INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Trehab 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, the facility failed to ensure that one applicable employee received a minimum of 4 hours of TB/STD training using a department approved curriculum within the regulatory timeframeEmployee #4 has been in the position of counselor since December 30, 2024 and was current in that position at time of licensing process. Employee # 4 was due to have the communicable disease training no later than December 30, 2025; however, the TB/STD training was not completed as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility acknowledges that one counselor (Employee #4) did not complete the required minimum hours of tuberculosis/sexually transmitted disease training using a department-approved curriculum within the regulatory timeframe. Employee #4 has been scheduled to complete the required TB/STD training on February 24, 2026, and documentation of completion will be maintained in the employee's personnel file.
To prevent recurrence, the facility will implement ongoing monitoring of staff training requirements and deadlines. Required communicable disease trainings will be reviewed at hire and tracked regularly by supervisory staff to ensure all counselors complete mandated trainings within required timeframes and that documentation is maintained |
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.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the person, agency, or organization to whom disclosure is made to in one of seven client records reviewed.Client #4 was admitted to outpatient program on May 19, 2025 and discharged on July 31, 2025. A release of information form was completed on May 19, 2025, that only identified "Emergency contact", it did not include the name of person, agency, or organization of the emergency contact. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the program will ensure that all Release of Information (ROI) forms include the specific name of the person, agency, or organization to whom information may be disclosed. Generic identifiers such as "emergency contact" will no longer be accepted.
All clinical and intake staff will be re-educated on confidentiality requirements and proper completion of ROI forms during staff meeting on 2/04/2026.
To prevent recurrence, supervisory staff will review ROI forms at intake and during routine chart audits to ensure compliance. The Program Director and quality management coordinator will monitor ongoing adherence and address any deficiencies promptly.
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