INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 30, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Oil Region Recovery, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the personnel training records, the facility failed to ensure one counselor completed at least 25 clock hours of annual training in one of three records.
Employee #3 was hired as counselor on November 27, 2023 and still employed. Employee #3 documented 21 hours of training for the July 1, 2024 to June 30, 2025 training year.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The identified counselor's training record will be reviewed. Required annual training hours will be prorated and monitored quarterly to prevent end-of-year deficiencies. Automated reminders or calendar tracking will be utilized to notify staff and supervisors of upcoming training deadlines. Training requirements will be incorporated into staff performance evaluations. All clinical staff will receive training on: Annual training requirements (minimum 25 clock hours) Acceptable training topics and documentation standards Training will be conducted by the Clinical Supervisor and will include: Review of DDAP training requirements Instruction on proper documentation and submission of training certificates. ORR will be in compliance 5/5/26 |
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.
|
Observations
Based on a review of administrative information and staff interview, the project failed to document an annual financial audit for the year end 2024.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The accounting firm used by Oil Region Recovery has changed due to their inability to accommodate our needs. The new firm is able to have the audit completed in the time frame we require. Project Director will have quarterly reviews with the accounting firm to ensure the audit remains on target for completion. ORR will be in compliance by 5/10/26 |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff 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.
|
Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in three of three applicable client records.
There was no documentation in the following client records to verify that an involuntary termination letter was provided to the client.
Client #4 admitted to the detoxification level of care on December 4, 2025 and discharged on December 6, 2025.
Client #10 admitted to the residential level of care on October 2, 2025 and discharged on October 23, 2025.
Client #11 admitted to the residential level of care on September 12, 2025 and discharged on September 24, 2025.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The letter clients were offered at time of DC is now being given, not offered so they have a copy at the time of DC indicating why they are being DC and the status of their DC. Administrative assistant and admin Director have updated the document. All program Assistant staff will be trained by the Program Assistant Supervisor in staff meetings on 5/2/26. This will be updated as of 5/2/26, implemented and followed by the Administrative Director. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on a review of administrative information, the facility failed to inform the Department of an unusual incident.
The facility had unusual incidents occur on June 22, 2025, November 19, 2025, and February 28, 2026 which involved ambulance or fire personnel onsite and the facility did not submit an incident report to the Department.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor will: Review all incident reports within 24 hours of submission Ensure timely escalation to the Program Director. The Program Director will: Verify that all reportable incidents are submitted to the Department within required timeframes, Address any delays or failures immediately with corrective action. The Clinical Supervisor is responsible for: Initial review and tracking of incidents, Ensuring staff compliance with reporting procedures. The Program Director is responsible for: Final determination of reportability, Submission to the Department, Overall compliance with incident reporting regulations. ORR will be in compliance as of May 8th |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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.
|
Observations
Based on a review of the client records, the facility failed to include the type and frequency of treatment and rehabilitation services on the treatment plan in the residential level of care in five of seven records.
Client #8 admitted August 20, 2025 and discharged September 10, 2025. Treatment plan was developed on August 23, 2025 and did not include type and frequency of treatment and rehabilitation services.
Client #9 admitted September 12, 2025 and discharged September 27, 2025. Treatment plan was developed on September 15, 2025 and did not include type and frequency of treatment and rehabilitation services.
Client #11 admitted September 12, 2025 and discharged September 24, 2025. Treatment plan was developed on September 17, 2025 and did not include type and frequency of treatment and rehabilitation services.
Client #13 admitted January 16, 2026 and discharged February 4, 2026. Treatment plan was developed on January 19, 2026 and did not include type and frequency of treatment and rehabilitation services.
Client #14 admitted February 7, 2026 and still a current client. Treatment plan was developed on February 10, 2026 and did not include type and frequency of treatment and rehabilitation services.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Treatment plans will include Type of treatment services and the Frequency of services. Monthly random chart audits will specifically review treatment plan completeness in residential records. Clinical staff will have In-service explaining the procedure for adding type and frequency of services to the treatment plan. In-service will be completed by 5/8/26. Clinical Director and Lead counselor will track adherence to the protocol. |
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.
|
Observations
Based on a review of client records, the facility failed to complete treatment plan updates at least every 60 days in three of seven outpatient client records.
Client #15 admitted August 13, 2025 and discharged January 16, 2026. A treatment plan was completed on October 15, 2025 and an update was due by December 14, 2025 but not completed prior to discharge.
Client #18 admitted August 21, 2025 and discharged January 23, 2026. A treatment plan was completed on November 5, 2025 and an update was due by January 4, 2026 but not completed prior to discharge.
Client #20 admitted October 20, 2025 and still a current client. A treatment plan was completed on January 12, 2026 and an update was due by March 13, 2026 but not completed prior to inspection.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from April 14, 2025 annual licensure inspection.
|
Plan of Correction
All clinical staff will receive training on: 60-day treatment plan update requirements for outpatient services, Proper documentation of client progress and plan revisions, Use of internal tracking tools and due date monitoring systems, Training will be conducted by the Clinical Supervisor and will include: Review of compliant vs. non-compliant treatment plan timelines Case-based examples demonstrating proper updates, Training will occur 5/7/26. The Clinical Supervisor will: Conduct monthly reviews of treatment plan due dates for all outpatient clients, Verify that no treatment plan exceeds the 60-day update requirement, Require immediate corrective action for overdue plans The Clinical Supervisor is responsible for: Monitoring treatment plan timelines. Method of Monitoring Compliance: Weekly tracking of all outpatient treatment plan due dates, Monthly chart audits focusing on timeliness of updates, Documentation of any late updates and corrective actions taken, Supervisory review of compliance trends. |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document case consultations in three of seven outpatient records.
The facility's policy and procedure states a case consultation must be completed every 30 days. There were no case consultations in the following client records.
Client #16 admitted August 14, 2025 and discharged January 16, 2026.
Client #19 admitted September 16, 2025 and still a current client.
Client #20 admitted October 20, 2025 and still a current client.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
A 30-day Case Consultation Tracking Log will be implemented for all outpatient clients. A supervisory sign-off requirement will be added to confirm documentation of each consultation within required timeframes. Case consultation compliance will be reviewed by Clinical Supervisor during monthly chart audits. All clinical staff will receive training on: Policy requirement for case consultations every 30 days, proper documentation standards for case consultations, Required elements (participants, clinical discussion, decisions, and follow-up actions) Training will be conducted by the Clinical Supervisor and will include: Review of policy expectations, Examples of properly documented consultations, Training will be provided by 5/7/26 |