INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 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, MCP/Caring Together 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 written individual training plans were developed for each employee, with input from both the employee and the supervisor, in three of five applicable personnel records reviewed.Employee # 1 was hired as the project director and facility director on January 23, 2017. There was no individual training plan documented in the personnel record at the time of the inspection. Employee # 2 was hired as a clinical supervisor on September 1, 2024. The individual training plan was completed on May 2, 2025, but there was no documentation indicating there was any input from both the employee and the supervisor. Employee # 3 was hired as a counselor on May 8, 2023. The individual training plan was completed on May 2, 2025, but there was no documentation indicating there was any input from the supervisor.This is a repeat citation from the March 10, 2025 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to ensure that training plans are developed, signed and filed in a timely manner, a Training Plan date will be scheduled annually during the month of May. Upon completions of the training plan, the supervisor will review individually with the staff person. Once the review is completed, the document will be signed by the supervisor and filed in the staff persons' individual binder. The supervisor will be responsible for managing the binder.
The Clinical Supervisor will review the training files of the employees who had deficiencies. All employees had completed the Training Plan in a timely manner; however the plans were not accurate filed. This review will be corrected by May 26, 2026. |
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 all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in two of two applicable personnel records reviewed. Employee # 3 was hired as a counselor on May 8, 2023 and was due to complete the HIV/AIDS training and the TB/STD training no later than May 8, 2024. There was no documentation indicating the TB/STD training was completed as of the date of the inspection.Employee # 4 was hired as a counselor on April 22, 2024 and was due to complete the HIV/AIDS training and the TB/STD training no later than April 22, 2025. There was no documentation indicating the HIV/AIDS training was completed as of the date of the inspection.This is a repeat citation from the March 10, 2025 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff in question completed the training however was unable to provide a certificate, as they failed to complete the mandatory evaluation of the training.
Going forward, staff will notify the supervisor of completion of the training, and the supervisor will ensure that the evaluation is completed in a timely manner. Upon completion of the training, and the evaluation, the certificate will be issued. A copy of the certificate will be placed in the individual's training binder.
After reviewing the scheduled trainings, it has been determined that the employee engaged in the training and did not complete the survey/evaluation. Completion of the survey/evaluation is mandatory in order to receive the certificate. This employee has been rescheduled to engage in the training next month and is aware that the survey/evaluation must be completed in a timely manner. A copy of the certificate will be submitted to the Clinical Supervisor to be placed in the training file. |
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 that the project director and facility director completed at least 12 clock hours of training annually during the facility's July 1, 2024 through June 30, 2025 training year in one of one applicable personnel record reviewed.Employee # 1 was hired as the project director and facility director on January 23, 2017. The personnel record documented 0 hours of training received during the training year reviewed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director/Facility Director will use the Training Binder, as will the other staff. This will ensure that the training documentation is filed appropriately. The Project Director engages in trainings almost monthly. This binder will be reviewed monthly by the Clinical Supervisor.
During the first week of employment, new hires will be provided with the list of mandatory trainings. The Clinical Supervisor will assist the employee with registering for the mandatory trainings.
At the start of the workday, the staff engage in a brief morning huddle. During this huddle, staff will announce any trainings scheduled for that day. During the following day's huddle, the Clinical Supervisor will follow-up with obtaining the certificate, to be filed in the training binder.
The training binder will be reviewed monthly during a Supervision session. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's July 1, 2024 through June 30, 2025 training year in one of three applicable personnel record reviewed.Employee # 5 was hired as a counselor on December 20, 2019. The personnel record documented 1.5 hours of training received during the training year reviewed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor was educated on the need to ensure that all Counselors engage in the required 25 hours of training, regardless of full-time or part-time status. The Clinical Supervisor is directed to include part-time counselors in monthly review of their Training Binders.
The Clinical Supervisor and Program Director will continue to inform staff of upcoming trainings via emails and during meetings. Staff will be informed of the trainings that are recommended and trainings that management feel are warranted to enhance skills/increase knowledge of current topics. Upon registering for trainings, the employee will provide the date and time of the scheduled training. The morning of the training, the employee will inform the Clinical Supervisor of the time of engagement. The Clinical Supervisor will obtain the certificate of completion to file in the Training Binder.
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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 personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure the Full Time Equivalent (FTE) counselor caseload in outpatient programs did not exceed 35 active clients in one of five applicable personnel records reviewed.The counselor FTE is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.Employee # 2 was hired as a clinical supervisor on September 1, 2024. The employee's counselor caseload calculation was as follows: 30/40 = 0.75 (FTE); 29/0.75 = 38.6666, which equals to a client/counselor FTE ratio of 38:1.This is a repeat citation from the March 10, 2025 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency is a result of not reviewing the current census before assigning the new participants admitted to the program. The formula for determining the number of participants assigned on a caseload was not used. This has been reviewed with the Clinical Supervisor and going forward assigning participants to the caseload will be conducted appropriately.
The Clinical Supervisor and Program Director met on 5/11 to adjust the caseload. We will continue to monitor this issue to ensure that the ration is being used accurately. |
711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for failing to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days was submitted and approved by the Department for the March 29, 2023, October 10, 2023, March 11, 2024, November 22, 2024, and March 10, 2025 licensing inspections. Failing to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days was again found to be a deficiency in the March 25, 2026 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Program Director will review approved Plan of Corrections monthly during a supervision session. The review will document progress/lack of progress. Issues of non-compliance will be addressed, to include increase is reviews/trainings.
These reviews will begin on 6/1/26 |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client in six of seven client records reviewed.Client # 1 was admitted on August 12, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 11, 2025; however, there was no documentation that the treatment plan was developed with the client. Client # 3 was admitted on September 8, 2025 and was still active at the time of the inspection. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection. Client # 4 was admitted on July 3, 2025 and was discharged on November 17, 2025. The individual treatment and rehabilitation plan was completed on August 3, 2025; however, there was no documentation that the treatment plan was developed with the client. Client # 5 was admitted on August 28, 2025 and was discharged on February 16, 2026. The individual treatment and rehabilitation plan was completed on September 26, 2025; however, there was no documentation that the treatment plan was developed with the client. Client # 6 was admitted on September 29, 2025 and was discharged on December 23, 2025. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection. Client # 7 was admitted on July 23, 2025 and was discharged on February 23, 2026. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will edit the Treatment Plans to provide an area that notes that the plan was developed with the client. Counselors will engage in a training to ensure that the development of the Treatment Plan is with the client and that it is noted on the document.
The Clinical Supervisor will review the treatment plans to ensure that this is occurring. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) 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 four applicable client records reviewed.Client # 4 was admitted on July 3, 2025 and was discharged on November 17, 2025. The individual treatment and rehabilitation plan was completed on August 3, 2025 and the next update was due no later than October 3, 2025; however, the update was not completed prior to discharge.Client # 5 was admitted on August 28, 2025 and was discharged on February 16, 2026. A treatment plan update was completed on November 26, 2025 and the next update was due no later than January 26, 2026; however, the update was not completed at the time of discharge.This is a repeat citation from the March 29, 2023, October 10, 2023, March 11, 2024, November 22, 2024, and March 10, 2025 licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will continue to offer trainings regarding Treatment Plans. The upcoming training will stress the need for counselors to complete the Update Treatment Plans a minimum every 60 days. The training will emphasize the need to complete the treatment plan whether the participant is engaged and that as long as the participant remains on the active census, the Treatment Plan must be completed. The review of the documents will include ensuring that the counselors noted that the plans were developed with the client.
The Clinical Supervisor will monitor treatment plans during supervisory sessions. |
711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i) Confidentiality of client identity and records.
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Observations
Based on a review of client records, the facility failed to maintain the confidentiality of client identity and records by not following procedures pertaining to how the project plans to address the security and release of electronic records.Client # 5 was admitted on August 28, 2025 and was still active at the time of the inspection. During the client record review, there was documentation pertaining to another client filed within client # 5's record.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will meet with the clerical staff to review the need to ensure the accuracy of filing documents in the correct record.
The policy will be reviewed with those staff members responsible for filing documents in the appropriate record.
The Clinical Supervisor will review the records to ensure that there are no documents in the incorrect file and that the confidentiality of the client identity is maintained. |