INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 13, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Minsec Treatment LLC 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure a written individual training plan was developed for each employee with the input of both the employee and the supervisor, in two of six applicable personnel records reviewed.
Employee # 1 was hired as the project director on July 9, 2020. The individual training plan was completed on December 17, 2025; however, there was no documentation in the personnel record indicating the training plan was developed with the supervisor.
Employee # 2 was hired as the facility director on March 27, 2015. The individual training plan was completed on January 13, 2026; however, there was no documentation in the personnel record indicating the training plan was developed with the supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and Project Director met on 5/14/2026 to discuss Individual Training Plan requirements.
Project Director will sign and return Facility Director's ITP on 5/27/2026. Project Director will have his supervisor sign off on his ITP and forward it Facility Director on 5/27/2026.
Project Director and Facility Director will complete ITP via Zoom meeting in the event an in person meeting is not available. ITP will be emailed to supervisors for their signatures. Date of the ITP will be set up and added to the calendar. |
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 provide CPR certification and first aid training 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, facility staff provided documentation of current CPR certification and first aid training for employee #4 only. Employee #4 works Monday through Firday from 10:00am to 6:00pm; however, the facility's hours of operation are Monday through Thursday 8:00am to 7:30pm and Friday 8:00am to 5:00pm.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director met with the staff to review citations.
Facility Director will set up and pay for all staff to acquire CPR training by 6/30/2026.
Facility Director will monitor all required trainings at least once per quarter to assure compliance. This will include CPR training. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all stairways, hallways, and exits from rooms and from the nonresidential facility were unobstructed.
At the time of the inspection, conducted on May 13, 2026 at approximately 12:45 p.m., the rear exit stairwell was obstructed by a large garbage dumpster.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director met with the owner and the manager of the stores in regards to their dumpster and food truck blocking our exit. Dumpster was removed on 5/14/2026. Truck was removed the same day as the audit.
Facility Director or designee will inspect the back area at opening, during the afternoon and at closing daily to assure the area is not blocked. A checkoff list will be created for this task by 6/30/2026. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document the short and long-term goals for treatment, formulated by both staff and client, on the individual treatment and rehabilitation plan in seven of seven client records reviewed.
At the time of the inspection, the individual treatment and rehabilitation plan documented in every client record reviewed did not include documentation indicating the client's long-term goals for treatment.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director held a staff meeting will all staff in regards to citations to include but not limited to treatment planning goal.
Facility Director will review master treatment plans prior to signing.
Facility Director will coach staff as needed who may be in violation of this POC |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in two of six applicable client records reviewed.
Client # 2 was admitted on November 17, 2025 and was still active at the time of the inspection. A treatment plan update was completed on February 3, 2026 and the next update was due no later than April 3, 2026; however, the update was not completed at the time of the inspection.
Client # 3 was admitted on October 3, 2025 and was still active at the time of the inspection. A treatment plan update was completed on March 3, 2026 and the next update was due no later than May 3, 2026; however, the update was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director held a staff meeting will all staff on 5/15/2026 in regards to citations to include but not limited to treatment plan updates.
Client #2 and Client #3 treatment plans were updated on 5/14/2026
Facility Director or designee will review 5 random charts per week of participant who have been engaged in treatment for 60 days to assure updates are completed
Facility Director will coach staff as needed who may be in violation of this POC |
709.93(a)(5) LICENSURE Client records
709.93. 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of progress notes, in five of seven client records reviewed.
Client # 1 was admitted on October 15, 2025 and was still active at the time of the inspection. The record of service indicated there was an individual session completed on January 20, 2026, and individual and group counseling sessions completed on February 3, 2026, and February 10, 2026; however, there were no corresponding progress notes documented in the record for any of the sessions.
Client # 2 was admitted on November 17, 2025 and was still active at the time of the inspection. The record of service indicated there were individual and group sessions completed on February 5, 2026, February 26, 2026, March 12, 2026, March 26, 2026, and May 7, 2026; however, there were no corresponding progress notes documented in the record for any of the sessions.
Client # 3 was admitted on October 3, 2025 and was still active at the time of the inspection. The record of service indicated that there were individual and group sessions completed on February 4, 2026, February 11, 2026, February 18, 2026, March 4, 2026, March 11, 2026, March 20, 2026, March 25, 2026, April 1, 2026, and April 30, 2026; however, there were no corresponding progress notes documented in the record for any of the sessions.
Client # 4 was admitted on August 21, 2025 and was discharged on February 17, 2026. The record of service indicated that there were individual counseling sessions completed on December 3, 2026, December 8, 2026, December 15, 2026, December 23, 2026, December 29, 2026, January 5, 2026, January 12, 2026, January 28, 2026, February 6, 2026, February 10, 2026, and February 17, 2026; however, there were no corresponding progress notes documented in the record for any of the sessions.
Client # 7 was admitted on September 22, 2025 and was discharged on February 13, 2026. The record of service indicated that there were group counseling sessions completed on October 2, 2025, October 9, 2025, October 16, 2025, October 23, 2025, October 30, 2025, November 6, 2025, November 20, 2025, December 4, 2025, December 11, 2025, and January 23, 2026; however, there were no corresponding progress notes documented in the record for any of the sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director held a staff meeting will all staff on 5/15/2026 in regards to citations to include but not limited to documentation of progress note
Program Counselors will hand in notes daily to Facility Director. Facility Director or designee will review 5 random charts per week days to assure progress notes are completed
Facility Director will coach staff as needed who may be in violation of this POC |