INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Bucks County Treatment Solutions 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 and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff completed a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health topics training within the regulatory time frame in one of one personnel record reviewed.
Employee #1 was hired as the project director/facility director on January 1, 2024. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than January 1, 2026. There was no documentation in the personnel record indicating either course was completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 will be immediately enrolled in the required HIV/AIDS and TB/STD training courses. All required training will be completed no later than March 30th, 2026. Documentation of completed training certificates will be obtained and placed in the employee's personnel file.
The facility will implement a training tracking system to monitor all required staff trainings and due dates. Facility Director will be responsible for maintaining and reviewing training compliance on a monthly basis.
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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.
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Observations
Based on a review of personnel records, 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.
At the time of the inspection, there was no documentation provided indicating any currently employed staff persons were certified in CPR and trained in first aid.
This is a repeat citation from February 24, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All employees will be immediately enrolled in the required CPR/ First Aid training courses. All required training will be completed no later than March 30th, 2026. Documentation of completed training certificates will be obtained and placed in the employee's personnel file.
The facility will implement a training tracking system to monitor all required staff trainings and due dates. Facility Director will be responsible for maintaining and reviewing training compliance on a monthly basis.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director and facility director completed at least 12 clock hours of annual training during the facility's January 1, 2025 through December 31, 2025 training year.
Employee #1 was hired as the project director and facility director on January 1, 2024. There were 0 hours of annual training documented in the personnel record for the training year reviewed.
This is a repeat citation from February 24, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director employee file will be updated. All required training will be completed no later than March 30th, 2026. Documentation of completed training certificates will be obtained and placed in the employee's personnel file.
The facility will implement a training tracking system to monitor all required staff trainings and due dates. Facility Director will be responsible for maintaining and reviewing training compliance on a monthly basis. |
704.12(a)(1)(ii) LICENSURE On Call Physician
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.
(1) Inpatient nonhospital detoxification (residential detoxification).
(ii) There shall be a physician on call at all times.
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Observations
Based on a review of personnel records and the Staffing Requirement Facility Summary Report, the facility failed to ensure there was a physician on call at all times for the inpatient nonhospital detoxification activity.
At the time of the inspection, there were no active clients reported; however, there was no documentation provided indicating if a physician was on call in the event the facility admitted clients into the inpatient nonhospital detoxification activity.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will secure a licensed physician prior to accepting clients to provide on-call coverage for the inpatient nonhospital detoxification activity. A written on-call agreement will established to ensure physician availability 24 hours per day, 7 days per week, including periods when clients may be admitted.
Facility Director will review the on-call schedule weekly to confirm continuous physician coverage. Documentation will be maintained and made available for review during inspections. |
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.
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Observations
Based on a review of the facility's January 2025 through December 2025 fire drill logs, the facility failed to ensure unannounced fire drills were conducted at least once a month
At the time of the inspection, there was no documentation indicating any monthly fire drills were conducted during the entire reviewed period.
This is a repeat citation from February 24, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the facility has initiated monthly unannounced fire drills. A fire drill for the current month has been conducted (or will be conducted) and properly documented, including date, time, staff participation, and outcomes. A standardized fire drill log form has been implemented to ensure consistent documentation.
Facility director will review fire drill documentation monthly to ensure compliance. Additionally, a quarterly audit will be conducted to verify that all required drills have been completed and documented. Any missed drills will be addressed immediately with corrective action. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for the completion of an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will obtain audit from accountant. Completed audit report will be maintained on file.
Facility Director will monitor compliance with the annual audit requirement by tracking contract execution and audit completion dates. Documentation will be reviewed annually and maintained for inspection. Any delays or issues will be addressed immediately to ensure continued compliance. |
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.
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Observations
Based on the review of personnel records, the facility failed to ensure an annual written individual staff performance evaluation was completed, reviewed, and signed by the employee in one of one personnel record reviewed.
Employee # 1 was hired as the project director and facility director on January 1, 2024. There was no annual performance evaluation documented in the personnel record at the time of the inspection.
This is a repeat citation from February 24, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An annual performance evaluation for Employee #1 will be completed immediately. The evaluation will be reviewed with the employee, signed by both the supervisor and the employee, and placed in the personnel file.
The Facility Director and/or designee will review personnel records on a monthly basis to ensure all required performance evaluations are completed on time. A log will be maintained to track completion dates and ensure ongoing compliance. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review, the project failed to maintain a data collection and record keeping system that allows for the efficient retrieval of data needed to measure the project's performance in relations to its stated goals and objectives.
Leading up to and during the inspection, requested documentation required for the inspection was not submitted to the Licensing Representative in a timely manner.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will conduct monthly reviews of the record-keeping system to ensure documents are current, complete, and easily retrievable. Periodic internal audits will be conducted to verify compliance with documentation and reporting requirements, and corrective actions will be taken as needed. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of the policy and procedure manual, the facility failed to include written procedures, within their medication policy for medications used by clients, the administration of medication by individuals permitted to administer by Pennsylvania law.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will revise its medication management policy and procedures to include clear, written guidelines specifying who is authorized to administer medications in accordance with Pennsylvania law. The updated policy will outline roles, responsibilities, and scope of practice for all staff involved in medication administration.
The Facility Director and/or Medical Director will conduct periodic audits (at least quarterly) of medication administration practices and policy compliance. Policy reviews will be conducted annually, or more frequently as regulations change, to ensure continued compliance. |
709.34 (c) (3) 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:
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
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Observations
Based on a review of the facility's unusual incident logs and a discussion with facility staff, the facility failed to file a written unusual incident report with the Department within 3 business days following a significant disruption of services due to a disaster such as fire, storm, flood, or other occurrence that results in the closure of the facility for more than 1 day.
The facility had discharged/referred all then-active clients and ceased operations as of September 20, 2024. As of the date of the inspection, there was no documentation indicating the temporary facility closure was reported to the Department.
This is a repeat citation from February 24, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will immediately submit, a written unusual incident report to the Department documenting the temporary closure and all actions taken, including the discharge/referral of clients. Documentation of the submission will be maintained in the facility records.
Facility Director will maintain a log of all unusual incidents and closures, including submission dates of reports to the Department, to ensure compliance with reporting requirements. Monthly audits of the log will be conducted to verify timely reporting. |