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 August 5, 2026, and the client record review was conducted on August 13, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Treatment & Healing - Milton 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)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to follow their staff development program to have a mechanism to collect feedback on trainings completed by the employee following each training, per facility policy, in three out of three applicable records reviewed.
Employee #1 was hired as the project director on May 22, 2023, and was still in that position at the time of the inspection. Employee #1 completed the required number of training hours for the July 2025 - June 2026 training year; however, there was no documentation of a mechanism to provide feedback following each training completed.
Employee #2 was hired as the facility director on September 18, 2017, and was still in that position at the time of the inspection. Employee #2 completed the required number of training hours for the July 2025 - June 2026 training year; however, there was no documentation of a mechanism to provide feedback following each training completed.
Employee #3 was hired as a counselor on May 10, 2021, and was still in that position at the time of the inspection. Employee #3 completed the required number of training hours for the July 2025 - June 2026 training year; however, there was no documentation of a mechanism to provide feedback following each training completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On August 24, 2026, the facility conducted a staff meeting during which the requirements of the agency's Staff Development Program were reviewed with all applicable personnel. Staff were specifically retrained on the requirement that a Training Evaluation/Feedback Form be completed following each training attended or completed, regardless of whether the training is completed internally, externally, in person, virtually, or through an online training platform.
The facility has implemented a standardized Training Evaluation/Feedback Form to provide a consistent mechanism for employees to evaluate completed trainings. The form includes an opportunity for the employee to document the relevance of the training to their job responsibilities, effectiveness of the training, knowledge or skills gained, applicability to service delivery, and recommendations for future training needs.
Effective immediately, each employee is responsible for completing a Training Evaluation/Feedback Form following each completed training. The completed evaluation will be submitted with the corresponding training certificate or other documentation of training completion and maintained as part of the employee's staff development/training record.
The Project Director or designee will be responsible for ensuring compliance with this requirement. Training documentation will be reviewed monthly to verify that each documented training has a corresponding completed feedback/evaluation form. Training documentation will not be considered complete until both the documentation of attendance/completion and the required training feedback form are present.
If a monthly review identifies a completed training for which the required feedback form is missing, the employee will be notified and required to complete the missing documentation within five business days. The employee will also receive individual retraining regarding the agency's Staff Development Program requirements. Continued failure to complete required training feedback documentation will be addressed through the agency's progressive disciplinary process. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection on August 5, 2026, the facility failed to light interior exits and stairs at all times, as the emergency exit on the second floor of the facility led to an unlit stairwell.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately following notification of the deficiency, the facility addressed the lighting issue associated with the second-floor emergency exit and stairwell. Appropriate lighting was installed/restored to ensure that the stairwell and emergency egress route remain adequately illuminated and safely accessible at all times.
To prevent recurrence, the facility has incorporated verification of all emergency exits, exit routes, hallways, and stairwells into its routine facility safety inspections. The designated Facility Director or designee will conduct and document a monthly physical plant safety inspection, which will include verification that lighting along all emergency egress routes is operational and sufficient for safe evacuation.
In addition, emergency exit and stairwell lighting will be visually checked during the facility's monthly random emergency preparedness drills. Any lighting deficiency identified during an inspection, drill, or routine facility operation will be reported immediately to the Facility Director or Project Director. Corrective action will be initiated promptly, and any area that cannot be safely utilized will not be considered an available emergency egress route until the deficiency has been corrected.
Documentation of monthly inspections and any corrective actions taken will be maintained by the facility and made available for review during future licensing inspections.
The Facility Director will be responsible for ongoing monitoring of compliance, with oversight by the Project Director. This monitoring process is intended to ensure that all emergency exits and stairways remain properly illuminated and that the facility maintains safe and accessible emergency evacuation routes at all times. |
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 that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Employee #4 was hired on May 11, 2026, as a counselor and was still in the position as of the date of the inspection. There was no documentation in the employee record to show that training on emergency procedures at the facility was completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On August 24, 2026, a facility-wide training was conducted with staff regarding fire safety, emergency preparedness procedures, evacuation protocols, and individual staff responsibilities during an emergency event. During this training, emergency procedures were reviewed in detail, and each staff member was assigned a specific role and responsibility to perform during an emergency. This training was conducted by the Project Director, who will be responsible for ensuring that all steps of the corrective action are taken and employed consistently.
Following the training, each employee completed and signed an Emergency Preparedness Training Attestation acknowledging that they received training on the facility's emergency procedures, understand their individually assigned emergency responsibilities, and understand the actions they are expected to take during an emergency. The employee's specific assigned emergency role was documented on the attestation. The completed attestations were signed by both the employee and supervisor and placed in each employee's personnel file, including the personnel record of Employee #4.
To ensure continued compliance, all newly hired personnel will receive facility-specific fire safety and emergency preparedness training as part of the orientation process and prior to being assigned independent responsibilities within the facility. Documentation of the training and the employee's assigned emergency role will be maintained in the employee's personnel record.
The facility will conduct random emergency preparedness drills monthly to evaluate staff knowledge of emergency procedures and their ability to perform assigned responsibilities. Participation and results of the drills will be documented. If an employee is unable to demonstrate knowledge of or appropriately perform their assigned emergency responsibility during a drill, the employee will receive documented retraining.
Additionally, annual refresher training on fire safety and emergency preparedness procedures will be provided to all staff. Emergency assignments will be reviewed and modified as necessary when staffing changes occur to ensure adequate coverage of essential emergency functions on all shifts.
The Facility Director or designee will monitor compliance through monthly review of emergency preparedness documentation and personnel records. The Project Director will provide additional oversight to ensure that required training documentation remains current and available for review. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of seven records reviewed.
Client #5 was admitted on September 9, 2025, and was active at the time of inspection. There was no documentation that the facility obtained an informed and voluntary consent for this client for the funding source. The facility confirmed that the funding source was billed for the services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon notification of the deficiency, the facility reviewed its procedures related to obtaining and documenting informed and voluntary consent for the disclosure of client information. The facility recognizes that appropriate authorization must be obtained and documented prior to the disclosure of protected client information to applicable funding sources, consistent with confidentiality requirements and facility policy.
On August 31, 2026, a mandatory staff training will be conducted for all applicable clinical and administrative personnel. The training will review the proper completion of informed and voluntary consent forms, including identification of the specific individual or entity to whom information may be disclosed, the purpose and extent of the disclosure, applicable expiration provisions, required signatures and dates, and documentation of whether the client accepted or declined a copy of the consent. Particular emphasis will be placed on ensuring that an appropriate consent is completed for the client's applicable funding source when disclosure of protected client information is necessary for billing or authorization purposes. This training will be provided by the Project Director who will then be responsible for ensuring that the corrective action is upheld through the monitoring process.
Following the training, staff will be required to acknowledge their understanding of the consent and confidentiality requirements. Documentation of attendance and completion of the training will be maintained by the facility.
The record of Client #5 will be reviewed immediately, and the appropriate informed and voluntary consent for the funding source will be obtained and properly documented in the client record. Additionally, applicable active client records will be reviewed to identify and correct any similar deficiencies.
To ensure continued compliance, the Clinical Supervisor or Project Director will conduct monthly random chart audits consisting of three records from each clinician and each applicable level of care. The audits will include verification that required consents are present, properly completed, current, and appropriately authorize disclosures being made by the facility.
If an audit identifies a missing, incomplete, or otherwise invalid consent, the responsible clinician will be notified and will have seven calendar days to contact the client and correct the deficiency. The record will be re-reviewed within 10 calendar days to verify correction. If the deficiency has not been appropriately corrected, the employee will receive documented one-on-one retraining regarding consent and confidentiality requirements. Repeated deficiencies will be addressed through the facility's progressive disciplinary process.
This corrective action and monitoring process will be incorporated into ongoing quality assurance activities to ensure that client information is disclosed only when appropriate informed and voluntary consent has been obtained and documented. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent which included the dated signature of the client in two out of seven records reviewed.
Client # 4 was admitted on May 27, 2026, and discharged on June 25, 2026. The client record contained a release of information form to a funding source that included the client signature; however, it did not include the date the client signed. The facility acknowledged that the funding source was billed for the services.
Client #6 was admitted on May 6, 2026, and was active at the time of inspection. The client record contained a release of information form to a funding source that listed the date of May 6, 2026, in the body of the form; however, the client signature itself was not dated. The facility acknowledged that the funding source was billed for the services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On August 31, 2026, the facility will conduct a mandatory training for all applicable clinical and administrative staff regarding the proper completion of informed and voluntary consent/release of information forms. The training will specifically address all required components of a valid consent, with particular emphasis on ensuring that each client signature is accompanied by the date on which the client signed the consent. This training will be provided by the Project Director who will be responsible for ensuring that the corrective action is implemented and followed consistently.
During the training, staff will review the facility's consent procedures and be instructed that a date appearing elsewhere within the body of the consent form does not replace the requirement for the client's signature to be properly dated. Staff will also be reminded to review each consent for completeness before it is accepted, utilized for disclosure, or filed in the client record.
The training will include review of the required elements of informed and voluntary consent, including the specific person or organization to whom disclosure is authorized, the specific information to be disclosed, the purpose of the disclosure, expiration or revocation provisions as applicable, the client's signature and date of signature, and documentation regarding whether the client accepted or declined a copy of the consent.
Documentation of staff attendance and completion of the August 31, 2026 training will be maintained by the facility.
The record for Client #6, who remains active in treatment, will be reviewed and the deficient consent will be corrected by obtaining a properly completed and dated consent from the client, as applicable. The record for Client #4, who has been discharged, will remain unchanged so that documentation is not improperly altered after discharge; however, the identified deficiency will be incorporated into staff retraining and ongoing monitoring efforts.
To ensure continued compliance, the Clinical Supervisor or Project Director will conduct monthly random chart audits consisting of three client records from each clinician for each applicable level of care. The audit will include review of all applicable consent forms to ensure that they are complete and contain all required elements, including the client's signature and corresponding date.
If a current client record is identified as containing a missing, incomplete, or otherwise invalid consent, the responsible clinician will be notified and given seven calendar days to contact the client and obtain a properly completed consent. The record will then be re-reviewed within 10 calendar days to verify that the deficiency has been corrected.
If the deficiency remains unresolved following the corrective period, the responsible staff member will receive documented one-on-one refresher training regarding informed and voluntary consent requirements. Repeated occurrences will be addressed through the facility's progressive disciplinary process. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an onsite licensing inspection, the facility failed to develop a data collection and recordkeeping system that allowed for the identification of clients ' admissions and discharges within a specific time period.
The list provided by the facility was broken down by counselor caseloads and did not include the admission dates or discharge dates since the last annual inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency was addressed the day following the licensing inspection. The facility immediately revised its client tracking system to ensure that admissions and discharges can be readily identified and reviewed for any specified period of time.
A centralized Admission and Discharge Tracking Log was developed and implemented. The tracking log is maintained separately from individual counselor caseload lists and includes, at minimum, the client's name or identifying information, date of admission, assigned level of care, assigned clinician, discharge date when applicable, and discharge status/type. Active clients without a discharge date are clearly identified as currently enrolled.
The revised system allows facility leadership to identify all clients admitted and/or discharged during a requested time period without having to compile information from individual clinician caseloads.
Administrative staff will be responsible for updating the centralized tracking log as admissions and discharges occur. The Facility Director or designee will review the log monthly to verify that newly admitted and discharged clients have been accurately entered and that applicable admission and discharge dates are documented.
As an additional quality-assurance measure, the Facility Director or designee will periodically compare the Admission and Discharge Tracking Log with the facility's current census and individual counselor caseloads to identify and correct any discrepancies.
Any discrepancy identified during monitoring will be corrected promptly. If an employee responsible for maintaining the tracking system demonstrates difficulty with the procedure, additional instruction and retraining will be provided.
The centralized Admission and Discharge Tracking Log will be maintained on an ongoing basis and will be available for review during future licensing inspections to demonstrate admissions and discharges occurring between annual inspections or during any other specified reporting period. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the 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 one out of two applicable client records reviewed.
Client #4 was admitted on May 27, 2026, and discharged on June 25, 2026. There was no documentation that the client was notified of the decision to involuntarily terminate the client ' s treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On August 24, 2026, the facility addressed this deficiency during a team meeting with applicable clinical staff. During the meeting, the facility's procedures regarding involuntary termination of treatment and the required use of written termination notices were reviewed. This training was conducted by the Project Director who is responsible for ensuring that the corrective action is upheld via routine monitoring.
Staff were instructed that when a client is involuntarily terminated from treatment, the client must be provided with written notification of the facility's decision. The written termination notice must be completed and a copy maintained in the client's record as documentation that the required notification was provided. Staff were also reminded to document the method by which the notice was provided or sent to the client.
The training emphasized that documentation of the reason for discharge within a progress note, discharge summary, or other clinical documentation does not replace the requirement for a written termination notice when a client is involuntarily discharged.
To ensure continued compliance, the Clinical Supervisor or Project Director will conduct monthly random chart audits consisting of three records from each clinician for each applicable level of care. Discharged records included in the audit will be reviewed to determine whether the discharge was voluntary, successful, or involuntary. For all involuntary terminations, the reviewer will verify that a written termination notice is present in the client record.
If an involuntary discharge is identified without the required written notification, the responsible clinician will receive immediate documented retraining regarding the facility's involuntary termination procedures. When the client record remains active or corrective notification remains appropriate, the required documentation will be completed promptly. The facility will not backdate or otherwise alter previously completed records.
Repeated failure to follow the facility's involuntary termination procedures will be addressed through the facility's progressive disciplinary process. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in six out of seven applicable records reviewed.
Client #1 was admitted on October 4, 2023, and was discharged on June 16, 2026. The treatment plan dated April 12, 2026, indicated individual sessions once per month. There was no documentation that the client received an individual counseling session in the month of May or June 2026.
Client #2 was admitted on February 27, 2026, and was discharged on May 20, 2026. The treatment plan dated March 19, 2026, indicated individual sessions once per week. There was no documentation of an individual session the week of April 19 -25, 2026.
Client #3 was admitted on September 23, 2025, and was discharged on December 11, 2025. The treatment plan dated September 23, 2025, indicated individual and group sessions once per week. There was no documentation of any group sessions between September 23, 2025 and December 11, 2025. There was no documentation of any individual sessions in the weeks of September 28, 2025 - October 4, 2025, October 5-11, 2025, October 19-25, 2025, October 26, 2025 - November 1, 2025, November 16-22, 2025, or November 23-29, 2025.
Client #5 was admitted on September 9, 2025, and was still active at the time of the inspection. The treatment plan dated May 30, 2026, indicated individual sessions once per week. There was no documentation of any individual sessions May 31, 2026 - June 6, 2026, or June 21-27, 2026.
Client #6 was admitted on May 6, 2026, and was still active at the time of the inspection. The treatment plan dated June 15, 2026, indicated individual sessions once per week. There was no documentation of any individual sessions the weeks of June 21-27, 2026, July 5-11, 2026, July 19-25, 2026, or July 26, 2026 - August 1, 2026.
Client #7 was admitted on March 20, 2026, and was still active at the time of the inspection. The treatment plan dated April 17, 2026, indicated individual sessions once per week, and the treatment plan update dated June 17, 2026, indicated individual sessions biweekly. There was no documentation that the client received any individual sessions the weeks of May 24-30, 2026, or May 31, 2026 - June 6, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On September 8, 2026, the facility will conduct a mandatory training for all applicable clinical staff regarding the requirement to provide and document counseling services in accordance with each client's current individualized treatment and rehabilitation plan. The Project Director will provide this training and will be responsible for ensuring that the corrective action is upheld and followed.
The training will specifically address the importance of ensuring that the type and frequency of services identified on the treatment plan accurately reflect the client's current clinical needs and the services being provided. Staff will be instructed to review each client's current treatment plan when scheduling and providing services and to ensure that required individual and group counseling sessions occur at the frequency specified in the plan.
The training will also reinforce that when a scheduled service does not occur due to client cancellation, no-show, hospitalization, incarceration, clinician absence, or another circumstance, the reason for the missed service must be appropriately documented in the client record. Clinical staff will be instructed to make reasonable efforts to reschedule missed services when clinically appropriate and to document those efforts.
Staff will further be trained that if a client's clinical needs, progress, availability, or level of care indicate that the established frequency or type of counseling services is no longer appropriate, the treatment plan must be reviewed and updated in accordance with applicable requirements rather than allowing the documented treatment plan and actual service delivery to remain inconsistent.
Documentation of attendance at the September 8, 2026 training will be maintained by the facility.
To ensure ongoing compliance, the Clinical Supervisor or Project Director will conduct monthly random chart audits consisting of three client records from each clinician for each applicable level of care. During these audits, the reviewer will compare the type and frequency of services identified on the client's current treatment plan with the actual counseling services documented in the record.
If an audit identifies that services were not provided or appropriately documented according to the treatment plan, the responsible clinician will be notified and the record will be reviewed to determine the reason for the discrepancy. When corrective documentation or an appropriate treatment plan update can be completed, the clinician will be required to address the deficiency within seven calendar days. The record will be re-reviewed within 10 calendar days to verify compliance. Documentation will not be backdated or altered to indicate that a service occurred when it did not.
The clinician will also receive documented one-on-one retraining regarding treatment plan implementation and service-frequency requirements when a deficiency is identified. Repeated failure to provide and/or appropriately document services according to the individualized treatment plan will be addressed through the facility's progressive disciplinary process.
Additionally, Clinical Supervisors will reinforce treatment plan compliance during ongoing clinical supervision and case consultation meetings, including review of whether the client's prescribed service frequency remains clinically appropriate and is being met. |
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.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual that included information relative to the client ' s involvement with the project including case consultation notes at 30 days, 90 days, 180 days, 270 days, 365 days and annually following the biopsychosocial evaluation, per facility policy, in four out of seven records reviewed.
Client #1 was admitted on October 4, 2023, and was discharged on June 16, 2026. The case consultation dated September 22, 2025, did not indicate who the primary counselor consulted with for the case consultation.
Client #2 was admitted on February 27, 2026, and was discharged on May 20, 2026. The case consultations dated March 19, 2026, and May 20, 2026, did not indicate who the primary counselor consulted with for the case consultation.
Client #6 was admitted on May 6, 2026, and was still active at the time of the inspection. The case consultation dated May 6, 2026, did not indicate who the primary counselor consulted with for the case consultation. The 90-day case consultation was due August 4, 2026, per facility policy; however, there was no documentation that a 90-day case consultation was completed.
Client #7 was admitted on March 20, 2026, and was active at the time of inspection. A case consultation dated March 20, 2026, did not indicate who the primary counselor consulted with for the case consultation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On August 24, 2026, a team meeting was held with applicable clinical staff to review the facility's case consultation policies, documentation requirements, and staff responsibilities. During this meeting, the facility also reviewed and implemented an updated Case Consultation Policy. The Project Director facilitated the training and is responsible to ensure that the POC is upheld through routine monitoring.
Under the revised policy, formal case consultations will be required at the time of admission and at discharge, rather than at the previously established 30-, 90-, 180-, 270-, 365-day, and annual intervals. The policy was revised to establish a clear, consistent, and clinically meaningful process for interdisciplinary review while ensuring that required case consultation documentation is completed and maintained in the client record.
Staff were trained that each required case consultation must be documented in the client's record and include, at minimum, the date of the consultation, name of the primary counselor, name(s) and/or role(s) of the staff member(s) participating in the consultation, relevant clinical information discussed, treatment recommendations or decisions resulting from the consultation, and any follow-up actions indicated. Staff were specifically reminded that a case consultation must identify with whom the primary counselor consulted and cannot simply indicate that a consultation occurred.
The updated policy and expectations were reviewed with clinical staff during the August 24, 2026 meeting, and staff were informed that all case consultations occurring after implementation of the revised policy must comply with the updated requirements.
To ensure ongoing compliance, the Clinical Supervisor and/or Project Director will conduct monthly random chart audits consisting of three client records from each clinician for each applicable level of care. Audits will verify that required admission and discharge case consultations are present and that all required components, including identification of consultation participants, are documented.
If a required case consultation is found to be missing or incomplete, the responsible clinician will be notified and required to correct any correctable documentation deficiency within 72 hours. The clinician will also receive documented retraining regarding the case consultation policy and documentation requirements. Documentation will not be backdated or altered to indicate that a consultation occurred when it did not.
If subsequent audits identify repeated noncompliance with the case consultation policy, the matter will be addressed through the facility's progressive disciplinary process. |