INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 4, 2025 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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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 obtain a completed informed and voluntary consent which included the specific information to be disclosed in one out of seven records reviewed.
Client #1 was admitted on October 14, 2024 and was still active at the time of the inspection. A release of information form was signed and dated October 14, 2024 to a family member did not include the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 25, 2024 licensing inspection.
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Plan of Correction
During a team meeting to be held on 9/11/25, the Project Director will review the citation with the treatment team. During that review, the policy for consent /release completion will be reviewed, and a walk-through training conducted. Staff will then be asked to attest that they have attended the training and policy review. To ensure compliance, upon completion of the intake/assessment episode, the file will immediately be provided to a supervisor to ensure that consents/releases are completed appropriately, via an audit. Should a consent/release be found to be lacking, the staff member will be offered individual supervision and retraining on the issue. The clinician will also mark the consent invalid and contact the client to come in and complete a new consent/release within 48 business hours. Should an error occur again, disciplinary action will be taken.
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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 obtain a completed informed and voluntary consent which included the purpose of the disclosure in one out of seven records reviewed.
Client #1 was admitted on October 14, 2024 and was still active at the time of the inspection. A release of information form was signed and dated October 14, 2024 to a family member did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 25, 2024 licensing inspection.
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Plan of Correction
During a team meeting to be held on 9/11/25, the Project Director will review the citation with the treatment team. During that review, the policy for consent /release completion will be reviewed, and a walk-through training conducted. Staff will then be asked to attest that they have attended the training and policy review. To ensure compliance, upon completion of the intake/assessment episode, the file will immediately be provided to a supervisor to ensure that consents/releases are completed appropriately, via an audit. Should a consent/release be found to be lacking, the staff member will be offered individual supervision and retraining on the issue. The clinician will also mark the consent invalid and contact the client to come in and complete a new consent/release within 48 business hours. Should an error occur again, disciplinary action will be taken.
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