INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on September 23-24, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site investigation, Resurrection House 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 investigation:
|
Plan of Correction
|
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
|
Observations
Based on the review of medication administration records, the facility failed to document the administration of medication. Client #1 was admitted on May 4, 2026, and discharged on August 4, 2026. Client #1 was prescribed Buprenorphine 2-8mgs, to be administered twice daily at 8:00 am and 8:00 pm. There was no documentation that this medication was administered on May 15, 2026, at 8:00 am and May 24, 2026, at 8:00 pm. These findings were reviewed with facility staff during the complaint investigation process.
|
Plan of Correction
Clinical supervisor re-educated all support staff responsible for medication observation on the proper protocol for missed medication observation and documentation. Clinical supervisor implemented a daily report that must be submitted to clinical supervisor for review on any missed medication observation. After report review, clinical supervisor will address with the staff any missed medication observations immediately. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan within timeframes established by the facility ' s policy. The facility's policy is to complete a preliminary treatment plan on the date of admission. Client #1 was admitted on May 4, 2026, and discharged on August 4, 2026. There was no preliminary treatment plan documented in the client record. This finding was reviewed with facility staff during the complaint investigation process.
|
Plan of Correction
Clinical Supervisor re-educated the admission/Intake specialist on the initial treatment plan policy and timeframes for completion. Clinical supervisor will monitor the completion of the initial treatment through weekly chart audits to ensure for compliance. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
|
Observations
Based on a review of client records, the facility failed to complete treatment plans within the timeframes established by facility policies. The facility ' s policy is to complete the comprehensive treatment plan within seven days of admission. Client #1 was admitted on May 4, 2026, and discharged on August 4, 2026. A comprehensive treatment plan should have been developed no later than May 11, 2026; however, the comprehensive treatment plan was completed on June 9, 2026.This finding was reviewed with facility staff during the complaint investigation process.
|
Plan of Correction
Clinical Supervisor re-educated counselor on the treatment plan policy and timeframes for timely implementation of the client's treatment plan. Clinical Supervisor will monitor through weekly chart audits for adherence with this policy for documentation compliance. |
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 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 May 4, 2026, and discharged on August 4, 2026. A comprehensive treatment plan was developed on June 9, 2026, with no type or frequency identified.This finding was reviewed with facility staff during the complaint investigation process.
|
Plan of Correction
Clinical Supervisor re-educated counselor on the treatment plan policy and timeframes for documentation of frequency and type of treatment services. Clinical Supervisor will monitor through weekly chart audits for adherence with this policy for documentation compliance. |