INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 25, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Alpha House 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 inspection:
|
Plan of Correction
|
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.
|
Observations
Based on a review of staff records, the facility failed to ensure that staff persons received at least 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training within the first 2 years of employment in one of one applicable record.
Staff #5 was hired to the position of monitor on January 9, 2023 and was in this position at the time of review. Staff #5 was due to receive 4 hours of TB/STD and 6 hours of HIV/AIDS training no later than January 9, 2025. Staff #5 did not complete 4 hours of TB/STD and 6 hours of HIV/AIDS training as of the time of review.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility and Program Director met to discuss deficiency in trainings. Facility and Program Directors will develop and maintain a tracking system for employee evaluation due dates and will schedule dedicated time to review previous evaluations and ensure timely completion. Program Director has scheduled an onsite training for August 28th for staff to complete HIV/AIDS, TB/STD/Other that will be conducted by Program Director. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of administrative information, the facility failed to ensure CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operations.
Staff schedules were reviewed from May 18, 2026 through June 24, 2026.
The following dates and times did not have staff people who were CPR certified or trained in first aid:
May 19, 2026 from 10pm to 12am
May 20, 2026 from 12am to 7:30am, 5pm to 12am
May 21, 2026 from 12am to 7:30am, 10pm to 12am
May 22, 2026 from 12am to 9am
May 23, 2026 from 9am to 5pm
May 26, 2026 from 10pm to 12am
May 27, 2026 from 12am to 7:30am, 5pm to 12am
May 28, 2026 from 12am to 7:30am, 10pm to 12am
May 29, 2026 from 12am to 9am
May 30, 2026 from 9am to 5pm
June 2, 2026 from 10pm to 12am
June 3, 2026 from 12am to 7:30am, 5pm to 12am
June 4, 2026 from 12am to 7:30am, 10pm to 12am
June 5, 2026 from 12am to 9am
June 6, 2026 from 9am to 5pm
June 9, 2026 from 10pm to 12am
June 10, 2026 from 12am to 7:30am, 5pm to 12am
June 11, 2026 from 12am to 7:30am, 10pm to 12am
June 12, 2026 from 12am to 9am
June 13, 2026 from 9am to 5pm
June 16, 2026 from 10pm to 12am
June 17, 2026 from 12am to 7:30am, 5pm to 12am
June 18, 2026 from 12am to 7:30am, 10pm to 12am
June 19, 2026 from 12am to 9am
June 20, 2026 from 9am to 5pm
June 23, 2026 from 10pm to 12am
June 24, 2026 from 12am to 7:30am, 5pm to 12am
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Facility Director, Project Director and RSS Supervisor have meet to discuss the deficiency in CPR/First Aid training. Schedules were updated to ensure someone trained will be on shift. Remaining staff that have not been trained have been scheduled for training. Facility and Project Director will review CPR/First Aid quarterly to ensure compliance. Facility and Program Directors will ensure that no staff untrained in CPR/First Aid will be on shift alone. Schedules will be reviewed weekly to ensure that staff is not on shift without training. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the fire drill log, the facility failed to conduct fire drills at least once a month.
The fire drill log was reviewed from March 2025 through May 2026. No fire drills were completed for the following months: August 2025, September 2025, November 2025, December 2025, January 2026, February 2026, and May 2026.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Facility Director, Project Director and RSS Supervisor have meet to discuss the deficiency and how fire drills need to be conducted per DDAP regulations. Fire Drills will be conducted at least once a month. Facility Director will review fire drill logs by the 20th of the month and if one was not completed, it will be conducted unannounced before the end of the month.
|
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of the fire drill log, the facility failed to ensure that a fire drill was conducted during sleeping hours at least every 6 months.
The fire drill log was reviewed from March 2025 through May 2026. A fire drill was conducted during sleeping hours on March 14, 2025. The next fire drill during sleeping hours was due to be conducted on or before September 2025. The next fire drill during sleeping hours was conducted on April 12, 2026.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Facility Director, Project Director and RSS Supervisor have meet to discuss the deficiency and how fire drills need to be conducted per DDAP regulations. Fire Drills will be conducted at least once every 6 months during sleeping hours. Facility Director will review fire drill logs to ensure that a fire drill has been completed during sleeping hours. Facility and Project Directors will meet review logs quarterly to monitor if a drill was completed and if not, ensure that one is completed before the next review. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on a review of staff records, the facility failed to ensure an annual written individual staff performance evaluation was reviewed and signed by the employee in one of one applicable record.
Facility policy and procedure states that Annual performance evaluations are completed in annually in June and December.
Staff #3 was hired to the position of counselor on January 31, 2022 and was in this position at the time of review. Staff #3 had an annual performance evaluation completed December 7, 2024, however no performance evaluations were completed for Staff #3 in 2025.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Facility and Program Director completed all updated performance evaluations in July of 2026. Performance evaluations will be completed regularly in June and December every year. Facility and Program Directors will completed all performance evaluations and submit to HR consultants by the end of June and December each year. Facility and Program Directors will develop and maintain a tracking system for employee evaluation due dates and will schedule dedicated time to review previous evaluations and ensure timely completion. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
|
Observations
Based on a review of administrative information, the facility failed to provide documentation of inspection of storage areas that ensures compliance with state and federal regulations and program policy.
The facility's policy and procedure manual states the inspection of storage areas should be done quarterly. Medication storage area inspection logs were requested from July 2025 through May 2026, however the facility was unable to provide any medication storage area inspection documentation.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Facility Director will complete an updated policy regarding inspections and logs that will be kept in a binder in the facility Directors office by August 31st. Facility Director is working with the facilities staff to ensure that the policy meets DDAP standards and can be implemented immediately. Medication and facilities inspections will be completed by the Facilities Manager and/or Directors by August 31, 2026 and quarterly moving forward. Facility and/or Program Director will review records bi-monthly to ensure inspections are completed and/or will be completed. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project in one of two applicable records.
Client #4 was admitted to the inpatient level of care on March 20, 2026 and discharged March 25, 2026.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director met with clinical staff to address the deficiency on maintaining up to date client charts. Program Director will work on developing checklists for intake and discharge to ensure all necessary documents are completed by 8/31/2026.
Facility Director has directed clinical staff to notify client's in writing within 72 hours of being involuntarily terminated from the program. Facility Director will follow up with assigned counselor to ensure documentation was completed before the 72 hour window closes. |
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
|
Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against medical advice in one of one applicable record.
The facility's policy and procedure manual states the client ' s emergency contact will be notified within 24 hours of a client leaving against medical advice.
Client #5 was admitted to the inpatient level of care on January 1, 2026 and discharged on April 12, 2026.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
All Alpha House staff will be trained on how to make follow up calls to emergency contacts and document them in order to meet the requirements. Facility Director and Supervisors will ensure that calls are made, documented, and all staff are aware that calls are to be made within 24 hours regardless of it being a weekday or weekend. Facility Director will follow up after discharges to ensure that the calls are made and documented whether in the clients EHR chart or a paper document noting the attempt. |
709.52(a)(3) LICENSURE Support service type
709.52. 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:
(3) Proposed type of support service.
|
Observations
Based on a review of client records, the facility failed to ensure that individual treatment and rehabilitation plans include proposed types of support services in two of six applicable records.
Client #3 was admitted to the inpatient level of care on April 22, 2026 and was active at the time of review. Client #3 ' s comprehensive treatment plan was completed April 22, 2026. No support services were included in client #3 ' s comprehensive treatment plan.
Client #5 was admitted to the inpatient level of care on January 1, 2026 and was discharged April 12, 2026, Client #5 ' s comprehensive treatment plan was completed on January 7, 2026. No support services were included in client #5 ' s comprehensive treatment plan.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director met with the clinical staff regarding the lack of support services. Facility Director will continue to train clinical staff on appropriate treatment planning. Clinical Director will review treatment plans with staff when a client as first admitted and when treatment plans are updated before co-signing off on the treatment plan to ensure that support services are included. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 30 days in three of six applicable records.
Client #2 was admitted to the inpatient level of care on May 20, 2026 and was active at the time of review. Client #2's record contained a treatment plan update dated May 20, 2026. The next treatment plan update was due no later than June 20, 2026; however, no further treatment plan updates were completed for client #2.
Client #5 was admitted to the inpatient level of care on January 1, 2026 and was discharged April 12, 2026. Client #5's record contained a treatment plan update dated February 7, 2026. The next treatment plan update was due no later than March 9, 2026; however, the next treatment plan update was not completed until March 10, 2026.
Client #6 was admitted to the inpatient level of care on January 14, 2026 and was discharged April 6, 2026. Client #6 ' s record contained a treatment plan update dated February 14, 2026. The next treatment plan update was due no later than March 16, 2026; however, the next treatment plan update was not completed until March 18, 2026.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 11, 2025 annual licensing inspection.
|
Plan of Correction
Facility Director met with with the clinical staff regarding treatment plan compliance. Facility Director will check treatment plan update dates weekly and send reminders to staff a week prior to a review and then follow up the day before and day of the review to ensure that the treatment plan has been updated and signed. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 ensure there was a complete client record, which includes case consultations notes, in four of six applicable records.
Facility policy and procedure states that a case consultation is to be completed once for every month the client is in treatment.
Client #1 was admitted to the inpatient level of care on March 23, 2026 and was active at the time of review. No case consultation notes were found in Client #1 ' s record for April 2026 or May 2026.
Client #5 was admitted to the inpatient level of care on January 1, 2026 and was discharged April 12, 2026. No case consultation note was found in Client #5 ' s record for February 2026.
Client #6 was admitted to the inpatient level of care on January 14, 2026 and was discharged April 6, 2026. No case consultation note was found in Client #6 ' s record for February 2026.
Client #7 was admitted to the inpatient level of care on November 13, 2025 and was discharged March 10, 2026. No case consultation notes were found in Client #7 ' s record for January 2026 or February 2026.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 11, 2025 annual licensing inspection.
|
Plan of Correction
Facility Director met with the clinical staff to address the deficiency of missing case consultations not being documented for clients. Facility Director will review client files biweekly to ensure that case consults are present in client files. If they are not present, Facility Director will address with Counselor to be input immediately. Facility Director will keep a log of what date cases were presented and check the EHR to ensure that the documentation occurred. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 ensure there is a complete client record which includes follow-up information in four of four applicable records.
Facility policy and procedure states that follow-up information is to be acquired within 24 to 48 hours post discharge, and documentation of this call must be completed in the client record.
Client #4 was admitted to the inpatient level of care on March 20, 2026 and was discharged March 25, 2026. The client record did not contain any follow-up information at the time of review.
Client #5 was admitted to the inpatient level of care on January 1, 2026 and was discharged April 12, 2026. The client record did not contain any follow-up information at the time of review.
Client #6 was admitted to the inpatient level of care on January 14, 2026 and was discharged April 6, 2026. The client record did not contain any follow-up information at the time of review.
Client #7 was admitted to the inpatient level of care on November 13, 2025 and was discharged March 10, 2026. The client record did not contain any follow-up information at the time of review.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director met with the clinical team regarding the current policy in place. It was noted that sometimes discharges occur on weekends and the calls are missed. The policy has been updated to reflect calls within 72 hours of discharge to account for weekends so that the clinical team can review discharge and make any necessary phone calls that were not completed. Facility Director and clinical team will review discharge paperwork and ensure that phone calls are made and documented in the EHR. Facility Director will implement a discharge checklist to be reviewed by Facility Director within 48 hours of client's discharge to ensure that the follow up call was made and documented. |