INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, TUHS, Inc. 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure the FTE counselor caseload in outpatient programs did not exceed 35 active clients in one of three applicable personnel records reviewed.The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.Employee # 3 was hired as a clinical supervisor on March 4, 2024 and was still employed at the time of the inspection. The employee's ratio calculation was as follows: 18/40 = 0.45 (FTE); 29/0.45 = 64.4444, which equals to a client/counselor FTE ratio of 64:1.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the Facility and Project Directors will review client/counselor ratio monthly to monitor compliance with DDAP regulation 704.12. Adjustments to staffing patterns will be made in accordance with their findings and in coordination with TUHS Human Resources Department, specific to candidate recruitment and selection. |
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 personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon staff employment in one of two applicable personnel records reviewed.Employee # 1 was hired as the project director on March 4, 2024. There was documentation in the personnel record indicating the fire extinguisher training was not completed until July 23, 2024. This is a repeat citation from the June 27, 2024 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective June 30, 2025 all new hires will receive mandatory orientation materials that incorporates emergency preparedness and fire extinguisher training. The Facility Director will be responsible for ensuring completion of required orientation training. Within 72 hours of any new hire start date, the Facility Director will audit training materials to ensure 100% of new hire training has been completed. New hire staff will not be permitted to work beyond day 3 with any outstanding training requirements until they are satisfactorily completed. |
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 personnel records, the facility failed to ensure all personnel on all shifts are trained to perform assigned tasks during emergencies in one of three applicable personnel records reviewed.Employee # 1 was hired as the project director on March 4, 2024. There was documentation in the personnel record indicating the training to perform assigned tasks during emergencies was not completed until July 23, 2024. This is a repeat citation from the June 27, 2024 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective June 30, 2025 all new hires will receive mandatory orientation materials that incorporates emergency preparedness training. The Facility Director will be responsible for ensuring completion of required orientation training.
Within 72 hours of any new hire start date, the Facility Director will audit training materials to ensure 100% of new hire training has been completed. New hire staff will not be permitted to work beyond day 3 with any outstanding training requirements until they are satisfactorily completed. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on an administrative review of the facility's July 2024 through April 2025 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.At the time of the inspection, each monthly fire drill conducted during the timeframe reviewed indicated the front entrance was the only exit route utilized.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective June 16, 2025, fire drills will include practicing multiple exit points. Documentation of the alternative routes will be captured on monthly fire drill logs. The Facility Director will be responsible for ensuring completion of revised fire drill practices.
Monthly, the Facility Director will review fire drill log with Project Director demonstrating expectation was achieved with utilizing alternative evacuation routes. |
711.91(b)(1) LICENSURE Disclosure of Criteria
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, disclosure to the client of the criteria for admission, treatment, completion and discharge in eight of eight client records reviewed. In every client record reviewed, there was no documentation indicating the disclosure to the client of the criteria for admission, treatment, completion and discharge.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The SUD clinic does have new client orientation materials that disclose criteria for admission, treatment completion and discharge. These materials are provided during initial client intake. An acknowledgement form for receipt and understanding of these materials is signed by the client. This signed acknowledgement form is scanned into the electronic medical record. Effective June 16, 2025, the SUD clinic Office Manager will conduct a monthly audit of 100% of new client paperwork to monitor completion of the acknowledgement form. Monthly audits will continue until audit results are 100% compliant for 3 consecutive months.
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711.91(b)(2)(i) LICENSURE Project Policies orientation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, client orientation to the project in eight of eight client records reviewed. In every client record reviewed, there was no documentation indicating the client was provided any type of client orientation to the project.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The SUD clinic does have new client orientation materials. These materials are provided during initial client intake. An acknowledgement form for receipt and understanding of these materials is signed by the client. This signed acknowledgement form is scanned into the electronic medical record. Effective June 16, 2025, the SUD clinic Office Manager will conduct a monthly audit of 100% of new client paperwork to monitor completion of the acknowledgement form. Monthly audits will continue until audit results are 100% compliant for 3 consecutive months. |
711.91(b)(7) LICENSURE Preliminary Treatment Plan
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, a preliminary treatment and rehabilitation plan in six of seven applicable client records reviewed. Client # 1 was admitted on September 26, 2024 and was still active at the time of the inspection. There was no preliminary treatment and rehabilitation plan documented in the record at the time of the inspection.Client # 2 was admitted on January 25, 2025 and was still active at the time of the inspection. There was no preliminary treatment and rehabilitation plan documented in the record at the time of the inspection.Client # 3 was admitted on January 8, 2025 and was still active at the time of the inspection. There was no preliminary treatment and rehabilitation plan documented in the record at the time of the inspection.Client # 4 was admitted on December 11, 2024 and was discharged on February 20, 2025. There was no preliminary treatment and rehabilitation plan documented in the record at the time of the inspection.Client # 5 was admitted on January 10, 2025 and was discharged on April 4, 2025. There was no preliminary treatment and rehabilitation plan documented in the record at the time of the inspection.Client # 8 was admitted on December 11, 2024 and was discharged on January 30, 2025. There was no preliminary treatment and rehabilitation plan documented in the record at the time of the inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Policy number 712 will be updated effective June 16, 2025 to read: "a comprehensive treatment plan that is completed within 72 hours, will serve as both the preliminary and comprehensive treatment plan."
Effective June 23, 2025, the SUD clinic Office Manager will conduct a monthly audit of 100% of new client paperwork to monitor completion of the preliminary treatment plan. Monthly audits will continue until audit results are 100% compliant for 3 consecutive months. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan, which is to be developed with the client, in three of seven applicable client records reviewed. The facility policy and procedure manual states that the individual treatment and rehabilitation plan is to be completed within thirty days of admission.Client # 1 was admitted on September 26, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by October 26, 2024; however, the plan was not completed until April 21, 2025. Client # 4 was admitted on December 11, 2024 and was discharged on February 20, 2025. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection. Client # 5 was admitted on January 10, 2025 and was discharged on April 4, 2025. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection. This is a repeat citation from the June 27, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Provider education reinforcing this standard will be provided by June 16, 2025.
Beginning Ju1y 1, 2025, the treatment team will review 10% of treatment plans during bi-monthly clinical supervision meetings to ensure compliance with this standard. This review process will continue until audit results demonstrate 100% compliance for 3 consecutive months.
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711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five of five applicable client records reviewed.Client # 1 was admitted on September 26, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 21, 2025; however, there was no frequency of treatment and rehabilitation services documented on the plan.Client # 2 was admitted on January 25, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 16, 2025; however, there was no frequency of treatment and rehabilitation services documented on the plan.Client # 3 was admitted on January 8, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 29, 2025; however, there was no frequency of treatment and rehabilitation services documented on the plan.Client # 6 was admitted on October 4, 2024 and was discharged on March 31 2025. The individual treatment and rehabilitation plan was completed on October 4, 2024; however, there was no frequency of treatment and rehabilitation services documented on the plan.Client # 8 was admitted on December 11, 2024 and was discharged on January 30, 2025. The individual treatment and rehabilitation plan was completed on December 30, 2024; however, there was no frequency of treatment and rehabilitation services documented on the plan.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Provider education reinforcing this standard will be provided by June 16, 2025.
Beginning Ju1y 1, 2025, the treatment team will review 10% of treatment plans during bi-monthly clinical supervision meetings to ensure compliance with this standard. This review process will continue until audit results demonstrate 100% compliance for 3 consecutive months.
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711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of three applicable client records reviewed. Client # 2 was admitted on January 25, 2025 and was still active at the time of the inspection. The individual treatment plan was completed on January 16, 2025 and an update was due no later than March 16, 2025; however, the update was not completed until April 25, 2025. Client # 3 was admitted on January 8, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 29, 2025 and an update was due no later than March 29, 2025; however, the update was not completed at the time of the inspection.Client # 6 was admitted on October 4, 2024 and was discharged on March 31 2025. The individual treatment plan was completed on October 4, 2024 and an update was due no later than December 4, 2024; however, the update was not completed until February 27, 2025. Additionally, a treatment plan update was completed on February 27, 2025 and another update was due no later than April 27, 2025; however, it was not completed at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Provider education reinforcing this standard will be provided by June 16, 2025. Beginning Ju1y 1, 2025, the treatment team will review 10% of treatment plans during bi-monthly clinical supervision meetings to ensure compliance with this standard. This review process will continue until audit results demonstrate 100% compliance for 3 consecutive months.
Additionally, an audit of all active client charts will be completed by July 1, 2025 to identify any missing treatment plan reviews/updates. Those updates will be completed as appropriate. |
711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
711.93. 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:
(ii) The specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in one of eight client records reviewed. Client # 3 was admitted on January 8, 2025 and was still active at the time of the inspection. The release of information form to a probation officer was signed by the client and on January 15, 2025; however, the release form failed to include documentation of the specific information to be disclosed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The SUD clinic does informed consent forms indicating information to be disclosed. Effective June 16, 2025, the SUD clinic Office Manager will conduct a monthly audit of 100% of informed consent forms to monitor accurate completion. Monthly audits will continue until audit results are 100% compliant for 3 consecutive months.
In addition, an audit of all currently active clients will be completed by June 30, 2025 to identify any incomplete information and updated those forms as appropriate. |
711.93(c)(2)(iii) LICENSURE Purpose of Disclosure
711.93. 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 client records, the facility failed to document the purpose of the disclosure on release of information forms in four of eight client records reviewed.Client # 1 was admitted on September 26, 2024 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on September 24, 2024; however, the form did not include documentation of the purpose of the disclosure. Client # 3 was admitted on January 8, 2025 and was still active at the time of the inspection. The release of information form to a probation officer was signed by the client on January 15, 2025; however, the form did not include documentation of the purpose of the disclosure.Client # 6 was admitted on October 4, 2024 and was discharged on March 31 2025. The release of information forms to the funding source and an individual were signed by the client on October 4, 2025; however, the form did not include documentation of the purpose of the disclosure.Client # 7 was admitted on August 15, 2024 and was discharged on February 4, 2025. The release of information form to the funding source was signed by the client on August 15, 2024; however, the form did not include documentation of the purpose of the disclosure.This is a repeat citation from the June 27, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The SUD clinic does informed consent forms indicating purpose of disclosure.
Effective June 16, 2025, the SUD clinic Office Manager will conduct a monthly audit of 100% of informed consent forms to monitor accuracy in completion. Monthly audits will continue until audit results are 100% compliant for 3 consecutive months.
In addition, an audit of all currently active client charts will be completed by June 30, 2025 to identify any incomplete forms and update those forms as appropriate. |
711.96(b) LICENSURE Appeal of Termination
711.96. Notification of termination.
(b) The client shall have the opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.Client # 4 was admitted on December 11, 2024 and was administratively discharged on February 20, 2025. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective June 16, 2025, language instructing a client on how to appeal a termination of treatment has been included in the notification of termination letter template that is provided to any terminated patient. The Office Manager will ensure compliance with the use of this revised letter. |