D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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ROSEWOOD RECOVERY LLC
140 TERRY DRIVE, SUITE 118
NEWTOWN, PA 18940

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Survey conducted on 09/17/2026

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on September 16-17, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Rosewood Recovery 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:	Plan of Correction
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.
Observations Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employees received at least 4 hours of TB/STD and other health related topics using a Department approved curriculum within the regulatory timeframe.Employee #4 was hired as a counselor on April 9, 2025, and was still in the position as of the date of the inspection. Employee #4 was due to complete the communicable disease trainings no later than April 9, 2026. There was no documentation in the personnel file for the completion of the TB/STD training using a Department approved curriculum as of the date of the inspection.The findings were reviewed with facility staff during the licensing process.	Plan of Correction The Project Director updated Rosewood Recovery's standard training plan guide on September 18, 2026, to reflect the requirement for four hours of TB/STD training using a Department-approved curriculum. On September 21, 2026, the Project Director notified staff who had not yet completed the approved training of the appropriate training they should register for and advised them of the required timeframe for completion. The identified staff was asked to register for the TB/STD training by September 30, 2026 and will continue to check for open classes that are local or virtual. Moving forward, the Project Director will review staff training requirements and completion status at least monthly during supervision to ensure ongoing compliance with Department training requirements.
704.11(f)(2) LICENSURE Trng Hours Req-Coun 704.11. Staff development program. (f) Training requirements for counselors. (2) Each counselor shall complete at least 25 clock hours of training annually in areas such as: (i) Client recordkeeping. (ii) Confidentiality. (iii) Pharmacology. (iv) Treatment planning. (v) Counseling techniques. (vi) Drug and alcohol assessment. (vii) Codependency. (viii) Adult Children of Alcoholics (ACOA) issues. (ix) Disease of addiction. (x) Aftercare planning. (xi) Principles of Alcoholics Anonymous and Narcotics Anonymous. (xii) Ethics. (xiii) Substance abuse trends. (xiv) Interaction of addiction and mental illness. (xv) Cultural awareness. (xvi) Sexual harassment. (xvii) Developmental psychology. (xviii) Relapse prevention. (3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
Observations Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors. Employee #3 was hired as a counselor on December 23, 2024 and was still in the position as of the date of the inspection. Employee #3 ' s record for the reviewed training year, January 1 - December 31, 2025, documented only 22 hours and 25 minutes out of the required 25 hours of annual training. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The Project Director miscalculated the total training hours completed by Employee #3 for the 2025 training year. Moving forward, the Project Director will regularly review and reconcile staff training certificates to ensure that each employee meets the required 25 hours of annual training.
705.23 (3) LICENSURE Counseling or activity areas and office space 705.23. Counseling or activity areas and office space. The nonresidential facility shall: (3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
Observations Based on a physical plant inspection on September 17, 2026, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling sessions could be heard inside the adjoined counselor ' s office which was currently not assigned to a specific counselor. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The Project Director obtained additional white noise machines for counseling offices and placed them into use on September 21, 2026. Staff will routinely monitor whether conversations or sessions can be heard from adjoining offices and will notify the Project Director of any concerns so that additional privacy measures can be implemented as needed.
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.
Observations Based on a review of 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 twelve out of twelve client records reviewed.Client #1 was admitted to the outpatient level of care on December 8, 2025, and was discharged on March 16, 2026. The record documented identifying information and lab samples released to an outside laboratory for lab services dated December 8, 23, and 29, 2025, January 6, 8, and 12, 2026, and February 17, 2026. There was no documentation that the facility obtained a valid release of information prior to the disclosure. Client #2 was admitted to the outpatient level of care on March 27, 2026, and was discharged on June 22, 2026. The record documented identifying information and lab samples released to an outside laboratory for lab services dated March 27, 2026, April 7, 15, 16, and 30, 2026, May 5, 14, 20, 21, and 26, 2026, and June 3 and 16, 2026. There was no documentation that the facility obtained a valid release of information prior to the disclosure. Client #3 was admitted to the partial hospitalization level of care on February 9, 2026, stepped down to the outpatient level of care on March 16, 2026, and was discharged from the facility on June 1, 2026. The record documented identifying information and lab samples released to an outside laboratory for lab services dated February 9, 17, 26, and 27, 2026, March 2, 9, 19, 27, and 30, 2026, and April 9, 14, 23, and 24, 2026. There was no documentation that the facility obtained a valid release of information prior to the disclosure. Client #4 was admitted to the outpatient level of care on June 24, 2026, and was discharged on August 19, 2026. The record documented identifying information and lab samples released to an outside laboratory with lab services dated June 24, 2026, and July 2, 9, 15, and 30, 2026. There was no documentation that the facility obtained a valid release of information prior to the disclosure. Client #5 was admitted to the partial hospitalization level of care on April 29, 2026, stepped down to the outpatient level of care on June 22, 2026, and was active at the time of inspection. The record documented identifying information and lab samples released to an outside laboratory for lab services dated April 29, 2026, May 4, 6, 8, 11, 13, 15, 21, and 27, 2026, June 4, 9, and 17, 2026, July 9, 30, and 31, 2026, and August 5, 14, 21, and 28, 2026. There was no documentation that the facility obtained a valid release of information prior to the disclosure. Additionally, there was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for services. Client #6 was admitted to the outpatient level of care on July 1, 2026, and was active at the time of inspection. The record documented identifying information and lab samples released to an outside laboratory for lab services dated July 1, 14, 25, and 31, 2026, August 13 and 18, 2026, and September 1, 10, and 15, 2026. There was no documentation that the facility obtained a valid release of information prior to the disclosure. Client #7 was admitted to the outpatient level of care on February 24, 2026, and was active at the time of inspection. The record documented identifying information and lab samples released to an outside laboratory for lab services dated February 24, 2026, March 4, 12, 17, and 25, 2026, April 2, 8, 15, 23, and 30, 2026, May 6, 12, 20, and 28, 2026, June 2, 4, 10, 16, 17, 25, and 30, 2026, July 7, 15, and 21, 2026, August 5, 20, and 27, 2026, and September 8 and 15, 2026. There was no documentation that the facility obtained a valid release of information prior to the disclosure. Client #8 was admitted to the partial hospitalization level of care on October 15, 2025, and was discharged on December 22, 2025. The record documented identifying information and lab samples released to an outside laboratory for lab services dated October 15, 23, and 29, 2025, November 3, 6, 13, 20, and 25, 2025, and December 2, 5, 11, 16, and 19, 2025. There was no documentation that the facility obtained a valid release of information prior to the disclosure. Client #11 was admitted to the partial hospitalization level of care on February 5, 2026, and was discharged on February 27, 2026. The record documented identifying information and lab samples released to an outside laboratory for lab services dated February 5, 9, and 10, 2026. There was no documentation that the facility obtained a valid release of information prior to the disclosure. Client #12 was admitted to the partial hospitalization level of care on August 12, 2026, and was active at the time of inspection. The record documented identifying information and lab samples released to an outside laboratory for lab services dated August 12, 20, and 24, 2026 and September 1 and 14, 2026. There was no documentation that the facility obtained a valid release of information prior to the disclosure. Client #13 was admitted to the partial hospitalization level of care on August 11, 2026, and was active at the time of inspection. The record documented identifying information and lab samples released to an outside laboratory for lab services dated August 11, 18, and 27, 2026 and September 3, 9, and 15, 2026. There was no documentation that the facility obtained a valid release of information prior to the disclosure. Client #14 was admitted to the partial hospitalization level of care on August 25, 2026, and was active at the time of inspection. The record documented identifying information and lab samples released to an outside laboratory for lab services dated August 25 and 31, 2026, and September 9 and 15, 2026. There was no documentation that the facility obtained a valid release of information prior to the disclosure. These findings were reviewed with facility staff during the licensing process.	Plan of Correction The Project Director obtained an updated Services Agreement with the designated laboratory on September 24, 2026. Moving forward, the Project Director will document the agreement's review and renewal date on their administrative task list to ensure it is reviewed and updated in a timely manner and to prevent any lapse in the agreement.