INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Bold Steps of PA LLC 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(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 personnel records and the facility ' s Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #7 was hired as a stress reduction contract staff on April 9, 2023 and was due to have the communicable disease training no later than April 9, 2025. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #8 was hired as a sound healing contract staff on April 16, 2023 and was due to have the communicable disease training no later than April 16, 2025. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Facility will ensure that all staff receive a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training within the required time of employment. Plan: Employee #7 and Employe #8 have been registered for the August 11, 2025, TB/STD web-based training. Ongoing: Each employee has a training plan for the year. Executive Director and HR will review assigned trainings with employees bi-annually to ensure employees are obtaining their required trainings. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form which included purpose of disclosure in one out of fourteen records reviewed.
Client #5 was admitted on March 4, 2025 and discharged on April 14, 2025. A release of information form dated March 7, 2025 was to a family member.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility will ensure that consents to release information are completed in their entirety. Plan: Clinical Director will complete a training during our next all staff meeting on how to complete a ROI as to not leave any blanks. Employees will sign off on the procedure. Client #5 is no longer in programing. Ongoing: Clinical Director will include review of consents in her current client weekly chart reviews. |
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 the review of partial hospitalization client records, the facility failed to document treatment plan updates within the regulatory timeframe in two of the six records reviewed.
Client #2 was admitted on November 14, 2024 and discharged on January 14, 2025. A treatment plan update was completed on December 12, 2024 and the next update was due no later than January 12, 2025; however, it was completed on January 14, 2025.
Client #6 was admitted on December 12, 2024 and discharged on February 24, 2025. A treatment plan update was completed on January 15, 2025 and the next update was due no later than February 15, 2025; however, it was completed on February 17, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility will ensure PHP treatment plan updates will be completed within the required 30-day regulatory time frame.
Plan: Clinical Director will track upcoming treatment plans and inform Counselors daily in morning meeting for the next 60 days. Client #2 and #6 are no longer in treatment. Ongoing: Clinical Director and case manager will send out a list weekly of upcoming treatment plans.
Monthly Clinical Director will check treatment plans for compliance. |
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 the review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in four of the nine records reviewed.
Client #8 was admitted on December 23, 2024 and discharged on April 14, 2025. A comprehensive treatment plan was completed on January 10, 2025 and an update was due no later than March 10, 2025; however, it was completed on March 14, 2025.
Client #14 was admitted on October 31, 2024 and discharged on March 10, 2025. A treatment plan update was completed on December 9, 2024 and the next update was due no later than February 9, 2025; however, none of was completed at the time of the inspection.
Client #16 was admitted on March 26, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 21, 2025 and an update was due no later than June 21, 2025; however, it was completed on June 25, 2025.
Client #17 was admitted on December 10, 2024 and was still active at the time of the inspection. . A treatment plan update was completed on January 7, 2025 and the next update was due no later than March 7, 2025; however, it was completed on April 2, 2025. In addition, the next update was due on June 2, 2025; however, it was completed on June 14, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility will ensure OP treatment plan updates will be completed within the required 60-day regulatory time frame.
Plan: Clinical Director will track upcoming treatment plans and inform Counselors daily in morning meeting for the next 60 days. Client #8, #14, are no longer in treatment. Client #16 and #17 will be updated as required if still enrolled in treatment Ongoing: Clinical Director and case manager will send out a list weekly of upcoming treatment plans.
Monthly Clinical Director will check treatment plans for compliance. |