INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on September 17-18, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site investigation, UHS Recovery Foundation, 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 investigation:
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Plan of Correction
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of rehab patient records and facility policies, the facility failed to follow written procedures for the management of treatment/rehabilitation services for clients.
The facility ' s "Patient Observation Rounds " policy notes that " patients will be monitored every Q 60 minutes for Rehab ... "
Client # 4 was admitted on September 7, 2026, and was still active at the time of the investigation. It was observed by DDAP staff that on September 17, 2026, rounds for this client were not completed as per the facility ' s policy. The rounding log noted the following rounding times for September 17, 2026:
this round should have been completed no later than 16:58hrs.
this round should have been completed no later than 18:25hrs.
this round should have been completed no later than 20:07 hrs.
These findings were reviewed with facility staff during the complaint investigation process.
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Plan of Correction
Responsible staff for late rounding was addressed for late rounding immediately following finding on 9/18/2026.
Leadership formed a Performance Improvement Team on 9/25/2026 which put in place 1. leadership rounding checks on boards daily; 4 times per day; 2. weekly compliance checks; and 3. more structured corrective action plan upon compliance checks falling below the benchmark. All rounding staff were met with and informed of goals and expectations on 9/28/2026.
Overall monthly compliance of rounding is reviewed monthly in the Performance Improvement Committee however; this PIT will be addressing staff and deficiencies weekly when compliance is not meeting the benchmark. Leadership will follow HR policies for corrective actions for compliance within rounding. |
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.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services.
Client #1 was admitted on September 6, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 11, 2026, with no type or frequency identified.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Quality Assurance immediately reeducated all Primary Therapists of the treatment plan requirement for type and frequency development.
All active patient's treatment plans noted with deficiencies during inspection were immediately addressed, corrected and implemented with the patient.
Ongoing, the Director of Quality Assurance will audit 20 open charts monthly for the inclusion of type and frequency of treatment within the master treatment plan. The compliance of the monthly audit will be reported to the Performance Improvement Committee. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on a review of rehab client records, the facility failed to provide a complete client record, which is to include a discharge summary.
Client #5 was admitted on June 11, 2026, and was discharged on June 29, 2026. There was no discharge summary documented in this client ' s record.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
The Director of Quality Assurance reeducated the Medical Director and Psychiatric Team on the requirement for completion of the discharge summaries for all discharges.
The deficient record was addressed and corrected on 9/18/2026- the discharge summary was completed and retained in the medical record.
Ongoing, the Director of Quality Assurance will audit 100% of the discharges to ensure compliance. Monthly, the compliance will be reported to the Performance Improvement Committee. |