INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 14, 2026 through September 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, St. Luke's Penn Foundation 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirement Facility Summary Report, the facility failed to ensure the Full-Time Equivalent counselor caseload in outpatient programs may not exceed 35 active clients.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee # 12 was hired as a counselor on September 26, 2021 and was still employed at the time of the inspection. Their ratio calculation was as follows: 6/40= .15(FTE); 6/.15 = 40 which equals a client/counselor ratio of 40:1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility staffing form was completed inaccurately due to a misunderstanding regarding the information required in the caseload column. As a result, the error was not corrected during the onsite inspection. To prevent future occurrences, the Facility Director will review and verify all caseload data for accuracy both at the time of the inspection and prior to the conclusion of the inspection process. The facility director will educate the program manager and clinical supervisor about completing the staffing form correctly by 10/12/2026 |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 the facility's August 2025 through July 2026 fire drill logs, the facility failed to maintain a complete written fire drill record, which is to include the documentation of the exit route used during the fire drill.
At the time of the inspection, the outpatient building's fire drill logs for the drills conducted during the months of December 2025 and May 2026 did not include documentation of which exit route was used for each drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/29/2026 the Facilities Manager re-educated facilities staff on the requirements for completing fire drill forms including ensuring that the form is completed in its entirety and that an exit route is being described during every drill. The facilities manager will audit the frill drill logs quarterly to ensure compliance with the regulation. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility's September 2025 through July 2026 fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every six months.
At the time of the inspection, the inpatient non-hospital/residential building's fire drill logs indicated sleeping hours fire drills were conducted during the months of September 2025 and June 2026; however, the two overnight fire drills were not conducted within six months of each other.
This is a repeat citation from the October 1, 2025, annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the facilities director will conduct one fire drill during hours of sleep one time per quarter. Fire drill reports will be given to the program manager monthly. The program manager will monitor overnight drill frequency to ensure compliance with the regulation. |
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 client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of three applicable client records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice.
Client # 12 was admitted to the inpatient non-hospital activity on February 25, 2026 and was discharged against medical advice on March 6, 2026. There was no documentation, in the record, indicating the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
This is a repeat citation from the October 1, 2025, annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Patient Care Manager sent an email communication to behavioral health technician and nursing staff on 10/5/2026 to remind staff of the requirement to notify the emergency contact when a client leaves treatment against medical advice. The Patient Care Manager will also review this policy at the monthly staff meeting on 10/13/2026.Nursing Clinical Coordinators are responsible for conducting chart audits to monitor compliance with this regulation. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be released on a consent to release information form in one of twenty-eight client records reviewed.
Client # 14 was admitted to the inpatient non-hospital activity on August 10, 2026 and was active at the time of inspection. There was a release of information form to a recovery house that was signed and dated by the client on August 27, 2026; however, the specific information to be released was not documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program manager re-educated clinical staff on how to complete a consent to release confidential information form (ROI) on 9/22/2026. The education focused on completing all elements of the ROI including specific information to be released. The clinical coordinator will monitor completion of ROI forms via monthly chart audits. |
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 a review of client records, the facility failed to include the purpose of the disclosure on a consent to release information form in one of twenty-eight client records reviewed.
Client # 14 was admitted to the inpatient non-hospital activity on August 10, 2026 and was active at the time of inspection. There was a release of information form to a recovery house that was signed and dated by the client on August 27, 2026; however, the purpose of the disclosure was not documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program manager re-educated clinical staff on how to complete a consent to release confidential information form (ROI) on 9/22/2026. The education focused on completing all elements of the ROI including the purpose of the disclosure. The clinical coordinator will monitor completion of ROI forms via monthly chart audits. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent to release information form was offered to the client in two of twenty-eight client records reviewed.
Client # 13 was admitted to the inpatient non-hospital activity on August 19, 2026 and was active at the time of inspection. There was a release of information form to a recovery house that was signed and dated by the client on September 3, 2026; however, there was no documentation in the record indicating a copy of the release form was offered to the client.
Client # 14 was admitted to the inpatient non-hospital activity on August 10, 2026 and was active at the time of inspection. There was a release of information form to a recovery house that was signed and dated by the client on August 27, 2026; however, there was no documentation in the record indicating a copy of the release form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program manager re-educated clinical staff on how to complete a consent to release confidential information form (ROI) on 9/22/2026. The education focused on completing all elements of the ROI including confirming that a copy of the completed form was offered to the client and that they accepted/refused. The clinical coordinator will monitor completion of ROI forms via monthly chart audits. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every fifteen days in three of five applicable client records reviewed.
Client # 11 was admitted to the inpatient non-hospital activity on February 18, 2026 and was discharged on March 18, 2026. The individual treatment and rehabilitation plan was completed on February 23, 2026 and the first update was due to be completed no later than March 10, 2026; however, the update was completed on March 13, 2026.
Client # 13 was admitted to the inpatient non-hospital activity on August 19, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 22, 2026 and the first update was due to be completed no later than September 5, 2026; however, the update was not completed as of the date of the inspection.
Client # 14 was admitted to the inpatient non-hospital activity on August 10, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 16, 2026, and the first update was due to be completed no later than August 31, 2026; however, the update was not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/22/2026, the program manager and clinical coordinator reviewed the policy related to conducting treatment plan reviews. Counselors were reminded that reviews must be conducted every 15 days for individuals remaining in treatment for less than 30 days. The Clinical Coordinator will conduct monthly chart audits to monitor 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 a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of six applicable client records reviewed.
Client #16 was admitted to the outpatient activity on March 12, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 7, 2026 and the first update was due no later than July 7, 2026; however, the update was completed on July 15, 2026.
Client #17 was admitted to the outpatient activity on May 20, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 3, 2026 and the first update was due no later than August 3, 2026; however, the update was completed on August 25, 2026.
Client #21 was admitted to the outpatient activity on December 5, 2025 and was discharged on March 30, 2026. The individual treatment and rehabilitation plan was completed on January 5, 2026 and the first update was due no later than March 5, 2026; however, the update was completed on March 23, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The treatment plan update policy will be reviewed in a group supervision with the Outpatient staff by10/31/2026. We will have staff complete an attestation indicating that they understand the policy that treatment plan updates are due within 60 days of the comprehensive treatment plan being created. If a client is not attending services at the time the update is due the primary counselor assigned will complete the treatment plan review without the client present and indicate that in the note. At the next session the client attends the treatment plan will be reviewed and signed by the client. Clinical supervisor will conduct monthly chart audits to ensure this regulation 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 and the facility's policy and procedure manual, the facility failed to maintain a complete client record, which is to include the documentation of case consultation notes, in five of six applicable client records reviewed.
The facility's policy and procedure manual stated case consultations will occur every three months.
Client #15 was admitted to the outpatient activity on March 29, 2026 and was still active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client #16 was admitted to the outpatient activity on March 12, 2026 and was still active at the time of the inspection. A case consultation should have been completed no later than June 12, 2026; however, a case consultation was completed on July 6, 2026.
Client #17 was admitted to the outpatient activity on May 20, 2026 and was still active at the time of the inspection. A case consultation should have been completed no later than August 20, 2026; however, a case consultation was completed on September 1, 2026.
Client #18 was admitted to the outpatient activity on November 17, 2025 and was discharged on April 13, 2026. A case consultation should have been completed no later than February 17, 2026; however, a case consultation was completed on April 2, 2026.
Client #21 was admitted to the outpatient activity on December 5, 2025 and was discharged on March 30, 2026. A case consultation should have been completed no later than March 5, 2026; however, a case consultation was completed on March 30, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The case consultation policy will be reviewed in a group supervision with the Outpatient staff by 10/31/2026. We will have staff complete an attestation indicating that they understand the policy that case consultations are due every 90 days for clients in treatment less than one year and annually for clients in treatment over one year. Clinical supervisor will conduct monthly chart audits to ensure this regulation is being met. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of an aftercare plan, in one of three applicable client records reviewed.
Client #21 was admitted to the outpatient activity on December 5, 2025 and was discharged on March 30, 2026. There was no aftercare plan documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 10/31/2026 the clinical supervisor will review the aftercare policy with counselors in group supervision. Counseling staff will sign an attestation that the policy was reviewed and that they understand the policy. The clinical supervisor will monitor compliance via monthly chart audits. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in two of three applicable client records reviewed.
The facility's policy and procedure manual stated follow-up information will occur within seven days after discharge.
Client #20 was admitted to the outpatient activity on August 27, 2025 and was discharged on December 17, 2025. The follow-up should have been completed no later than December 24, 2025; however, the follow-up information was completed on January 7, 2026.
Client #21 was admitted to the outpatient activity on December 5, 2025 and was discharged on March 30, 2026. The follow-up should have been completed no later than April 6, 2026; however, the follow-up information was completed on April 29, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will review the follow up and aftercare policy with front desk staff by 10/31/2026. They will sign an attestation which indicates their understanding of the policy ensuring that the follow-up call and documentation of that call will be made within 7 days of successful completion of treatment. Clinical supervisor will review a sample closed client charts quarterly to ensure this regulation is being met. |