INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on July 20, 2026 through July 22, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Eagleville Hospital 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on an administrative review, the facility failed to present a plan documenting the qualifications and training of staff to the Department licensing representatives at the time of the project's site visit.
At the time of the inspection, facility staff was unable to produce a completed Staffing Requirements Facility Summary Report, which documents the staff qualifications and trainings. On the staffing report, there were several individuals initially identified as counselors that were later determined to be clinical supervisors. Additionally, those individuals had incorrect hire dates for their current clinical supervisor position as the correct hire dates were not identified until a full review of the personnel records was completed by the Licensing Representative. Also, on the hospital rehabilitation activity caseload page, the current patient census is incorrectly documented, as well as the accurate number of clients on each counselor's caseload. Even after the Licensing Representative provided technical assistance on several occasions and requested corrections, the staffing report was still not corrected with the accurate information at the conclusion of the licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will maintain a current Staffing Requirements Facility Summary Report in accordance with DDAP requirements.
Corrective Action - Compliance and Human Resources will create and maintain the 2027 staffing report.
Counseling Leadership will update the report as staffing changes occur, with the exception of medical, which will be completed by compliance, including employee separations and counselor caseload assignments. The last two tabs of the report will be maintained and retained to ensure current and historical information is available.
Monitoring - Compliance, Human Resources, and Counseling Leadership will review the report periodically to ensure it remains current and accurate so that by the time we have to upload for DDAP presubmission, all employees/trainings/schedules are accounted for. Updated report will be maintained and available for review upon request.
Expected Outcome - The facility will maintain 100% compliance with staffing and caseload reporting requirements through ongoing review and timely updates of the staffing report. The 2027 report will be submitted without duplicative errors. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors, who have not functioned for 2 years as supervisors in the provision of clinical services, completed a core curriculum in clinical supervision in two of eight applicable personnel records reviewed.
Employee # 10 was hired as a clinical supervisor on August 5, 2025 with no documentation of clinical supervision experience prior to being hired. The core curriculum in clinical supervision training was not completed until April 16, 2026.
Employee # 11 was hired as a clinical supervisor on July 22, 2025 with no documentation of clinical supervision experience prior to being hired. The core curriculum in clinical supervision training was not completed until June16, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that all Clinical Supervisors and Lead Counselors who have been in their supervisory role for less than two (2) years complete the required core curriculum in clinical supervision.
Corrective Action - Effective immediately, Counseling Leadership will enroll newly appointed Clinical Supervisors: Clinical Managers, Clinical Leads, and Senior Therapists, in the required supervisor training curriculum or ensure its completion onsite. All required clinical supervision training will be completed within the first four (4) weeks of assuming a supervisory role. Documentation of completed training will be maintained by Counseling Leadership.
Monitoring - Counseling Leadership will develop and maintain a supervisor training tracking log to monitor completion of required training. Training records and tracking logs will be maintained in facility drives and will be available for review upon request. Counseling Leadership will review supervisory staff records periodically to ensure training requirements are met.
Expected Outcome - The facility will maintain 100% compliance with supervisory training requirements by ensuring all new Clinical Supervisors and Lead Counselors complete the required core curriculum in clinical supervision within two weeks of assuming their supervisory responsibilities. The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure clinical supervisors participated in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position in two of ten applicable personnel records reviewed.
Employee # 52 was hired as a clinical supervisor on November 23, 2024. There was no documentation in the record indicating monthly meetings with their supervisor were held during the months of December 2025 and January 2026.
Employee # 54 was hired as a clinical supervisor on April 11, 2023. There was no documentation in the record indicating monthly meetings with their supervisor were held during the months of April 2023 and May 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that newly hired/promoted Counseling Supervisors receive and document clinical supervision during their first six (6) months of employment in their supervisory position.
Corrective Action - Effective immediately, Counseling Leadership will create a supervision tracking log for all newly hired/promoted Counseling Supervisors. Clinical supervision sessions will be documented throughout the employee's first six months in their new role. Supervision records will be maintained and readily accessible through facility database.
Monitoring - Counseling Leadership will review supervision tracking logs monthly to ensure required supervision is occurring and documented. Documentation will be maintained in the employee's HR file and will be available for review upon request.
Expected Outcome - The facility will maintain 100% compliance with clinical supervision requirements by ensuring supervision is provided, documented, tracked, and retained for all newly hired/promoted Counseling Supervisors during their first six months of employment. The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
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 plan being appropriate to that employee's skill level and developed annually with input from both the employee and the supervisor, in five of fifty-three applicable personnel records reviewed.
Employee # 17 was hired as a counselor on May 27, 2025. There was no current individual training plan documented in the personnel record at the time of the inspection.
Employee # 18 was hired as a counselor on March 17, 2025. The individual training plan was completed by the employee on June 20, 2026, however, there was no documentation indicating the training plan was also developed with input from the supervisor.
Employee # 24 was hired as a counselor on October 14, 2024. There was no current individual training plan documented in the personnel record at the time of the inspection.
Employee # 40 was hired as a counselor on September 2, 2025. The individual training plan was completed by the employee on September 2, 2025, however, there was no documentation indicating the training plan was also developed with input from the supervisor.
Employee # 48 was hired as a counselor on April 15, 2024. There was no current individual training plan documented in the personnel record at the time of the inspection.
This is a repeat citation from the July 31, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
Effective immediately, the facility will ensure all employees have an individualized training plan completed during orientation and reviewed annually as part of the employee evaluation process. Training plans will be appropriate to the employee's position and skill level and will include documented input from both the employee and supervisor.
Corrective Action for Employees Identified:
The facility will immediately correct the deficiencies identified for Employees #17, #18, #24, #40, and #48.
Employees #17, #24, and #48: An individualized training plan will be completed with input from the employee and supervisor and placed in the personnel record.
Employees #18 and #40: The existing training plans will be reviewed with the employee and supervisor, and supervisor input will be documented. The plans will be updated as necessary.
The facility will verify that all five identified employees have compliant training plans documented in their personnel records.
Monitoring:
HR and/or the employee's supervisor will maintain training plans in the personnel file. HR will conduct an initial review of the identified employees' records and quarterly audits thereafter to verify that training plans are completed, include employee and supervisor input, and are reviewed annually.
Any identified deficiencies will be corrected immediately.
Expected Outcome:
The facility will maintain 100% compliance with individualized training plan requirements. Full compliance is expected within 30 days of Plan of Correction approval and will be maintained through ongoing quarterly monitoring and documented oversight. |
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 sixteen of thirty-three applicable personnel records reviewed.
Employee # 13 was hired as a counselor on May 12, 2025 and was due to have the HIV/AIDS training no later than May 12, 2026; however, the HIV/AIDS training was not completed until June 27, 2026.
Employee # 15 was hired as a counselor on February 3, 2025 and was due to have the HIV/AIDS training no later than February 3, 2026; however, the HIV/AIDS training was not completed until June 12, 2026.
Employee # 19 was hired as a counselor on August 19, 2024 and was due to have the HIV/AIDS training no later than August 19, 2025; however, the HIV/AIDS training was not completed until June 19, 2026.
Employee # 21 was hired as a counselor on May 12, 2025 and was due to have the TB/STD training no later than May 12, 2026; however, the TB/STD training was not completed until May 24, 2026.
Employee # 22 was hired as a counselor on October 16, 2023 and was due to have the HIV/AIDS training no later than October 16, 2024; however, the HIV/AIDS training was not completed until June 2, 2026.
Employee # 48 was hired as a counselor on April 15, 2024 and was due to have the TB/STD training no later than April 15, 2025; however, the TB/STD training was not completed until June 3, 2026.
Employee # 55 was hired as the Director of Revenue on April 1, 2024 and was due to have the HIV/AIDS training and the TB/STD training no later than April 1, 2026; however, both the HIV/AIDS training and the TB/STD training were not completed as of the date of the inspection.
Employee # 56 was hired as a housekeeping aide on April 5, 2024 and was due to have the HIV/AIDS training no later than April 5, 2026; however, the HIV/AIDS training was not completed as of the date of the inspection.
Employee # 57 was hired as a housekeeping aide on September 6, 2022 and was due to have the HIV/AIDS training no later than September 6, 2024; however, the HIV/AIDS training was not completed as of the date of the inspection.
Employee # 58 was hired as a housekeeping aide on March 1, 2023 and was due to have the HIV/AIDS training no later than March 1, 2025; however, the HIV/AIDS training was not completed as of the date of the inspection.
Employee # 59 was hired as a housekeeping aide on December 6, 2023 and was due to have the HIV/AIDS training and the TB/STD training no later than December 6, 2025; however, both the HIV/AIDS training and the TB/STD training were not completed as of the date of the inspection.
Employee # 60 was hired as a housekeeping aide on February 5, 2024 and was due to have the HIV/AIDS training no later than February 5, 2026; however, the HIV/AIDS training was not completed as of the date of the inspection.
Employee # 61 was hired as a housekeeping aide on March 18, 2024 and was due to have the HIV/AIDS training no later than March 18, 2026; however, the HIV/AIDS training was not completed as of the date of the inspection.
Employee # 62 was hired as a housekeeping aide on May 15, 2023 and was due to have the HIV/AIDS training no later than May 15, 2025; however, the HIV/AIDS training was not completed as of the date of the inspection.
Employee # 63 was hired as a housekeeping aide on April 22, 2024 and was due to have the HIV/AIDS training no later than April 22, 2026; however, the HIV/AIDS training was not completed as of the date of the inspection.
Employee # 64 was hired as a housekeeping aide on November 27, 2023 and was due to have the HIV/AIDS training no later than November 27, 2025; however, the HIV/AIDS training was not completed as of the date of the inspection.
This is a repeat citation from the July 31, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
The facility will ensure that all required DDAP trainings are completed within the required regulatory timeframe. Effective immediately, all new hires will complete required DDAP training during orientation or provide acceptable documentation of prior completion.
Corrective Action for Employees Identified:
The facility will immediately address the training deficiencies identified for Employees #13, #15, #19, #21, #22, #48, #55, #56, #57, #58, #59, #60, #61, #62, #63, and #64, if they are still employed with the facility.
Employees with overdue or incomplete HIV/AIDS and/or TB/STD training will complete the required training immediately. HR will verify completion and ensure documentation is placed in each employee's personnel file. For Employees #55, #59, and any other employees requiring both trainings, HR will verify completion of both required courses, provided they are still employed with the facility.
HR and department leadership have been educated on the regulatory requirements and will be responsible for ensuring required training is completed within the applicable timeframe.
Monitoring:
HR will maintain documentation of training completion or acceptable proof of prior training in each employee's personnel file. HR will monitor new hire and existing employee training records quarterly to verify that HIV/AIDS and TB/STD training is completed within the required regulatory timeframe.
Any identified deficiency will be corrected immediately and reported to the appropriate department leader.
Expected Outcome:
The facility will maintain 100% compliance with DDAP training requirements. Full compliance is expected within 30 days of Plan of Correction approval and will be maintained through ongoing quarterly monitoring and documented oversight to prevent recurrence of this repeat citation. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure each clinical supervisor completed at least 12 clock hours of training annually, during the facility's July 1, 2025 through June 30, 2026 training year, in one of nine applicable personnel records reviewed.
Employee # 53 was hired as a clinical supervisor on June 13, 2024. The personnel record documented 11.75 hours of training received during the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Department scheduled quarterly reviews with Human Resources to conduct and verify each counselor's year-to-date training hours and category compliance under 704.11(f)(2).
Counseling/Human Resources will assign 12 clock hours of annual training to each clinical supervisor at the start of the training year. Training will be assigned within approved regulatory categories. HR will maintain a centralized training log documenting hours completed, dates, and subject areas. Clinical Supervisors will be monitored to ensure progress toward completion of 12 hours by year-end. Clinical Supervisors not meeting quarterly benchmarks will be taken off of the schedule until they meet requirements. Clinical Supervisors will be expected to complete approximately:
6 hours per half year
12 hours by year-end (the month prior to DDAP preparedness)
The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
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 each counselor completed at least 25 clock hours of training annually, during the facility's July 1, 2025 through June 30, 2026 training year, in two of eighteen applicable personnel records reviewed.
Employee # 12 was hired as a counselor on October 14, 2024. The personnel record documented 24.75 hours of training received during the training year reviewed.
Employee # 19 was hired as a counselor on August 19, 2024. The personnel record documented 23.7 hours of training received during the training year reviewed.
This is a repeat citation from the July 31, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Department scheduled quarterly reviews with Human Resources to conduct and verify each counselor's year-to-date training hours and category compliance under 704.11(f)(2).
Counseling/Human Resources will assign 25 clock hours of annual training to each counselor at the start of the training year. Training will be assigned within approved regulatory categories. HR will maintain a centralized training log documenting hours completed, dates, and subject areas. Counselors will be monitored to ensure progress toward completion of 25 hours by year-end. Counselors not meeting quarterly benchmarks will be taken off of the schedule until they meet requirements. Counselors will be expected to complete approximately:
6.25 hours per quarter
12.5 hours by mid-year
18.75 hours by Q3
25 hours by year-end (the month prior to DDAP preparedness)
The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees, and visitors.
At the time of the inspection, which was conducted on July 21, 2026 between 10:00 a.m. and 12:00 p.m., the railings leading to the entrance of the administrative building had many areas of peeling paint and rust.
This is a repeat citation from the July 31, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon identification of the deficient railings, the facility immediately assessed the condition of the affected areas to ensure resident, employee, and visitor safety. The railings continue to provide their intended function and the area has not been determined to present an immediate safety hazard requiring closure. The organization has demonstrated its commitment to resolving this deficiency by obtaining multiple contractor quotes over 2025/26 and incorporating the project into its capital planning process. While financial constraints have delayed implementation, the facility has established interim safety measures and ongoing monitoring to ensure the protection of residents, visitors, and staff until permanent corrective action can be completed.
Systemic Changes - The facility has incorporated the railing project into its capital improvement planning process. Due to competing facility priorities requiring immediate allocation of available financial resources, the railing replacement project had been delayed. However, the organization remains committed to completing the required repairs and has continued to evaluate funding options to support the project.
Interim Measures to Ensure Safety - The affected railings will be inspected routinely by the Director of Facilities to monitor for severe deterioration or changes in condition. Any condition identified that may create an immediate safety risk will be addressed promptly, including temporary repairs, restriction of access, or other appropriate mitigation measures. Findings from inspections will be documented and maintained by the Facilities Department until permanent repairs are completed.
Monitoring - The Director of Facilities and Chief Operating Officer will review the condition of the railings on a monthly basis and provide updates regarding project funding, contractor selection, and repair timelines to hospital leadership. Documentation of inspections and project progress will be maintained.
Completion Date - The facility intends to complete the railing repair/replacement project as soon as sufficient capital resources become available. The organization anticipates completing the project no later than October 2026 and will provide updates regarding progress as requested.
Responsible Person - Chief Operating Officer |
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on a physical plant inspection, the facility failed to provide toilet paper at each toilet at all times.
At the time of the inspection, conducted on July 21, 2025 between 10:00 a.m. and 12:00 p.m., there was no toilet paper in the bathroom of bedroom #240, which is located in Birch 2B.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility endorses a clean, functional and sanitary area for all patients. The toilet paper will be replenished prior to or immediately upon identification of any deficiency. All facility restrooms will undergo a check to ensure adequate supplies are available.
Prevention: Environmental Services staff are reminded of the requirement to ensure toilet paper is available in all restrooms at all times. Restrooms will be checked and restocked during routine cleaning rounds.
Monitoring: The Director of Operational Support will conduct weekly spot checks for 120 days to ensure compliance and address any deficiencies immediately.
Responsible Person: Director of Operational Support
Expected Outcome: All toilets will have an adequate supply of toilet paper available at all times. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
At the time of the inspection, conducted on July 21, 2025 between 10:00 a.m. and 12:00 p.m., there was a broken paper towel dispenser in the bathroom of bedroom #221, which is located in Birch 2A . Additionally, there was graffiti written on the wall in the bathroom of room #616, which is located in Oak 2A.
This is a repeat citation from the July 31, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The paper towel dispenser was repaired/replaced, and the graffiti was removed immediately upon identification. A review of resident rooms and common areas was completed to identify any additional maintenance concerns.
Prevention: Environmental Services and Maintenance staff were reminded of the requirement to maintain the facility in a clean, safe, and sanitary condition. Staff will continue routine environmental rounds and promptly report and correct any maintenance or housekeeping issues identified. FMX Work List Submissions will be reported immediately for undertaking.
Monitoring: The Director of Operational Support will conduct weekly environmental rounds for 120 days to ensure identified issues are addressed promptly.
Responsible Person: Director of Operational Support
Expected Outcome: Resident rooms and common areas will be maintained in good repair and free from damage, graffiti, and other environmental concerns. |
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 September 2025 through June 2026 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, there was no documentation indicating monthly fire drills were completed for the Birch building during the month of March 2026; for the CTW building during the month of December 2025; and for the Price building during the months of February 2026 and March 2026.
This is a repeat citation from the July 31, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will conduct at least one unannounced fire drill each month in accordance with 28 PA Code 705.10(d)(1). Fire drills will be conducted under varying conditions to assess staff readiness and response to emergency situations.
The Director of Operational Support or designee will be responsible for scheduling and ensuring completion of a minimum of one unannounced fire drill each month.
All staff will receive training on fire response procedures, evacuation routes, use of the RACE protocol, and resident evacuation/assistance procedures during orientation and annual training.
Fire drill logs will clearly identify:
Date and time of the drill, Names of staff participating in and conducting the drill, Number of patients participating, Areas involved in the drill, Whether evacuation procedures were properly followed, Any issues or deficiencies identified during the drill, Corrective actions implemented as a result of the drill, Confirmation that the drill was conducted on an unannounced basis. Documentation will be maintained on-site and made available for DDAP review upon request.
Monitoring to Ensure Ongoing Compliance
The Chief Operations Officer will receive and review fire drill logs at least quarterly to verify: A minimum of one fire drill is conducted each month, Fire drills are conducted on an unannounced basis, Any identified deficiencies are addressed through corrective action and staff re-education as appropriate, Documentation is complete and maintained in accordance with regulatory requirements
The Director of Operational Support will immediately address any missed or overdue drills to ensure ongoing compliance with 28 Pa. Code §705.10(d)(1). |
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.
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Observations
Based on a review of the September 2025 through June 2026 fire drill logs, the facility failed to ensure a fire drill was conducted during sleeping hours at least every six months.
The facility currently has an approved exception to complete partial overnight fire drills once every six months where they are not required to evacuate the building, and the fire alarm or smoke detectors are not required to be set off.
The facility completed partial drills more often than every six months for the campus buildings listed, which is in direct violation of the approved exception.
overnight fire drills were conducted for the D'Arclay building during the months of October 2025, March 2026 and May 2026.
overnight fire drills were conducted for the Oak building during the months of December 2025, February 2026, and April 2026.
overnight fire drills were conducted for the Birch building during the months of December 2025, February 2026, and April 2026.
overnight fire drills were conducted for the Cedar building during the months of September 2025, November 2025, January 2026, and June 2026.
overnight fire drills were conducted for the CTW building during the months of September 2025, October 2025, February 2026, and June 2026.
overnight fire drills were conducted for the Patient Care building during the months of December 2025, January 2026, and May 2026.
overnight fire drills were conducted for the Price building during the months of September 2025 and November 2025. Additionally, there was another overnight fire drill due no later than May 2026; however, there was no overnight fire drill completed after November 2025.
This is a repeat citation from the July 31, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
The facility will follow the approved exception for sleeping-hour fire drills. Effective immediately, the facility will conduct one simulated/partial fire drill during sleeping hours every six (6) months, in accordance with the approved exception. Sleeping-hour drills will not require evacuation of the building, activation of the fire alarm or smoke detectors, or other actions prohibited by the approved exception.
Correction of Identified Deficiency:
The facility will review the fire drill schedule for each campus building to ensure compliance with the approved exception. The Director of Operations Support will establish a tracking schedule identifying the required six-month interval for each building and will ensure that sleeping-hour drills are not conducted more frequently than permitted by the approved exception.
The required sleeping-hour drill for the one facility building, which was due no later than May 2026, will be completed and documented in accordance with the approved exception.
Staff will be re-educated on the approved exception and the required frequency and format of sleeping-hour fire drills by the COO.
Documentation:
Fire drill documentation will clearly identify the building, date and time of the drill, that the drill was a simulated/partial sleeping-hour drill conducted under the approved exception, staff participating, resident participation as applicable, issues identified, and corrective actions taken. Documentation will be maintained on-site and available for DDAP review.
Monitoring:
The Director of Operations Support or designee will monitor the fire drill schedule monthly to ensure each building remains within the required six-month interval. The Chief Operating Officer will review fire drill documentation at least quarterly to verify compliance with the approved exception.
Any scheduling or documentation deficiency identified will be corrected immediately.
Expected Outcome:
The facility will maintain 100% compliance with the approved exception by conducting one simulated/partial sleeping-hour fire drill for each applicable building every six (6) months and will not conduct sleeping-hour drills more frequently than permitted by the exception. Full compliance is expected within 30 days of Plan of Correction approval and will be maintained through ongoing monitoring and documented oversight. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in the record, the verification of the individual's identity, which is to include the name, address, date of birth, emergency contact, and other identifying data prior to the administration of an agent in one of eighteen applicable patient records reviewed.
Patient # 9 was admitted to the inpatient hospital rehabilitation activity on June 30, 2026 and was active at the time of the inspection. An agent was first administered to the patient on June 30, 2026; however, the documentation of the verification of the patient's identity was not completed until July 1, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that all patients are verified and eligible to receive services prior to the administration of any agent.
Corrective Action - The Insurance Verification team has been re-educated on the importance of completing eligibility and insurance verification in a timely manner to support uninterrupted patient care. Effective immediately, patient verification will be completed and documented prior to medication administration. Admissions, Insurance Verification, and MAT staff will work collaboratively to ensure verification issues are identified and resolved as early as possible in the admission process.
Monitoring - Leadership will periodically review admission and verification records to ensure patient verification is completed prior to medication administration. Any identified delays or deficiencies will be addressed through corrective action and staff re-education as needed.
Expected Outcome - The facility will maintain 100% compliance by ensuring patient verification is completed timely and documented prior to the administration of a narcotic agent, reducing delays in treatment and supporting continuity of care. The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
715.10(b) LICENSURE Pregnant patients
(b) A narcotic treatment program shall give pregnant patients the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers.
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Observations
Based on a review of patient records, the narcotic treatment program failed to give pregnant patients the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers in one of one applicable patient record reviewed.
Patient # 31 was admitted to the inpatient non-hospital detoxification activity on April 9, 2026 and was discharged on April 14, 2026. During the intake process, the narcotic treatment program administered an initial pregnancy test to the patient. The test results indicated the patient was positive for pregnancy. However, there was no documentation, in the record, indicating the narcotic treatment program gave the pregnant patient an opportunity for prenatal care either by the program itself or by referral to an appropriate health-care provider.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility acknowledges the finding and has taken corrective action to address the identified documentation deficiency. Upon review, it was determined that while the patient was informed of available prenatal care resources, the discussion and offer of prenatal services were not documented in the medical record as required.
Effective immediately, all nursing, admissions, and clinical staff have been re-educated regarding the requirements of 28 Pa. Code §715.10(b), including the requirement to document that pregnant individuals are offered the opportunity to receive prenatal care either through the program or through referral to an appropriate healthcare provider. Documentation requirements and location within the electronic health record have been reviewed with staff. The positive pregnancy test will be confirmed by an additional test. The referral to an outside source section of the admission process will be completed for all patients with a positive pregnancy test or known pregnancy status.
Chief Nursing Officer will conduct monthly audits of admissions involving pregnant patients to ensure compliance with the documentation requirements. Audit results will be reviewed through the Quality Improvement process, and any identified deficiencies will result in immediate corrective coaching and re-education.
Monitoring: Monthly chart audits of 100% of pregnant admissions for three months, with a compliance goal of 100% documentation of prenatal care offers and referrals. Any non-compliance identified will be addressed through corrective action and follow-up monitoring. The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure counseling records reflected the nature of prenatal support provided by the narcotic treatment program in one of one applicable patient record reviewed.
Patient # 31 was admitted to the inpatient non-hospital detoxification activity on April 9, 2026 and was discharged on April 14, 2026. During the intake process, the narcotic treatment program administered an initial pregnancy test to the patient. The test results indicated the patient was positive for pregnancy. However, there was no documentation in the record of the nature of prenatal support provided by the narcotic treatment program.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility acknowledges the finding and has taken corrective action to address the identified documentation deficiency.
Effective immediately, all NTP nursing and counseling staff have been re-educated regarding the requirement to document all prenatal support services offered and provided to pregnant patients, including counseling, education regarding the effects of substance use during pregnancy, referral coordination, communication with obstetrical providers, and transferring pregnant patients to the appropriate location in the event of a true pregnancy.
The Chief Nursing Officer or designee will conduct monthly audits of 100% of patient records identified as pregnant during admission to ensure prenatal support services and follow-up activities are appropriately documented in the medical record. Audit results will be reviewed through the Quality Improvement process, and any identified deficiencies will result in immediate staff coaching and additional education.
Monitoring - Monthly review of 100% of records involving pregnant patients for three months, with a compliance goal of 100% documentation of prenatal support services, referrals, and follow-up activities. Any deficiencies identified during monitoring will be addressed through corrective action and continued oversight. The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure that if the narcotic treatment physician determining the initial dose was not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient's initial dose and schedule in three of eighteen applicable patient records reviewed.
Patient # 6 was admitted to the inpatient hospital detoxification activity on July 3, 2026 and was discharged on July 6, 2026. A narcotic treatment physician conducted the patient examination on July 3, 2026 and there was documentation indicating a physician assistant determined the initial medication dose and schedule on July 4, 2026; however, there was no consultation between the physician and physician assistant documented in the record prior to the determination.
Patient # 10 was admitted to the inpatient hospital rehabilitation activity on February 2, 2026 and was discharged on March 18, 2026. A physician assistant conducted the patient examination on July 7, 2026 and a narcotic treatment physician determined the initial dose and schedule of methadone on July 7, 2026; however, there was no consultation between the physician and physician assistant documented in the record prior to the determination.
Patient # 31 was admitted to the inpatient non-hospital detoxification activity on April 9, 2026 and was discharged on April 14, 2026. A physician assistant conducted the patient examination on April 9, 2026 and a narcotic treatment physician determined the initial dose and schedule of methadone on April 10, 2026; however, there was no consultation between the physician and physician assistant documented in the record prior to the determination.
This is a repeat citation from the July 31, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per regulation, when different providers complete the H&P and determine the initial dose, a brief consultation note will be entered into the patient's medical record prior to dosing.
A standard consultation note requirement will be implemented for all cases in which:
*One provider completes the H&P, and
*A different provider determines the initial dose.
Monitoring to Ensure Ongoing Compliance
- The Medical Director will review initial dose documentation to confirm the presence of a consultation note when applicable.
- Upon review, any missing documentation will be corrected immediately and addressed with the responsible provider(s).
Compliance with this standard will be monitored within the department on an ongoing basis until compliance has been established for a 3-month time period and, as appropriate, audited monthly under the hospital Quality Assurance and Performance Improvement (QAPI) program for 6 months to ensure compliance has been established.
The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure that a narcotic treatment physician determined the patient's initial dose in one of eighteen applicable patient records reviewed.
Patient #14 was admitted to the inpatient hospital rehabilitation activity on March 31, 2026 and was discharged on April 13, 2026. There was documentation in the record indicating the initial dose of medication was determined and ordered by a physician assistant, not a narcotic treatment physician.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that all initial MAT medication orders are completed and signed by the Narcotic Treatment Physician in accordance with 28 Pa. Code § 715.17(c)(1)(i).
The Provider staff have been educated on this requirement.
Effective immediately, Physician Assistants will not order initial MAT doses.
All initial MAT doses will be ordered and signed by the Narcotic Treatment Physician.
Monitoring - The Medical Director or another Narcotic Treatment Physician will review new MAT admissions weekly for 90 days to ensure compliance. Any identified issues will be corrected immediately and staff will be re-educated as needed.
Expected Outcome - The facility will maintain 100% compliance with the requirement that initial MAT doses are ordered by the Narcotic Treatment Physician. The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to transfer patient files, which is to include the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, in four of four applicable patient records reviewed.
Patient # 10 was admitted to the inpatient hospital rehabilitation activity on February 6, 2026 and was transferred to another narcotic treatment program on March 18, 2026. There was no documentation in the record indicating the program transferred the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient to the receiving narcotic treatment program.
Patient # 11 was admitted to the inpatient hospital rehabilitation activity on March 20, 2026 and was transferred to another narcotic treatment program on June 1, 2026. There was no documentation in the record indicating the program transferred the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient to the receiving narcotic treatment program.
Patient # 12 was admitted to the inpatient hospital rehabilitation activity on April 25, 2026 and was transferred to another narcotic treatment program on May 31, 2026. There was no documentation in the record indicating the program transferred the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient to the receiving narcotic treatment program.
Patient # 30 was admitted to the inpatient non-hospital rehabilitation activity on April 14, 2026 and was transferred to another narcotic treatment program on April 20, 2026. There was no documentation in the record indicating the program transferred the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient to the receiving narcotic treatment program.
This is a repeat citation from the July 31, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per regulation, when a patient transfers from our facility, to another narcotic treatment program, staff will transfer the patient files to their outward-bound facility.
Director of Case Management will review all outgoing NTP transfer records to confirm:
- The transfer packet was sent
- Documentation is present in the EMR
- Patient consent is included
Upon the director's review, any missing documentation will be corrected promptly and addressed with the responsible staff. Ultimately, the Director of Case Management will be responsible for ensuring compliance with this standard.
Compliance with this standard will be monitored within the department on an ongoing basis until compliance has been established for 3 months and, as appropriate, audited monthly under the hospital Quality Assurance and Performance Improvement (QAPI) program for 6 months to ensure 100% compliance has been established. The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in two of two applicable patient records reviewed.
Patient # 2 was admitted to the inpatient hospital detoxification activity on July 15, 2026 and was active at the time of the inspection. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the client's date of admission and the date the initial dose was given.
Patient # 31 was admitted to the inpatient non-hospital detoxification activity on April 9, 2026 and was discharged on April 14, 2026. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the client's date of admission and the date the initial dose was given.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per regulation, when a patient transfers into the facility from another licensed NTP, staff will notify the prior NTP of:
- Patient admission, and
- Date of the initial dose administered by our facility.
Notification and dosing will be documented using the First Dose Verification Form, sent to the previous NTP, and placed in the patient's electronic medical record.
This requirement applies only to licensed NTPs and does not apply to emergency departments or acute-care hospitals without NTP licensure.
Case Management staff will be responsible for completing the form at the time of the initial dose and for documenting prior NTP notification.
Monitoring to Ensure Ongoing Compliance
The Director of Case Management will audit a sample size of patient charts for compliance. Any missing documentation will be corrected promptly and addressed with the responsible staff. Ultimately, the Director of Case Management will be responsible for ensuring compliance with this standard.
Compliance with this standard will be monitored within the department on an ongoing basis until compliance has been established for 3 months, and, as appropriate, audited monthly under the hospital Quality Assurance and Performance Improvement (QAPI) program for 6 months to ensure compliance has been established. The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
711.62(a)(6) LICENSURE Follow-up Information
711.62. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(6) Follow-up information.
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in four of four applicable client records reviewed.
The facility policy and procedure manual stated that clinicians will ask patients to sign a referral follow-up consent form, and then staff shall attempt to contact the patient by telephone at their discharge address within seven (7) days of discharge.
Client # 18 was admitted to the inpatient non-hospital detoxification activity on July 6, 2026 and was discharged on July 9, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
Client # 19 was admitted to the inpatient non-hospital detoxification activity on March 17, 2026 and was discharged on March 22, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
Client # 20 was admitted to the inpatient non-hospital detoxification activity on July 10, 2026 and was discharged on July 14, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
Client # 21 was admitted to the inpatient non-hospital detoxification activity on December 3, 2026 and was discharged on December 8, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will strengthen its discharge follow-up process to ensure follow-up contact is attempted and documented within seven (7) days of discharge.
Corrective Action - The facility will hire a dedicated Follow-Up Specialist/Case Manager responsible for conducting and documenting post-discharge follow-up activities. The Follow-Up Specialist will attempt contact with discharged patients within seven (7) days of discharge and document the outcome of each attempt. If contact cannot be made, multiple attempts will be documented in the patient record as applicable.
Monitoring - The Follow-Up Specialist will maintain a tracking log of all discharged patients requiring follow-up. Counseling Leadership will periodically review the tracking log and documentation to ensure follow-up attempts are completed and recorded within the required timeframe.
Expected Outcome - The facility will maintain 100% compliance with discharge follow-up requirements by ensuring follow-up contact is attempted and documented within seven (7) days of discharge. The facility anticipates full compliance within 90 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
711.53(a)(7) LICENSURE Follow-up Information
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in six of six client records reviewed.
The facility policy and procedure manual stated that clinicians will ask patients to sign a referral follow-up consent form, and then staff shall attempt to contact the patient by telephone at their discharge address within seven (7) days of discharge.
Client # 25 was admitted to the inpatient non-hospital rehabilitation activity on February 24, 2026 and was discharged on March 20, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
Client #26 was admitted to the inpatient non-hospital rehabilitation activity on April 11, 2026 and was discharged on April 17, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
Client #27 was admitted to the inpatient non-hospital rehabilitation activity on March 26, 2026 and was discharged on April 9, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
Client # 28 was admitted to the inpatient non-hospital rehabilitation activity on January 5, 2026 and was discharged on January 15, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
Client #29 was admitted to the inpatient non-hospital rehabilitation activity on May 30, 2026 and was involuntarily terminated on June 21, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
Client #30 was admitted to the inpatient non-hospital rehabilitation activity on April 14, 2026 and was discharged on April 20, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will strengthen its discharge follow-up process to ensure follow-up contact is attempted and documented within seven (7) days of discharge.
Corrective Action - The facility will hire a dedicated Follow-Up Specialist/Case Manager responsible for conducting and documenting post-discharge follow-up activities. The Follow-Up Specialist will attempt contact with discharged patients within seven (7) days of discharge and document the outcome of each attempt. If contact cannot be made, multiple attempts will be documented in the patient record as applicable.
Monitoring - The Follow-Up Specialist will maintain a tracking log of all discharged patients requiring follow-up. Counseling Leadership will periodically review the tracking log and documentation to ensure follow-up attempts are completed and recorded within the required timeframe.
Expected Outcome - The facility will maintain 100% compliance with discharge follow-up requirements by ensuring follow-up contact is attempted and documented within seven (7) days of discharge. The facility anticipates full compliance within 90 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
711.53(c)(2) LICENSURE Consent to Release Information - Informed/Vol
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information in one of nine applicable client records reviewed.
Client # 25 was admitted to the inpatient non-hospital rehabilitation activity February 24, 2026 and was discharged on March 20, 2026. There was evidence of disclosures to the funding source during the treatment episode; however, there was no valid consent to release information form signed by the client documented in the record prior to any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that all Releases of Information (ROI) and consents are completed in accordance with confidentiality requirements and contain all required elements prior to obtaining the patient's signature.
Corrective Action - Admissions and Case Management staff have been re-educated on the requirements for valid Releases of Information and patient consents. Effective immediately, staff will not obtain or use "blanket" or incomplete consents. Each Release of Information will clearly identify the person, agency, or organization involved and include the specific purpose or reason for the disclosure before the patient signs the consent. Any incomplete or invalid consent forms identified will be corrected prior to the release of information.
Monitoring - Admissions Leadership and/or Compliance will periodically review patient records to ensure Releases of Information are completed appropriately. Any deficiencies identified will be addressed through staff re-education and corrective action as needed.
Expected Outcome - The facility will maintain 100% compliance with consent and confidentiality requirements by ensuring all Releases of Information contain the required purpose, reason for disclosure, and intended recipient prior to patient signature. The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
711.53(c)(2)(i) LICENSURE Person/Agency/Org to Whom Disclosure Made
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(i) The name of the person, agency, organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made on a consent to release information form in one of nine applicable client records reviewed.
Client # 28 was admitted to the inpatient non-hospital rehabilitation activity on January 5, 2026 and was discharged on January 15, 2026. There was a blank release of information form, signed by the client on January 5, 2026, in the record; however, the release form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that all Releases of Information (ROI) and consents are completed in accordance with confidentiality requirements and contain all required elements prior to obtaining the patient's signature.
Corrective Action - Admissions and Case Management staff have been re-educated on the requirements for valid Releases of Information and patient consents. Effective immediately, staff will not obtain or use "blanket" or incomplete consents. Each Release of Information will clearly identify the person, agency, or organization involved and include the specific purpose or reason for the disclosure before the patient signs the consent. Any incomplete or invalid consent forms identified will be corrected prior to the release of information.
Monitoring - Admissions Leadership and/or Compliance will periodically review patient records to ensure Releases of Information are completed appropriately. Any deficiencies identified will be addressed through staff re-education and corrective action as needed.
Expected Outcome - The facility will maintain 100% compliance with consent and confidentiality requirements by ensuring all Releases of Information contain the required purpose, reason for disclosure, and intended recipient prior to patient signature. The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
711.53(c)(2)(iii) LICENSURE Purpose of Disclosure
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(iii) The purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a consent to release information form in one of nine applicable client records reviewed.
Client # 28 was admitted to the inpatient non-hospital rehabilitation activity on January 5, 2026 and was discharged on January 15, 2026. There was a blank release of information form signed by the client on January 5, 2026 in the record; however, the release form did not include documentation of the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that all Releases of Information (ROI) and consents are completed in accordance with confidentiality requirements and contain all required elements prior to obtaining the patient's signature.
Corrective Action - Admissions and Case Management staff have been re-educated on the requirements for valid Releases of Information and patient consents. Effective immediately, staff will not obtain or use "blanket" or incomplete consents. Each Release of Information will clearly identify the person, agency, or organization involved and include the specific purpose or reason for the disclosure before the patient signs the consent. Any incomplete or invalid consent forms identified will be corrected prior to the release of information.
Monitoring - Admissions Leadership and/or Compliance will periodically review patient records to ensure Releases of Information are completed appropriately. Any deficiencies identified will be addressed through staff re-education and corrective action as needed.
Expected Outcome - The facility will maintain 100% compliance with consent and confidentiality requirements by ensuring all Releases of Information contain the required purpose, reason for disclosure, and intended recipient prior to patient signature. The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
711.56(a) LICENSURE Written Termination Notice
711.56. Notification of termination.
(a) The project director 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.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in two of two applicable client records reviewed.
Client #27 was admitted to the inpatient non-hospital rehabilitation activity on March 26, 2026 and was involuntarily terminated on April 9, 2026. There was no documentation, in the record, indicating the client received written notice of the project's involuntary termination decision.
Client #29 was admitted to the inpatient non-hospital rehabilitation activity on May 30, 2026 and was involuntarily terminated on June 21, 2026. There was no documentation, in the record, indicating the client received written notice of the project's involuntary termination decision.
This is a repeat citation from the July 31, 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 ensure that all patients subject to an involuntary termination are provided with written notification of the termination decision and informed of their right to appeal in accordance with applicable DDAP requirements.
Corrective Action - Counseling and Counseling Leadership staff will be re-educated on the requirements related to involuntary terminations, patient notification, and appeal rights. Effective immediately, all involuntary terminations will include documentation that the patient was notified of the decision and informed of their right to appeal. The notification and appeal process will be reviewed with the patient and documented in the clinical record whenever feasible.
Additional Action - The facility intends to submit a request for an exemption or clarification from DDAP regarding the notification and appeal process in situations involving patients who engage in acts of physical violence or hostile/threatening behavior toward staff or other patients, including but not limited to situations that require intervention by law enforcement. Until such guidance is received, the facility will continue to document the circumstances surrounding any involuntary termination and make reasonable efforts to comply with notification and appeal requirements while maintaining the safety of patients and staff.
Monitoring - Counseling Leadership and Compliance will periodically review involuntary termination records to ensure notification and appeal rights are documented appropriately. Any identified deficiencies will be addressed through staff re-education and corrective action as needed.
Expected Outcome - The facility will maintain 100% compliance with involuntary termination requirements by ensuring patients are notified of termination decisions, informed of their appeal rights, and that all actions are appropriately documented in the patient record. The facility anticipates full compliance within 60 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
711.56(b) LICENSURE Right to Appeal Termination
711.56. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating his treatment.
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Observations
Based on a review of client records, the facility failed to provide the client an opportunity to request reconsideration of a decision terminating treatment in two of two applicable client records reviewed.
Client #27 was admitted to the inpatient non-hospital rehabilitation activity on March 26, 2026 and was involuntarily terminated on April 9, 2026. There was no documentation, in the record, indicating the client was given an opportunity to request reconsideration of the involuntary termination from the project.
Client #29 was admitted to the inpatient non-hospital rehabilitation activity on May 30, 2026 and was involuntarily terminated on June 21, 2026. There was no documentation, in the record, indicating the client was given an opportunity to request reconsideration of the involuntary termination from the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that all patients subject to an involuntary termination are provided with written notification of the termination decision and informed of their right to appeal in accordance with applicable DDAP requirements.
Corrective Action - Admissions, Counseling, and Program Leadership staff will be re-educated on the requirements related to involuntary terminations, patient notification, and appeal rights. Effective immediately, all involuntary terminations will include documentation that the patient was notified of the decision and informed of their right to appeal. The notification and appeal process will be reviewed with the patient and documented in the clinical record whenever feasible.
Additional Action - The facility intends to submit a request for an exemption or clarification from DDAP regarding the notification and appeal process in situations involving patients who engage in acts of physical violence or hostile/threatening behavior toward staff or other patients, including but not limited to situations that require intervention by law enforcement. Until such guidance is received, the facility will continue to document the circumstances surrounding any involuntary termination and make reasonable efforts to comply with notification and appeal requirements while maintaining the safety of patients and staff.
Monitoring - Counseling Leadership and Compliance will periodically review involuntary termination records to ensure notification and appeal rights are documented appropriately. Any identified deficiencies will be addressed through staff re-education and corrective action as needed.
Expected Outcome - The facility will maintain 100% compliance with involuntary termination requirements by ensuring patients are notified of termination decisions, informed of their appeal rights, and that all actions are appropriately documented in the patient record. The facility anticipates full compliance within 60 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
710.23(a) LICENSURE Patient Records
§ 710.23. Patient records.
(a) In addition to the requirements contained in § 115.32 (relating to contents), the patient ' s medical record shall contain a drug and alcohol support plan, follow-up information, and an aftercare plan, if applicable.
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Observations
Based on a review of patient records and the facility policy and procedure manual, the facility failed to ensure the patient ' s medical record contained follow-up information in five of five applicable client records reviewed.
The facility policy and procedure manual stated that clinicians will ask clients to sign a referral follow-up consent form and then facility staff shall attempt to contact the patient by telephone at their discharge address within seven (7) days of discharge.
Client # 3 was admitted to the inpatient hospital detoxification activity on October 24, 2025 and was discharged on October 29, 2025. There was no follow-up information documented in the patient record at the time of the inspection.
Client # 4 was admitted to the inpatient hospital detoxification activity on January 9, 2026 and was discharged on January 11, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
Client # 5 was admitted to the inpatient hospital detoxification activity on April 27, 2026 and was discharged on May 2, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
Client # 6 was admitted to the inpatient hospital detoxification activity on July 3, 2026 and was discharged on July 6, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
Client # 7 was admitted to the inpatient hospital detoxification activity on April 20, 2026 and was discharged on April 25, 2026. There was no follow-up information documented in the patient 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 facility will strengthen its discharge follow-up process to ensure follow-up contact is attempted and documented within seven (7) days of discharge.
Corrective Action - The facility will hire a dedicated Follow-Up Specialist/Case Manager responsible for conducting and documenting post-discharge follow-up activities. The Follow-Up Specialist will attempt contact with discharged patients within seven (7) days of discharge and document the outcome of each attempt. In addition to discharge follow-up responsibilities, the Follow-Up Specialist will support other Case Managers with the development and completion of patient drug and alcohol support plans, aftercare plans, community referrals, and discharge planning activities. If contact cannot be made, all follow-up attempts will be documented in the patient record.
Monitoring - The Follow-Up Specialist will maintain a tracking log of all discharged patients requiring follow-up. Counseling Leadership will review the tracking log and follow-up documentation periodically to ensure contact attempts are completed within the required timeframe. Counseling Leadership will also monitor support plan and aftercare plan completion to ensure continuity of care and compliance with documentation requirements.
Expected Outcome - The facility will maintain 100% compliance with discharge follow-up requirements by ensuring follow-up contact is attempted and documented within seven (7) days of discharge, while enhancing the quality and timeliness of patient support plans and aftercare planning through dedicated case management support. The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
710.23(b) LICENSURE Patient Records
§ 710.23. Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code § § 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects; and coordinating bodies: disclosure of client-oriented information).
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Observations
Based on a review of patient records, the facility failed to ensure patient records were kept confidential, in accordance with applicable Federal and state drug and alcohol regulations, in one of seven applicable patient records reviewed.
Patient # 3 was admitted to the inpatient hospital detoxification activity on October 24, 2025 and was discharged on October 29, 2025. In the record, there were release of information forms to a pharmacy, a medical provider, and an outside individual that were signed and dated by the patient on October 27, 2025; however, all of the release forms did not include what the purpose of the disclosure was.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that all Releases of Information (ROI) and consents are completed in accordance with confidentiality requirements and contain all required elements prior to obtaining the patient's signature.
Corrective Action - Admissions and Case Management staff have been re-educated on the requirements for valid Releases of Information and patient consents. Effective immediately, staff will not obtain or use "blanket" or incomplete consents. Each Release of Information will clearly identify the person, agency, or organization involved and include the specific purpose or reason for the disclosure before the patient signs the consent. Any incomplete or invalid consent forms identified will be corrected prior to the release of information.
Monitoring - Admissions Leadership and/or Compliance will periodically review patient records to ensure Releases of Information are completed appropriately. Any deficiencies identified will be addressed through staff re-education and corrective action as needed.
Expected Outcome - The facility will maintain 100% compliance with consent and confidentiality requirements by ensuring all Releases of Information contain the required purpose, reason for disclosure, and intended recipient prior to patient signature. The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
710.42(a)(3) LICENSURE Treatment and Rehabilitation Services
§ 710.42. Treatment and rehabilitation services.
(a) The director shall be responsible for a written plan for the coordination of patient treatment and rehabilitation services which shall include, but not be limited to:
(3) Written procedures for the development, approval, and ongoing management of treatment/rehabilitation services of patients.
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Observations
Based on a review of patient records and the facility policy and procedure manual, the facility failed to follow their written procedures for the development, approval, and ongoing management of treatment/rehabilitation services in five of five applicable patient records reviewed.
The facility policy and procedure manual stated that clinicians will ask patients to sign a referral follow-up consent form and then staff shall attempt to contact the patient by telephone at their discharge address within seven (7) days of discharge.
Client # 10 was admitted to the inpatient hospital rehabilitation activity on February 6, 2026 and was discharged on March 18, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
Client # 11 was admitted to the inpatient hospital rehabilitation activity on March 20, 2026 and was discharged on June 1, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
Client # 12 was admitted to the inpatient hospital rehabilitation activity on April 25, 2026 and was discharged on May 31, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
Client # 13 was admitted to the inpatient hospital rehabilitation activity on May 3, 2026 and was discharged on May 5, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
Client # 14 was admitted to the inpatient hospital rehabilitation activity on March 31, 2026 and was discharged on April 13, 2026. There was no follow-up information documented in the patient record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will strengthen its discharge follow-up process to ensure follow-up contact is attempted and documented within seven (7) days of discharge.
Corrective Action - The facility will hire a dedicated Follow-Up Specialist/Case Manager responsible for conducting and documenting post-discharge follow-up activities. The Follow-Up Specialist will attempt contact with discharged patients within seven (7) days of discharge and document the outcome of each attempt. If contact cannot be made, multiple attempts will be documented in the patient record as applicable.
Monitoring - The Follow-Up Specialist will maintain a tracking log of all discharged patients requiring follow-up.
Counseling Leadership will periodically review the tracking log and documentation to ensure follow-up attempts are completed and recorded within the required timeframe.
Expected Outcome - The facility will maintain 100% compliance with discharge follow-up requirements by ensuring follow-up contact is attempted and documented within seven (7) days of discharge. The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
710.42(b)(2) LICENSURE Treatment and Rehabilitation Services
§ 710.42. Treatment and rehabilitation services.
(b) An individual treatment and rehabilitation plan shall be developed with each patient. This plan shall include, but not be limited to, written documentation of the following:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of patient records, the facility failed to document the type and frequency of treatment and rehabilitation services on the patient's individual treatment and rehabilitation plan in six of seven applicable patient records reviewed.
Patient # 8 was admitted to the inpatient hospital rehabilitation activity on June 2, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan, completed on June 6, 2026, did not include documentation of the type and frequency of treatment and rehabilitation services the patient was to receive.
Patient # 9 was admitted to the inpatient hospital rehabilitation activity on June 30, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan, completed on July 6, 2026, did not include documentation of the type and frequency of treatment and rehabilitation services the patient was to receive.
Patient #10 was admitted to the inpatient hospital rehabilitation activity on February 6, 2026 and was discharged on March 18, 2026. The individual treatment and rehabilitation plan, completed February 11, 2026, did not include documentation of the type and frequency of treatment and rehabilitation services the patient was to receive.
Patient # 11 was admitted to the inpatient hospital rehabilitation activity on March 20, 2026 and was discharged on June 1, 2026. The individual treatment and rehabilitation plan, completed March 26, 2026, did not include documentation of the type and frequency of treatment and rehabilitation services the patient was to receive.
Patient # 12 was admitted to the inpatient hospital rehabilitation activity on April 25, 2026 and was discharged on May 31, 2026. The individual treatment and rehabilitation plan, completed April 28, 2026, did not include documentation of the type and frequency of treatment and rehabilitation services the patient was to receive.
Patient #13 was admitted to the inpatient hospital rehabilitation activity on May 3, 2026 and was discharged on May 5, 2026. The individual treatment and rehabilitation plan, completed May 4, 2026, did not include documentation of the type and frequency of treatment and rehabilitation services the patient was to receive.
This is a repeat citation from the July 31, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that all Individual and Comprehensive Treatment Plans clearly identify the type and frequency of treatment and rehabilitation services to be provided to each patient.
Corrective Action - Counseling staff have been educated on the requirement to include the specific type and frequency of services in each patient's Individual and Comprehensive Treatment Plan. Effective immediately, treatment plans will be developed with patient involvement and will clearly document the counseling, treatment, rehabilitation, and support services the patient is scheduled to receive, including the frequency of those services. Counseling Leadership will update treatment planning practices to ensure these elements are consistently addressed in patient records.
Monitoring - Counseling Leadership will periodically review Individual and Comprehensive Treatment Plans to ensure the type and frequency of services are documented. Any identified deficiencies will be addressed through staff re-education and corrective action as needed.
Expected Outcome - The facility will maintain 100% compliance with treatment planning requirements by ensuring all Individual and Comprehensive Treatment Plans clearly identify the type and frequency of treatment and rehabilitation services to be provided to each patient. The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |