INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 15, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Trehab 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 that one applicable employee received a minimum of 4 hours of TB/STD training using a department approved curriculum within the regulatory timeframeEmployee #4 has been in the position of counselor since December 30, 2024 and was current in that position at time of licensing process. Employee # 4 was due to have the communicable disease training no later than December 30, 2025; however, the TB/STD training was not completed as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility acknowledges that one counselor (Employee #4) did not complete the required minimum hours of tuberculosis/sexually transmitted disease training using a department-approved curriculum within the regulatory timeframe. Employee #4 has been scheduled to complete the required TB/STD training on February 24, 2026, and documentation of completion will be maintained in the employee's personnel file.
To prevent recurrence, the facility will implement ongoing monitoring of staff training requirements and deadlines. Required communicable disease trainings will be reviewed at hire and tracked regularly by supervisory staff to ensure all counselors complete mandated trainings within required timeframes and that documentation is maintained. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of administrative documents and discussion with facility staff, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel.There was documentation of the presence of ambulance and police personnel on December 18, 2024; however, there was no documentation that a written unusual incident report was ever filed with the Department.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The program will ensure that all unusual incidents involving police, fire, or ambulance personnel are documented and a written unusual incident report is filed with the Department within three (3) business days, in accordance with §709.34(c)(4). Staff will be re-educated on unusual incident reporting procedures and timelines to ensure compliance with state regulations on 02/04/2026 at staff meeting. Unusual incident report was submitted online on 2/05/2025.
To prevent recurrence, supervisory staff will review incident logs monthly to confirm that all required reports are submitted timely. The Program Director or quality manager will monitor compliance and address any missed or late submissions through corrective action and staff coaching as needed.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual, which includes information relative to the client's involvement with the project, including an aftercare plan, in one of two applicable records reviewed. Client #2 was admitted to the outpatient program on May 27, 2025 and discharged on September 26, 2025. There was no documentation of an aftercare plan in client record.These findings were reviewed with facility staff during licensing process.
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Plan of Correction
The drug and alcohol program will ensure that an aftercare plan is completed and documented for all applicable clients prior to discharge. Clinical staff will be re-educated on aftercare planning requirements and documentation standards to ensure continuity of care following discharge on 02/04/2026 at staff meeting.
To prevent recurrence, supervisory staff will review discharge documentation, including aftercare plans, as part of routine chart audits. The Program Director or quality manager will monitor compliance and address any missing or incomplete aftercare plans promptly through corrective action and staff coaching as needed.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including a discharge summary within seven days of discharge, per facility policy, in two of four applicable records reviewed. Client # 1 was admitted to the outpatient program on July 10, 2025 and was discharged on September 29, 2025. The client record contained documentation of a discharge summary dated January 13, 2026.Client #2 was admitted to the outpatient program on May 27, 2025 and discharged on September 26, 2025. The client record contained documentation of a discharge summary dated January 7, 2026.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program will ensure that all client discharge summaries are completed within seven (7) days of discharge, in accordance with our facility policy. Clinical staff will be re-educated on discharge documentation requirements, including timeliness and completeness of discharge summaries on 02/04/2026 during our staff meeting.
To prevent recurrence, supervisory staff will monitor discharge documentation through routine chart reviews and tracking of discharge dates. The Program Director or Quality Manager will oversee compliance and address any late or missing discharge summaries promptly through corrective action and staff coaching as needed.
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