INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lehigh Valley Drug and Alcohol Unit 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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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of fire drill logs from March 2025 through February 2026, the facility failed to conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts. The fire drill logs identified all fire drills were conducted on a Monday.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills will be conducted on an unannounced basis to ensure staff are not aware of their occurrence in advance. The Clinical Supervisor (or designated Staff) will be responsible for conducting all fire drills.
To ensure variability and compliance, fire drills will be conducted on different days of the week and at varying times. A tracking log will be maintained to document the date, time, and shift of each drill. The Clinical Supervisor will review the log monthly to ensure drills are not conducted on the same day of the week consecutively.
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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.
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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 one out of seven records reviewed.
Client #1 was admitted on June 30, 2025 and was discharged on June 30, 2025. There was no documentation that the facility obtained an informed and voluntary consent for a legal entity. There was documentation in the client record that contact was made with the legal entity on July 10, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor has scheduled a staff training on confidentiality requirements and the proper use of informed and voluntary consent forms prior to the disclosure of client information to any external entity by April 24th 2026. All clinical and administrative staff will be re-educated on verifying that a valid, signed consent is present in the client record before any communication occurs by April 24th 2026. Clinical Supervisors will conduct monthly chart reviews of at least two client records per staff to ensure appropriate releases of information are obtained and documented prior to any external contact. Any deficiencies identified during these reviews will result in immediate corrective feedback and additional staff training to ensure continued compliance. |
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 the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of seven client records reviewed.
Client #1 was admitted on June 30, 2025 and was discharged on June 30, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for substance abuse facilities dated June 30, 2025, was offered to the client.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will review this requirement with staff by April 24th 2026 to ensure compliance with 709.28(d) regarding client consent documentation. Staff will be re-educated by April 24th 2026 that a copy of the informed and voluntary consent must be offered to the client and documented in the client record at the time the consent is completed. Clinical Supervisor will conduct monthly reviews of at least two client records to ensure proper documentation is present. Any deficiencies identified will be addressed immediately through corrective feedback and additional staff training to ensure continued compliance. |