INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection. The physical plant inspection was conducted on July 13, 2026, and the client record review was conducted on July 15, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Truenorth Wellness Services 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of administrative documents from August 2025- June 2026, the facility failed to conduct unannounced fire drills in five out of eleven months reviewed.
There was no documentation of an unannounced fire drill occurring during the months of August, September, October, November and December 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following steps will be put into place to ensure fire drills are completed every month:
1. The Quality Improvement Coordinator will ensure monthly fire drill completion by sending emails to the Building Supervisor to complete monthly fire drill by the end of each month starting August 2026.
2. The Building Supervisor coordinates with the Facility Manager, as needed, to notify the Fire Department of monthly fire drill.
3. The Quality Improvement Coordinator will email completed fire drill log every month to the SUT OP Manager.
4. The SUT OP Manager will place completed monthly fire drill log in location specific electronic file.
5. The SUT OP Manager will notify Quality Improvement Coordinator if completed fire drill log is not received by the last week of each month.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of administrative documents from August 2025 - June 2026, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative in six out of six applicable fire drill records reviewed.
The written fire drill logs in the months of January and February 2026 did not have documentation of the exit route used during the drill or if the fire alarm or smoke detector was activated during the drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following steps will be put into place to ensure fire drill logs are completed accurately each month:
1. The Quality Improvement Coordinator will update the fire drill log to include exit route used during the drill and if the method of notification activated during the drill by August 1st, 2026.
2. The Quality Improvement Coordinator will review the fire drill log updates with Building Supervisors by August 7th, 2026.
3. Building Supervisors will complete updated fire drill logs for monthly fire drill by August 31st, 2026.
4. Building Supervisors send completed fire drill logs to Quality Improvement Coordinator who then sends to SUT OP Manager.
5. SUT OP Manager will review fire drill log to ensure exit route and method of notification are completed on each log.
6. SUT OP Manager will contact Building Supervisor for missing data to ensure correct form completion.
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709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document individual treatment and rehabilitation plans were developed with the client and completed within thirty days of admission, per facility policy, in three out of seven records reviewed.
Client #1 was admitted on March 31, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 30, 2026; however, it was not completed until May 13, 2026. There was no documentation that the plan was developed with the client.
Client #2 was admitted on March 5, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 4, 2026; however, it was not completed until April 23, 2026. There was no documentation that the plan was developed with the client.
Client #4 was admitted on December 31, 2025, and discharged on June 11, 2026. The comprehensive treatment plan completed on January 13, 2026, did not include documentation that it was developed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For Client #1, Client #2 and Client #4 (discharged) the treatment plan was not completed within 30 days of the first treatment visit and the client signatures were not obtained to show participation in development of the treatment plan.
To address both of the issues, the following steps will be taken by the Facility Director:
1. Facility Director will hold a staff meeting in mid-August (currently scheduled for 8/19/2026) to review policies related to treatment planning. Focusing on first treatment plans requiring client signatures and needing completion within 30 days of the first treatment visit.
2. Facility Director will also review during August individual supervision with staff.
3. Facility Director will follow the agency Quality Improvement audit policy, reviewing charts 3 times per year, to ensure this regulation is being met.
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