INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, AWJWI d/b/a Sobriety Solutions Pennsylvania was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's staff development program, the facility failed to develop a comprehensive staff development program for the current training year, December 1, 2024 through November 31, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
A comprehensive staff development program for the training year has been developed in accordance with regulation 704.11(a)(2).
The program will include: An annual training needs assessment for all personnel. An overall training plan addressing identified needs, required DDAP trainings, time frames for completion, and responsible staff. To prevent recurrence, The Project Director will complete and approve the annual staff development plan at least 30 days prior to the start of each new training year. A reminder system will be added to the facility's compliance calendar to prompt review, update, and completion of the plan annually. The staff development plan will be reviewed quarterly during administrative meetings held by Project Director and Clinical Supervisor to ensure it remains current and comprehensive. Project Director and Clinical Supervisor will present the quarterly staff development plan to Chief Clinical Officer during scheduled supervision meetings.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that 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 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.
Employee #7 was hired as a counselor on August 25, 2022. Her training was due no later than August 25, 2023; however, none was completed.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the January 1,2018, January 24, 2020, October 21, 2020, October 22, 2021, December 16, 2022, June 27, 2023, December 19, 2023 and October 16, 2024 licensing inspections.
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Plan of Correction
Pursuant to DDAP regulation 704.11(c)(1), new hires will be trained with at least 4 hours of TB/STD and at least 6 hours of HIV/AIDS when hired or will be asked to provide these trainings upon start date. If a new hire has not been trained or does not having training documentation, the new employee will be required to complete these trainings. During weekly clinical meetings with Clinical Director and Chief Clinical officer, CD will identify any new staff members and have them complete these required trainings if these have not already been completed. Leadership Team will meet monthly and review new hires' training needs to ensure that all new staff have been trained. Employee 7 will complete their TB/STD trainings by 12/12/205. Staff TB/STD trainings and HIV/AIDS training requirements will be on the monthly leadership meeting agenda in effort to ensure compliance for regulation 704.11(c)(1) |
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 the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Employee #7 was hired as a counselor on August 25, 2022. The facility's training year that was reviewed was from December 1, 2023 through November 31, 2024. Employee # 7's record only document 4 hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All Counselors will complete at least 25 clock hours of annual training in required subject areas. Required training topics could include but are not limited to confidentiality, ethics, counseling techniques, documentation, and substance use disorder?related competencies, and will be completed and documented in the personnel file no later than the end of the training year. To prevent recurrence, The Project Director will implement a quarterly audit of all counselor training records to monitor progress toward the 25-hour annual requirement. Training opportunities will be scheduled in advance at the start of each training year to ensure all staff have accessible and timely opportunities to meet the 25-hour requirement. A training tracker tool will be used to document completed and outstanding training hours for each counselor, and alerts will be provided for staff who are at risk of falling behind and training progress will also be reviewed monthly during supervision sessions.
Employee #7 has been scheduled to complete the remaining training hours necessary to meet the 25-hour requirement. All missing training documentation for the previous training year will be reviewed, and updated or corrected documentation will be placed in Employee #7's personnel record as applicable.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #3 was hired on April 15, 2025 as a counselor and was still in the position as of the date of the inspection. No training was completed.
Employee #4 was hired on April 14, 2025 as a counselor and was still in the position as of the date of the inspection. No training was completed.
Employee #5 was hired on May 27, 2025 as a counselor and was still in the position as of the date of the inspection. No training was completed.
Employee #6 was hired on June 23, 2025 as a counselor and was still in the position as of the date of the inspection. No training was completed.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the October 16, 2024 annual licensing inspection.
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Plan of Correction
Pursuant to 705.28 (c) (4), employees #3, #4, #5 and #6 completed use of fire extinguisher training by 12/12/2025. Leadership reviewed onboarding documentation and have included Fire Extinguisher Training in new hire orientation documentation packet. Clinical Director added Fire Extinguisher Training to new hire orientation checklist. This will be completed with new hired staff conducted by Clinical Director. Chief Clinical Officer, Clinical Director and Clinical Supervisor will continue to meet weekly for Clinical Supervisor supervision team meeting and review any new staff hired to ensure compliance to regulation 705.28(c)(4). |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies.
Employee #3 was hired on April 15, 2025 as a counselor and was still in the position as of the date of the inspection. No training was completed.
Employee #4 was hired on April 14, 2025 as a counselor and was still in the position as of the date of the inspection. No training was completed.
Employee #5 was hired on May 27, 2025 as a counselor and was still in the position as of the date of the inspection. No training was completed.
Employee #6 was hired on June 23, 2026 as a counselor and was still in the position as of the date of the inspection. No training was completed.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the October 16, 2024 annual licensing inspection.
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Plan of Correction
Pursuant to 705.28 (d) (3), it was found that employees #3, #4, #5 & #6 were not trained upon hire. This training was completed for employees #3, #4, #5 & #6 by 12/12/2025 Leadership reviewed onboarding documentation and have included Fire Safety Training including Fire Drills in new hire orientation documentation packet to ensure new staff are trained to perform assigned tasks during emergencies. Clinical Director added Fire Safety Training to new hire orientation checklist. This will be completed with new hired staff conducted by Clinical Director. Chief Clinical Officer, Clinical Director and Clinical Supervisor will continue to meet weekly for Clinical Supervisor supervision team meeting and review any new staff hired to ensure compliance to regulation 705.28(d)(3). |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents and an interview with the facility director, the project failed to document an annual financial audit for the fiscal year ending December 31, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO and CFO have secured a certified public accounting firm to complete annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities as the annual audit for fiscal year 2024 had not been completed at the time of annual survey which was still in process. The selected independent certified public accounting firm or any future independent certified public accounting firm will be contractually engaged to prepare annual audits within six months of the conclusion of the previous fiscal year.
The CFO will ensure that the annual financial audit is completed for the fiscal year of 2025 within 6 months of the conclusion of the fiscal year. CFO and CEO have added update and status of the fiscal audit to the monthly leadership agenda to ensure compliance of regulation 709.25.
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709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of partial hospitalization client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in two out of six client records reviewed.
Client #9 was admitted on September 29, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on October 1, 2025 with no type or frequency identified.
Client #11 was admitted on September 17, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 23, 2025 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 16, 2024 licensing inspection.
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Plan of Correction
Individual treatment and rehabilitation plans shall be developed with a client and The Project Director or Clinical Supervisor review and make applicable updates to the treatment plan template to ensure that the plans include: 1) Specific Type; 2) Frequency. Furthermore, The Project Director or Clinical Supervisor will ensure staff be retrained on: DDAP requirements under 709.82(a)(2), expectations for documenting service type and frequency, and use of the treatment plan template. The Clinical Director or Clinical Supervisor will conduct monthly audits of active client treatment plans. Any deficiencies identified will result in immediate correction and individual staff coaching. Audit findings will be reviewed during monthly clinical meetings and staff supervision times to ensure continuous compliance and prevent repeat citations. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of four client records reviewed.
Client #9 was admitted on September 29, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on October 1, 2025 and an update was due no later than November 1, 2025; however, it was not completed until November 14, 2025.
Client #11 was admitted on September 17, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 23, 2025 and an update was due no later than October 23, 2025; however, it was not completed until November 13, 2025.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the October 16, 2024 annual licensing inspection.
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Plan of Correction
Treatment and rehabilitation plans shall be updated in full within regulatory timeframes. The facility will implement a centralized tracking system that tracks due dates for all treatment plan reviews, to ensure treatment plans are updated. The Project Director and Clinical Supervisor will review the Treatment Plan Timeliness Policy with all staff to prevent overdue dates. Also, The Project Director and Clinical Supervisor will retrain all clinical staff on: DDAP requirement 709.82(b), Use of the tracking system and the Treatment Plan Timeliness Policy expectations. The Clinical Director or Clinical Supervisor will conduct monthly audits of active client treatment plans. Any deficiencies identified will result in immediate correction and individual staff coaching. Audit findings will be reviewed during monthly clinical meetings and staff supervision times to ensure continuous compliance and prevent repeat citations. |
709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in two out of three applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed seven days following discharge.
Client #13 was admitted on July 21, 2025 and discharged on August 8, 2025. A follow up was due no later than August 15, 2025; however, it was none was completed.
Client #14 was admitted on September 17, 2025 and was discharged on October 17, 2025. A follow up was due no later than October 24, 2025; however, none was completed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 16, 2024 annual licensing inspection.
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Plan of Correction
Pursuant to regulation 709.83(a)(11), it was found that follow up contact was not documented for clients #13 & #14 discharged from Partial Hospitalization Program.
Leadership team met and designated that all follow up contacts in CRM to be completed by Alumni Coordinator overseen by Program and Business Development Manager.
Program and Business Development Manager will review all partial hospitalization discharges weekly and audit CRM of partial hospitalization discharged clients to ensure follow up contacts are made by Alumni Coordinator. Program and Business Development Manager will report weekly CRM audit reports to Chief Clinical Officer to safeguard that facility is within compliance of regulation 709.83(a)(11).
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of outpatient client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include, but not limited to, written documentation of type and frequency of treatment and rehabilitation services in three out of seven client records reviewed.
Client #5 was admitted on June 4, 2025 and was discharged on October 21, 2025. A comprehensive treatment plan was developed on July 8, 2025 with no type or frequency identified.
Client #6 was admitted on April 3, 2025 and was discharged on October 24, 2025. A comprehensive treatment plan was developed on April 14, 2025 with no type or frequency identified.
Client #7 was admitted on April 7, 2025 and was discharged on July 17, 2025. A comprehensive treatment plan was developed on April 14, 2025 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 16, 2024 licensing inspection.
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Plan of Correction
The treatment plan form will be revised to include clearly designated fields requiring staff to specify the type of each service and the frequency of each service being offered. All clinical staff have been re-trained on DDAP requirements for treatment plan development with emphasis on client participation in plan development, clear documentation of service type and frequency, and deadlines for treatment plan completion and updates. The Clinical Director and/or Clinical Supervisor will conduct monthly audits of active treatment plans for verification of compliance with treatment plan requirements related to type and frequency of services rendered. Feedback and corrective coaching will be provided immediately when non-compliance is identified. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in five out of six client records reviewed.
Client #2 was admitted on August 4, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on August 18, 2025 and an update was due no later than October 18, 2025; however, none was completed.
Client #3 was admitted on June 17, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 14, 2025 and an update was due no later than September 14, 2025; however, it was not completed until October 10, 2025.
Client #4 was admitted on August 18, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 8, 2025 and an update was due no later than November 8, 2025; however, it was not completed until November 17, 2025.
Client #6 was admitted on April 3, 2025 and was discharged on October 24, 2025. A comprehensive treatment plan was developed on April 14, 2025 and an update was due no later than June 14, 2025; however, it was not completed until July 22, 2025.
Client #7 was admitted on April 7, 2025 and was discharged on July 17, 2025, 2025. A comprehensive treatment plan was developed on April 14, and an update was due no later than June 14, 2025; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the December 16, 2022, June 27, 2023, December 19, 2023, and October 16, 2024 annual licensing inspection.
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Plan of Correction
All clinical staff will be required to schedule the next treatment plan update session with their client at the time of creation or update of said treatment plan. This appointment is to be entered into EMR/personal calendar at the time of the appointment being established to ensure compliance. Clinical staff must present upcoming 60-day deadlines during weekly staff meeting as a means of creating structural accountability and shared visibility of deadlines with peers and supervisors. The Clinical Director and/or Clinical Supervisor will conduct monthly audits of active treatment plans for verification of compliance with treatment plan requirements related to frequency of treatment plan updates. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of outpatient client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in three out of three applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed seven days following discharge. No follow-up information was documented.
Client #5 was admitted on June 4, 2025 and discharged on October 21, 2025.
Client #6 was admitted on April 3, 2025 and discharged on October 24, 2025.
Client #7 was admitted on April 7, 2025 and discharged on July 17, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 16, 2024 annual licensing inspection.
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Plan of Correction
Pursuant to regulation 709.93(a)(11), it was found that follow up contact was not documented for clients #5, #6 & #7 discharged from the program.
Leadership team met and designated that all follow up contacts in CRM to be completed by Alumni Coordinator overseen by Program and Business Development Manager.
Program and Business Development Manager will review all discharges weekly and audit CRM of discharged clients to ensure follow up contacts are made by Alumni Coordinator. Program and Business Development Manager will report weekly CRM audit reports to Chief Clinical Officer to safeguard that facility is within compliance of regulation 709.93(a)(11).
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of personnel and client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for mandatory communicable disease training were submitted and approved by the Department for the January 1,2018, January 24, 2020, October 21, 2020, October 22, 2021, December 16, 2022, June 27, 2023, December 19, 2023 and October 16, 2024 licensing inspections. Mandatory communicable disease training was again found to be deficient in the November 18, 2025 licensing inspection.
Plans of correction for failing to document that treatment plan updates were submitted and approved by the Department for the December 16, 2022, June 27, 2023, December 19, 2023, and October 16, 2024 licensing inspections. Treatment plan updates was again found to be a deficiency in the November 18, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will implement a quarterly interdisciplinary team meeting between Project Manager, Program Director, Clinical Supervisor, HR, and administrative department leaders to review the status of training logs (with specific attention paid to the status of communicable diseases trainings), treatment plan update logs, plan of correction related deadlines, and compliance with any adjustments made to policies and procedures as a result of the current plan of corrections. Employee files will be reviewed by Program Director quarterly to ensure that compliance with training expectations. Program Director and Clinical Supervisor will conduct a plan of corrections compliance check on a monthly basis during clinical team meetings to ensure that training is being completed in a timely manner and that all staff are appropriately auditing client charts for overall treatment plan compliance. |