INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, STR Behavioral Health - Lancaster 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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709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of partial hospitalization client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in four out of seven records reviewed.
Client #1 was admitted on June 12, 2026 and discharged on July 13, 2026. The comprehensive treatment plan dated June 17, 2026 indicated individual therapy twice a week. The week of June 28 - July 4, 2026 had only one documented session on July 2, 2026.
Client #3 was admitted on April 24, 2026 and transferred to a lower level of care on June 3, 2026. The comprehensive treatment plan dated April 28, 2026 indicated individual therapy twice a week The week of May 10-16, 2026 had only one documented session on May 12, 2026.
Client #5 was admitted on July 28, 2026 and transferred to a lower level of care on September 9, 2026. A treatment plan update dated August 25, 2026 indicated individual therapy twice a week The week of August 30 - September 5, 2026 had no documented sessions.
Client #6 was admitted on June 22, 2026 and transferred to a lower level of care on August 5, 2026. A treatment plan update dated July 22, 2026 indicated individual therapy twice a week. The week of July 26 - August 1, 2026 had only one documented session on July 30, 2026.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clients 1, 3, 5, and 6 have since been discharged from programming.
Staff were retrained on documentation expectations, the use of missed session notes, and adherence to treatment plans on 9/28/26.
Moving forward, Office Manager will audit weekly to ensure that appropriate documentation is completed.The Executive Director will do random monthly audits. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of partial hospitalization client records, the facility failed to ensure that the clients received individual counseling at least twice weekly in four out of seven records reviewed.
Client #1 was admitted on June 12, 2026 and discharged on July 13, 2026. The week of June 28 - July 4, 2026 had only one documented session on July 2, 2026.
Client #3 was admitted on April 24, 2026 and transferred to a lower level of care on June 3, 2026. The week of May 10-16, 2026 had only one documented session on May 12, 2026.
Client #5 was admitted on July 28, 2026 and transferred to a lower level of care on September 9, 2026. The week of August 30 - September 5, 2026 had no documented sessions.
Client #6 was admitted on June 22, 2026 and transferred to a lower level of care on August 5, 2026. The week of July 26 - August 1, 2026 had only one documented session on July 30, 2026.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clients 1, 3, 5, and 6 have since been discharged from programming.
Staff were retrained on documentation expectations, the use of missed session notes, and adherence to treatment plans on 9/28/26.
Moving forward, Office Manager will audit weekly to ensure that appropriate documentation is completed.The Executive Director will do random monthly audits. |