INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 27, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Employee #3 was hired on October 14, 2024 as a counselor and was still in the position as of the date of the inspection. The training was completed on October 31, 2024.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Project Director will review the citation with all team members in a team meeting on September 11, 2025. During this meeting, the policy will be reviewed and all team members will be required to attest to reviewing the policy. Additionally, a new hire training plan has been created and implemented in December of 2025, that provides the employee with timelines for all trainings to be completed. This must be signed off on, daily, by the employee, the location supervisor, and the project director. This will prevent critical trainings from being late or missed. |
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.
|
Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which is to include the name of the person, agency or organization to whom the disclosure is made in one out of six records reviewed.
Client #4 was admitted on February 19, 2025 and was still active at the time of the inspection. A release of information form was signed and dated February 19, 2025 which 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.
|
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.
|
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.
|
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 three out of six records reviewed.
Client #3 was admitted on February 26, 2025 and was still active at the time of the inspection. A release of information form was signed and dated February 26, 2025 to parole did not include the specific information to be disclosed.
Client #4 was admitted on February 19, 2025 and was still active at the time of the inspection. A release of information form was signed and dated February 19, 2025 to parole did not include the specific information to be disclosed.
Client #5 was admitted on January 16, 2025 and was discharged on April 9, 2025. A release of information form signed and dated January 16, 2025 to probation 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 August 28, 2024 licensing inspection.
|
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.
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation or completed within the timeframe in four out of six applicable records reviewed. The facility's policy and procedures manual states that the preliminary treatment plan must be completed within 30 days of admission.
Client #2 was admitted on January 9, 2025 and was still active at the time of the inspection. No psychosocial evaluation was completed.
Client #4 was admitted on February 19, 2025 and was still active at the time of the inspection. The psychosocial evaluation was completed on July 14, 2025.
Client #5 was admitted on January 16, 2025 and was discharged on April 9, 2025. No psychosocial evaluation was completed.
Client #7 was admitted on October 18, 2024 and was discharged on May 13, 2025. The psychosocial evaluation was completed on April 15, 2025.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
During a team meeting to be held on 9/11/25, the team will review the citation, along with the policy for biopsychosocial completion. Each team member will be requested to attest to the policy review and an understanding of how and within what timeframe to complete the document. To ensure compliance, a member of the supervisory team will audit all client files following the intake/assessment episode to ensure that the biopsychosocial evaluation has been completed. Should a biopsychosocial be found to be not completed or incomplete, the staff member will be offered individual supervision and retraining on the issue. The staff member will also be directed to complete the evaluation during the next scheduled session. Should an error occur again, or the document not be completed within the next session and reviewed with a supervisor, disciplinary action will be taken. If the document is unable to be corrected or submitted, for an extenuating circumstance, a special note shall be placed in the client record.
|
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan within the regulatory timeframe in two out of six records reviewed. The facility's policy and procedures manual states that the preliminary treatment plan must be completed at the first session.
Client #2 was admitted on January 9, 2025 and was still active at the time of the inspection. There was no documentation of a preliminary treatment plan at the time of the inspection.
Client #7 was admitted on October 18, 2024 and discharged on May 13, 2025. There was no documentation of a preliminary treatment plan at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
During a team meeting to be held on 9/18/25, the team will review the citation, along with the policy for preliminary tx plan completion. Each team member will be requested to attest to the policy review and an understanding of how and within what timeframe to complete the document. To ensure compliance, a member of the supervisory team will audit all client files following the intake/assessment episode to ensure that the preliminary tx plan has been completed. Should a preliminary tx plan be found to be not completed or incomplete, the staff member will be offered individual supervision and retraining on the issue. The staff member will also be directed to complete the plan during the next scheduled session. Should an error occur again, or the document not be completed within the next session and reviewed with a supervisor, disciplinary action will be taken. If the document is unable to be corrected or submitted, for an extenuating circumstance, a special note shall be placed in the client record.
|
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:
|
Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan with the client and within guidelines established by the facility's policy and procedures manual in six out of six applicable records reviewed. The facility's policy and procedures manual states the treatment plan must be completed within 30 days following admission.
Client #1 was admitted on June 25, 2025 and was still active at the time of the inspection. The comprehensive treatment plan was completed on July 11, 2025 without the client.
Client #2 was admitted on January 9, 2025 and was still active at the time of the inspection. No comprehensive treatment plan was completed.
Client #3 was admitted on February 26. 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than March 28, 2025; however, it was not completed until June 25, 2025.
Client #4 was admitted on February 19, 2025 and was still active at the time of the inspection. No comprehensive treatment plan was completed.
Client #5 was admitted on January 16, 2025 and was discharged on April 9, 2025. No comprehensive treatment plan was completed.
Client #7 was admitted on October 18, 2024 and discharged on May 13, 2025. A comprehensive treatment plan was due no later than November 30, 2024; however, it was not completed until April 22, 2025.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
During a team meeting to be held on 9/18/25, the team will review the citation, along with the policy for comprehensive tx plan completion. Each team member will be requested to attest to the policy review and an understanding of how and within what timeframe to complete the document. To ensure compliance, the team will have a tracking spreadsheet that populates for the clinician when every tx plan is due. This will be reviewed daily by the supervisor and the clinicians. The supervisor will review all charts that have a comprehensive tx plan due the previous day to ensure it has been completed. Should a comprehensive tx plan be found to be not completed or incomplete, the staff member will be offered individual supervision and retraining on the issue. The clinician will also be directed to correct/complete the plan at the next scheduled session, and then update the tracking sheet and submit the chart to the supervisor. Should an error occur again, disciplinary action will be taken. If the document is unable to be corrected or submitted for an extenuating circumstance, a special note shall be placed in the client record.
|
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.
|
Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in five out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed at 30, 90,180, 270, 365 days and annually thereafter following admission.
Client #2 was admitted on January 9, 2025 and was still active at the time of the inspection. No case consultation was completed.
Client #3 was admitted on February 26. 2025 and was still active at the time of the inspection. A case consultation was completed on February 26, 2025 and the next one was due no later than May 26, 2025; however, it was not completed until August 25, 2025.
Client #4 was admitted on February 19, 2025 and was still active at the time of the inspection. A case consultation was due no later than March 21, 2025; however, it was not completed until July 14, 2025.
Client #6 was admitted on June 7, 2024 and was discharged on April 10, 2025. A case consultation was completed on June 7, 2024 and the next one was due no later than September 7, 2024; however, it was not completed until December 6, 2024.
Client #7 was admitted on October 18, 2024 and was discharged on May 13, 2025. A case consultation was completed on October 18, 2024 and the next one was due no later than January 18, 2025; however, it was not completed until April 15, 2025.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the August 7, 2023 and August 28, 2024 licensing inspection.
|
Plan of Correction
Following the completion of the audit, the Project Director amended the case consult policy to now reflect a case consult due within 30 days of admission and upon discharge from tx. During a team meeting to be held on 9/11/25, the team will review the citation, along with the new policy for case consult completion. Each team member will be requested to attest to the policy review and an understanding of how and within what timeframe to complete the document. To ensure compliance, a member of the supervisory team will audit all client files at 30 days from admission and upon discharge to ensure that case consults have been completed. Should a consult be found to be missing, the staff member will be offered individual supervision and retraining on the issue. The staff member will also be directed to complete the case consult within the next 3 days and provide it upon completion to the supervisor. Should an error occur again, or the document not be completed within the outlined period and submitted a supervisor, disciplinary action will be taken.
|
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.
|
Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in four out of four applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed 30 days following discharge.
Client #5 was admitted on January 16, 2025 and was discharged on April 9, 2025. No follow up was completed.
Client #6 was admitted on June 7, 2024 and was discharged on April 10, 2025. No follow up was completed.
Client #7 was admitted on October 18, 2024 and was discharged on May 13, 2025. No follow up was completed.
Client #8 was admitted on June 20, 2024 and was discharged on May 29, 2025. No follow up was completed.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the August 28, 2024 licensing inspection.
|
Plan of Correction
During a team meeting to be held on 9/11/25, the team will review the citation, along with the policy for follow-up completion. Each team member will be requested to attest to the policy review and an understanding of how and within what timeframe to complete the document. To ensure compliance, discharge dates will be tracked on a shared spreadsheet and reviewed daily by all team members. At 30 days post-discharge, all charts will be pulled and reviewed by a supervisor to ensure that all follow-ups have been completed. Should a follow-up be found to be not completed or incomplete, the staff member will be offered individual supervision and retraining on the issue. The staff member will also be directed to complete the follow-up before end of business the next day and submitted to the supervisor. Should an error occur again, or the document not be completed within the allotted time frame and reviewed with a supervisor, disciplinary action will be taken.
|
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.
|
Observations
Based on a review of outpatient 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 and August 28, 2024 annual licensing inspections. Case consultations were again found to be a deficiency in the August 27, 2025 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
On 9/8/2025, the Project Director reviewed the citation with all supervisory staff and amended the current case consult policy. This policy was then reviewed with all staff on 9/11/25, and they were requested to attest to the presentation and their understanding of it. The amended policy states that case consults will be completed on all clients admitted to the program, within 30 days of admission, and upon discharge. This will be monitored through a team-shared spreadsheet of admission and discharge dates, as well as routine and timely audits, within 30 days of admission and upon discharge, of all client charts by a supervisor. Should a case consult be found to not be completed, the clinician will be supplied a timeline to complete the consult and submit to the supervisor, as well as given 1-1 supervision and retraining. Should the error occur again, or the consult not be submitted, discioplinary action will be taken.
|