INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 31, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Three Rivers Youth 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 employees received the minimum of at least 4 hours of TB/STD and other health related topics within the first year of employment in two of two applicable records.
Staff #2 was hired as counselor on June 17, 2024, and was still in the position at the time of inspection. Staff #2 was due to have the communicable disease trainings no later than June 17, 2025. There was no documentation provided of the completion of the TB/STD or HIV/AIDS training as of the date of the inspection.
Staff #3 was hired as counselor on January 28, 2025, and was still in the position at the time of inspection. Staff #3 was due to have the communicable disease trainings no later than January 28, 2026. There was no documentation provided of the completion of the TB/STD training as of the date of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
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.
Three Rivers Youth has adopted policies and procedures related to personnel records, that ensure employees receive the minimum of at least 4 hours of TB/STD and other health related topics within the first year of employment.
Staff # 3 has registered for the TB/STD training and is currently on the waitlist for 6/16/26. Staff #3 will complete TB/STD training by the 6/30/26 or based on training availability. Staff #2 completed the HIV training on 3/30/26 and was registered for TB-STD on 4/2 but training was cancelled. Staff #2 will complete the TB-STD by 6/30/26 or next training availability.
The Facility Director will monitor training plans and training needs more closely during weekly supervisions. The Quality Assurance Team and HR Department will review staff training records periodically and during quarterly reviews to address any deficiencies.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document a purpose of disclosure on the release of information form in one of fourteen records.
Client # 5 was admitted to the outpatient level of care on July 1, 2025, and still active at the time of inspection. A release of information to the funder was signed and dated by the client on July 1, 2025, and did not indicate a purpose of disclosure.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
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.
Three Rivers Youth (TRY) understand the importance of confidentiality and will adhere accordingly as it relates to obtaining informed and voluntary consent from clients for disclosure of information. TRY has set policies and procedures that adhere to Confidentiality 709.28-federal, state and local laws and entities. All TRY staff are expectation to follow the procedure set forth in the confidential policies and procedures related to 709.28.
The Facility Director will reiterate the confidentiality policy and procedures with all staff during weekly supervision by 5/8/26. Also, The Facility Director will provide a refresher training to staff related to confidentiality by 6/5/26. The Director and/or Quality Assurance Team will conduct files reviews more closely on a monthly basis to ensure confidentially is followed by staff. The program staff will obtain proper consent prior to disclosure and follow policies, procedures and best practices as it relates to client confidentiality. On 4/13/26, Client #5 as referenced in the review has proper consent of information from government agency for future disclosures as per consent documentation and will indicate a purpose of disclosure.
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709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project which included familiarization with hours of operation in seven of seven records.
Client #1 was admitted to the outpatient level of care on May 8, 2025, and discharged on December 31, 2025.
Client #2 was admitted to the outpatient level of care on October 16, 2025, and discharged on December 18, 2025.
Client #3 was admitted to the outpatient level of care on September 25, 2025, and discharged on December 16, 2025.
Client #4 was admitted to the outpatient level of care on May 22, 2025, and discharged on December 24, 2025.
Client #5 was admitted to the outpatient level of care on July 1, 2025, and was still active at the time of the inspection.
Client #6 was admitted to the outpatient level of care on November 13, 2025, and was still active at the time of the inspection.
Client #7 was admitted to the outpatient level of care on November 7, 2025, and was still active at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Intake and admission:
709.91. Intake and admission. (b) Intake procedures shall include documentation of: (2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following: (ii) Hours of operation.
TRY will include client handbook that has the intake procedures for orientation with hours of operation to client files with client signatures by 5/11/26. Each client is given a copy of the handbook, but a copy is not kept in client file with signature verification.
The Director will reiterate during bi-weekly supervisions the need to ensure all clients have client handbooks signed and in client files. The Director discussed client records, intake, admission and orientation with staff during the staff meeting on 4/22/26. The Director and Quality Assurance Team will randomly review files monthly to limit deficiencies. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project which included familiarization with the fee schedule in seven of seven records.
Client #1 was admitted to the outpatient level of care on May 8, 2025, and discharged on December 31, 2025.
Client #2 was admitted to the outpatient level of care on October 16, 2025, and discharged on December 18, 2025.
Client #3 was admitted to the outpatient level of care on September 25, 2025, and discharged on December 16, 2025.
Client #4 was admitted to the outpatient level of care on May 22, 2025, and discharged on December 24, 2025.
Client #5 was admitted to the outpatient level of care on July 1, 2025, and was still active at the time of the inspection.
Client #6 was admitted to the outpatient level of care on November 13, 2025, and was still active at the time of the inspection.
Client #7 was admitted to the outpatient level of care on November 7, 2025, and was still active at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Intake and admission:
709.91. Intake and admission. (b) Intake procedures shall include documentation of: (2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following: (iii) Fee Schedule.
TRY will include client handbook that has the intake procedures for orientation including how to access the fee schedule to client files with client signatures by 5/11/26. Each client is given a copy of the handbook, but a copy is not kept in client file with signature verification. Fee schedules are posted in all staff offices, group rooms and front lobby area.
The Director will reiterate during bi-weekly supervisions the need to ensure all clients have client handbooks signed and in client files. The Director discussed client records, intake, admission and orientation with staff during the staff meeting on 4/22/26. The Director and Quality Assurance Team will randomly review files monthly to limit deficiencies. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 develop a treatment plan with the client in seven of seven records.
The facility policy and procedures state an individual treatment plan is to be developed with the client by their second session.
Client #1 was admitted to the outpatient level of care on May 8, 2025, and discharged on December 31, 2025. A treatment plan was developed on May 28, 2025, and did not indicate it was developed with the client.
Client #2 was admitted to the outpatient level of care on October 16, 2025, and discharged on December 18, 2025. The second session was documented on November 17, 2025; however, there was no individual treatment plan in the record.
Client #3 was admitted to the outpatient level of care on September 25, 2025, and discharged on December 16, 2025. A treatment plan was developed on October 10, 2025, and did not indicate it was developed with the client.
Client #4 was admitted to the outpatient level of care on May 22, 2025, and discharged on December 24, 2025. A treatment plan was developed on June 24, 2025, and did not indicate it was developed with the client.
Client #5 was admitted to the outpatient level of care on July 1, 2025, and was still active at the time of the inspection. A treatment plan was developed on July 18, 2025, and did not indicate it was developed with the client.
Client #6 was admitted to the outpatient level of care on November 13, 2025, and was still active at the time of the inspection. A treatment plan was developed on November 21, 2025, and did not indicate it was developed with the client.
Client #7 was admitted to the outpatient level of care on November 7, 2025, and was still active at the time of the inspection. The second session was documented on November 18, 2025; however, there was no individual treatment plan in the record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Three River Youth have adopted policies and procedures related to the treatment planning process with clients. Clients must be involved in their treatment plan as it is individualized and based their needs and strengths. Client must sign their treatment plans to ensure their collaborative involvement and development.
The Facility Director will review treatment plan process with staff during weekly supervision by 5/11/26. The Facility Director provided a refresher training on treatment plans to all staff on 4/22/26. TRY staff will complete comprehensive treatment plans with clients and document accordingly with client signature and progress notes.
The quality assurance team will provide random and monthly client file reviews to monitor that treatment plans are developed with clients. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support services on individual treatment plans in two of five applicable records.
Client #5 was admitted to the outpatient level of care on July 1, 2025, and was still active at the time of the inspection. The treatment plan was dated July 18, 2025.
Client #6 was admitted to the outpatient level of care on November 13, 2025, and was still active at the time of the inspection. The treatment plan was dated November 18, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Treatment and rehabilitation services:
709.92. 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: (3) Proposed type of support service
Three River Youth adhere to and have written policies and procedures in place related to treatment planning process with clients based on 709.92 (a). Based the above mentioned polices, clients must be involved in their treatment plan as it is individualized and based their needs and strengths. The treatment plan must include but not limited to the type of support service as formulated by both staff and client. Client must sign their treatment plans to ensure their collaborative involvement and development.
The Facility Director will review treatment plan process with staff during weekly supervision by 5/11/26. The Facility Director will provide a refresher training on treatment plans with added attention to support services to all staff on 4/22/26. TRY staff will complete comprehensive treatment plans with clients to include type of support service during the treatment planning process. The staff will document accordingly with client signature and progress notes.
The quality assurance team will provide random and monthly client file reviews to monitor that treatment plans are developed with clients and include type of support service |
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 a review of client records, the facility failed to document treatment plan updates every 60 days in five of five applicable records.
Client #1 was admitted to the outpatient level of care on May 8, 2025, and discharged on December 31, 2025. A treatment plan was developed on May 28, 2025, and an update was due no later than July 28, 2025; however, it was completed on July 31, 2025. A treatment plan update was completed on September 29, 2025, and the next update was due no later than October 29, 2025; however, there were no further updates documented in the record.
Client #3 was admitted to the outpatient level of care on September 25, 2025, and discharged on December 16, 2025. A treatment plan was developed on October 10, 2025, and an update was due no later than December 10, 2025; however, there were no further updates documented in the record.
Client #4 was admitted to the outpatient level of care on May 22, 2025, and discharged on December 24, 2025. A treatment plan was developed on June 24, 2025, and an update was due no later than August 24, 2025; however, it was completed on August 28, 2025.
Client #5 was admitted to the outpatient level of care on July 1, 2025, and was still active at the time of the inspection. A treatment plan was developed on July 18, 2025, and an update was due no later than September 18, 2025; however, it was completed on March 26, 2026.
Client #6 was admitted to the outpatient level of care on November 13, 2025, and was still active at the time of the inspection. A treatment plan was developed on November 21, 2025, and an update was due no later than January 21, 2026; however, it was completed on February 27, 2026.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
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
Three River Youth adheres to and have written polices and procedures in place related to treatment planning process with clients based on 709.92 (b). Based the above mentioned polices, clients must be involved in their treatment plan as it is individualized and based their needs, strengths and be time sensitive. The treatment plan must be reviewed and updated at least every 60 days as formulated by both staff and client. Client must sign their treatment plan update to ensure their collaborative involvement in the development within 60 days.
The Facility Director will review treatment plan process with staff during weekly supervision by 5/11/26. The Facility Director will provide a staff refresher training on 4/22/26 related to treatment plans with added focus on time sensitivity on updates to track progress within the 60-day period. TRY staff will complete comprehensive treatment plans with clients to include target date of 60 days for updates. The staff will document accordingly with client signature and progress notes.
The quality assurance team will provide random and monthly client file reviews to monitor that treatment plans are developed with clients and include an update within 60 days. |
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 document case consultations in four of five applicable records.
The facility's policy and procedure manual states a case consultation must be completed every 90 days following admission.
Client #4 was admitted to the outpatient level of care on May 22, 2025, and discharged on December 24, 2025. There were no case consultations documented in the record.
Client #5 was admitted to the outpatient level of care on July 1, 2025, and was still active at the time of the inspection. There were no case consultations documented in the record.
Client #6 was admitted to the outpatient level of care on November 13, 2025, and was still active at the time of the inspection. There were no case consultations documented in the record.
Client #7 was admitted to the outpatient level of care on November 7, 2025, and was still active at the time of the inspection. There were no case consultations documented in the record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
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.
Three Rivers Youth adhere to and have written policies and procedures in place related to client records and case consultations with clients based on 709.93. Based the above mentioned polices, a complete client record must include case consultations
The Facility Director will review client records related to case consultations with staff during weekly supervision by 5/11/26. The Facility Director provided a refresher training on 4/22/26 to all staff on case consultation and documentation of services. TRY staff will complete case consultation every 90 days for a full continuum of care and document accordingly.
The quality assurance team will provide random and monthly client file reviews to monitor case consultations are completed within 90 days and documented. |
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 a review of client records, the facility failed to document follow-up information in two of three applicable discharged records.
The facility's policy and procedures state follow-up contact is to be completed for all non-referred discharges within 90 days.
There was no follow-up information documented in client records #2 and #4.
Client #2 was admitted to the outpatient level of care on October 16, 2025, and discharged on December 18, 2025.
Client #4 was admitted to the outpatient level of care on May 22, 2025, and discharged on December 24, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
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.
Three Rivers Youth adhere to and have written policies and procedures in place related to client records and follow-up information with clients based on 709.93 (a) (11). Based the above mentioned polices, a complete client record must include client follow-up within 90 days after discharge.
The Facility Director will review client records related to client follow-up contact after discharge with staff during weekly supervision by 5/11/26. The Facility Director provided a refresher training on 4/22/26 to all staff on follow-up after discharge and documentation of services. TRY staff will complete client follow-up after discharge within 90 days and document accordingly.
The quality assurance team will provide random and monthly client file reviews to monitor client follow-up are completed within 90 days after discharge and documented. |