INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on July 24 & 28, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site investigation, Tadiso Inc. 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 investigation:
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of counselor caseload information, administrative documentation and staff interview, the facility failed to maintain outpatient counselor caseloads at or below 55/1.The facility was granted an exception on June 11, 2026 which permits extended caseloads from 35/1 to 55/1. Included in this exception approval, was a stipulation that the reduced counseling caseload calculation outline in Licensing Alert 01-2014 could not be utilized. Counselor caseloads exceeded 55/1 in staff records #3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15.Staff #3 works a total of 37.5 hours per week and all of these hours are dedicated to drug and alcohol clients. Staff #3 is assigned a caseload of 77 clients, resulting in a staff / client caseload of 77/1.Staff #5 works a total of 37.5 hours per week and all of these hours are dedicated to drug and alcohol clients. Staff #5 is assigned a caseload of 81 clients, resulting in a staff / client caseload of 81/1.Staff #6 works a total of 37.5 hours per week and all of these hours are dedicated to drug and alcohol clients. Staff #6 is assigned a caseload of 75 clients, resulting in a staff / client caseload of 75/1.Staff #7 works a total of 37.5 hours per week and all of these hours are dedicated to drug and alcohol clients. Staff #7 is assigned a caseload of 82 clients, resulting in a staff / client caseload of 82/1.Staff #8 works a total of 37.5 hours per week and all of these hours are dedicated to drug and alcohol clients. Staff #8 is assigned a caseload of 78 clients, resulting in a staff / client caseload of 78/1.Staff #9 works a total of 37.5 hours per week and all of these hours are dedicated to drug and alcohol clients. Staff #9 is assigned a caseload of 72 clients, resulting in a staff / client caseload of 72/1.Staff #10 works a total of 37.5 hours per week and all of these hours are dedicated to drug and alcohol clients. Staff #10 is assigned a caseload of 80 clients, resulting in a staff / client caseload of 80/1.Staff #11 works a total of 37.5 hours per week and all of these hours are dedicated to drug and alcohol clients. Staff #11 is assigned a caseload of 80 clients, resulting in a staff / client caseload of 80/1.Staff #12 works a total of 15 hours per week and all of these hours are dedicated to drug and alcohol clients. Staff #12 is assigned a caseload of 29 clients, resulting in a staff / client caseload of 72/1. The caseload calculation is as follows: 15 hours / 37.5 work week = .4 FTE.---- 29 clients / .4 FTE = 72.5 ---- 72/1.Staff #13 works a total of 15 hours per week and all of these hours are dedicated to drug and alcohol clients. Staff #13 is assigned a caseload of 54 clients, resulting in a staff / client caseload of 67/1. The caseload calculation is as follows: 30 hours / 37.5 work week = .8 FTE. ---- 54 clients / .8 FTE = 67.5 --- 67/1.Staff #14 works a total of 37.5 hours per week and all of these hours are dedicated to drug and alcohol clients. Staff #14 is assigned a caseload of 80 clients, resulting in a staff / client caseload of 80/1.Staff #15 works a total of 37.5 hours per week and all of these hours are dedicated to drug and alcohol clients. Staff #15 is assigned a caseload of 72 clients, resulting in a staff / client caseload of 72/1.In addition, there were three caseloads, a total of 133 clients, that were not assigned a counselor as of May 2026. These counselors resigned from their position and these clients were not re-assigned.These findings were reviewed with facility staff during the onsite investigation.
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Plan of Correction
Onboarding of three new FTE Counselors is in process. This is being completed by Human Resources and Behavioral Health Director.
All unassigned patients from three caseloads have been reassigned. All reassignments are being completed by a Clinical Supervisor.
Policy will be created by the Director of Accreditation and Licensing with input from Director of Behavioral Health on reassignment of caseloads after a staff resignation.
Currently, all counselors are at a 35:1 ratio. This will be monitored by Director of Behavioral Health.
To help with caseloads, Tadiso is offering counselors a wage differential of adding an additional 5 hours to their schedules, if they choose to take the wage differential for additional clinical work hours. Offer was given by Human Resources and Fiscal. 5 Counselors have opted to take the wage differential.
Tadiso rescinded the 55:1 exception with DDAP on 8.7.2026. Action completed by the Director of Accreditation and Licensing. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in seven of seven client records.Client #1 was admitted on November 26, 2025. The individual treatment plan dated January 9, 2026 stated that individual sessions were to be provided twice monthly. There were no sessions documented or scheduled for January, February, March, April and June 2026. One 15-minute session was documented on May 27, 2026. Client #1 was documented to be a no-show for sessions scheduled for July 8 and July 22, 2026.Client #2 was admitted on December 29, 2025. The individual treatment plan dated February 11, 2026, stated that 45 minutes of individual sessions were to be provided monthly. There were no sessions documented or scheduled for January, March, April, May and June 2026. One 37-minute session was documented on February 11, 2026. There were no additional sessions documented as scheduled.Client #3 was admitted on April 16, 2026. The individual treatment plan dated May 4, 2026, stated that counseling sessions were to be provided monthly. There were no sessions documented or scheduled for April, May and June 2026. There were no sessions documented in client record #3. There were no additional sessions documented as scheduled.Client #4 was admitted on December 11, 2025. The individual treatment plan dated January 9, 2026, stated that 30 minutes of individual sessions were to be provided bi- monthly. There were no sessions documented or scheduled for February, April and May 2026. 30-minute sessions were documented on January 9 and March 3, 2026. A 16-minute session was documented on June 5, 2026. There were no additional sessions documented as scheduled.Client #5 was admitted on December 5, 2025. The individual treatment plan dated December 31, 2025, stated that 1.5 hours of counseling were to be provided monthly. There were no sessions documented or scheduled for May and June 2026. One 30-minute session was documented on December 31, 2025. 16-minute sessions were documented on February 3, 18 and April 3, 2026. Client #5 was documented to be a no-show for sessions scheduled for January 20, 27 and March 20, 2026.Client #6 was admitted on December 12, 2025, discharged on April 22, 2026, and then re-admitted on May 4, 2026. The individual treatment plan dated January 9, 2026, stated that 2 - 30-minute individual counseling sessions were to be provided monthly. There were no sessions documented or scheduled for February, April and May 2026. Two 16-minute sessions were documented on January 9 and June 15, 2026. Client #6 was documented to be a no-show for sessions scheduled for March 6 and 14, 2026.Client #7 was admitted on February 10, 2026. The individual treatment plan dated March 11, 2026, stated that 1 hour of individual counseling was to be provided monthly. There were no sessions documented or scheduled for April, May and June 2026. One 30-minute session was documented on March 4, 2026. There were no additional sessions documented as scheduled.These findings were reviewed with facility staff during the onsite investigation.
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Plan of Correction
Director of Behavioral Health conducted a meeting on 8.6.2026 to re-review with counselors on how to properly document recommendations in the treatment plan under type and frequency of services that will include how many times the counselor's are to meet with the patient each month.
No Show Policy was re-reviewed by Director of Behavioral Health Services with the counselors to remind them that a no-show is documenting that the services were offered, but it is on the patient who is not attending as agreed upon and recommended from treatment plan.
Clinical Supervisors will monitor and discuss with counselors any concerns that they are having with patients in following agreed upon counseling services identified in the treatment plan, and if needed document in the patient's electronic health record the concerns.
During Quality Review checks by Policy Specialist on the electronic health records, treatment plan recommendations for counseling services will be verified against DAP notes or no show documentation in charts that are randomly reviewed, and shared with counselors and Clinical Supervisors.
Clinical Supervisors will discuss findings with counselors during individual sessions of the chart reviews. This action item will be placed on department meetings for review each month. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were provided on a regular and scheduled basis in seven of seven client records.Client #1 was admitted on November 26, 2025. There were no sessions documented or scheduled for January, February, March, April and June 2026. One 15-minute session was documented on May 27, 2026. Client #1 was documented to be a no-show for sessions scheduled for July 8 and July 22, 2026.Client #2 was admitted on December 29, 2025. There were no sessions documented or scheduled for January, March, April, May and June 2026. One 37-minute session was documented on February 11, 2026. There were no additional sessions documented as scheduled.Client #3 was admitted on April 16, 2026. There were no sessions documented or scheduled for April, May and June 2026. There were no sessions documented in client record #3. There were no additional sessions documented as scheduled.Client #4 was admitted on December 11, 2025. There were no sessions documented or scheduled for February, April and May 2026. 30-minute sessions were documented on January 9 and March 3, 2026. A 16-minute session was documented on June 5, 2026. There were no additional sessions documented as scheduled.Client #5 was admitted on December 5, 2025. There were no sessions documented or scheduled for May and June 2026. One 30-minute session was documented on December 31, 2025. 16-minute sessions were documented on February 3, 18 and April 3, 2026. Client #5 was documented to be a no-show for sessions scheduled for January 20, 27 and March 20, 2026.Client #6 was admitted on December 12, 2025, discharged on April 22, 2026, and then re-admitted on May 4, 2026. There were no sessions documented or scheduled for February, April and May 2026. Two 16-minute sessions were documented on January 9 and June 15, 2026. Client #6 was documented to be a no-show for sessions scheduled for March 6 and 14, 2026.Client #7 was admitted on February 10, 2026. There were no sessions documented or scheduled for April, May and June 2026. One 30-minute session was documented on March 4, 2026. There were no additional sessions documented as scheduled.These findings were reviewed with facility staff during the onsite investigation.
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Plan of Correction
During meeting on 8.6.2026, the Patient No-Show Policy was reviewed with the counselors by the Director of Behavioral Health Services.
Counselors are to document in the Plan section of DAP the note the next session date, time and length of session that was reviewed with the patient. Clinical Supervisors will randomly monitor charts for no show documentation.
Policy Specialist will also monitor no show documentation during the random checks of electronic health records, and communicate findings to Clinical Supervisors and counselors.
Counselors are then to document any no-show, call the patient, document that phone call or lack of answer form patient, place a hold and reschedule/check-in when the patient arrives at clinic.
This will be continually reviewed at Department meetings by the Director of Behavioral Health. |