INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 3, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Reading Hospital 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director met the educational qualifications for the position in one of one applicable personnel record reviewed.
Employee # 1 was hired as the project director on February 27, 2026 and was still in this position at the time of inspection. The personnel record verified the employee had a bachelor's degree in fine arts, which is not a qualifying major for the position. There was no other documentation in the record indicating the employee has a qualifying degree/major; therefore, the employee did not meet the educational degree requirements for the position upon hire.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The plan of correction is to seek an exception. An exception request was submitted on 4/9/26, and a response was received on 4/17/26 that additional information was required. The request was resubmitted on 4/28/26 with the supplemental documentation. If this exception is denied, the Facility Director will also fill the Project Director role.
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711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 5 was admitted on September 26, 2025 and was discharged on March 9, 2026. There was evidence of disclosures to the funding source; however, there was no consent to release information form signed by the client prior to any of the disclosures.
This is a repeat citation from the April 15, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 5/4/26, all consents to release information will be scanned into the patient chart within one week of signature. Ten patient charts will be reviewed monthly by the Project Director, Facility Director and Clinical Supervisor to ensure timely completion of consents to release information. This monthly review will continue for at least 3 months or until 100% compliance is reached.
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