INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 8, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Sanctury 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 inspection:
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of four personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #4 was hired on January 15, 2025 as a counselor assistant. Employee #4 has a high school diploma and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week. Employee #4 ' s personnel records did not have documented formal case reviews for the weeks of April 21, May 1, 29, June 5, 12, 26, July 3, 10, 17, 24, 31, August 21, 28, and September 4, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction (POC)
Facility Name: Sanctuary House
Regulation Number: 704.8(a)(5) and 704.9(c)
Deficiency Statement (per 2025 Licensing Survey Results):
The facility failed to ensure that one counselor assistant with a high school diploma or GED equivalent was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education, as required under 704.8(a)(5). In addition, the facility failed to maintain formal, documented case reviews and an additional hour of direct observation by a supervising counselor or clinical supervisor once per week, as required under 704.9(c). Employee #4's personnel file lacked documented formal case reviews for the weeks of April 21, May 1, May 29, June 5, June 12, June 26, July 3, July 10, July 17, July 24, July 31, August 21, August 28, and September 4, 2025.
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Corrective Action Plan:
Effective immediately, the Project Director has implemented a structured supervision and documentation protocol to ensure compliance with 704.8(a)(5) and 704.9(c).
1. Immediate Action:
The Project Director will create and maintain formal weekly supervision notes for Employee #4, the counselor assistant, reflecting one (1) hour of direct supervision conducted by the Project Director and one (1) documented case review of a current client.
Each session will identify the client reviewed, summarize supervisory feedback, and confirm observation of counseling activity where applicable.
2. Ongoing Compliance:
This enhanced supervision protocol will continue through January 15, 2026, and will be extended for an additional fourteen (14) weeks beyond that date to ensure consistent compliance and documentation standards.
Specific additional supervision dates include:
January 22, 29; February 5, 12, 19, 26; March 5, 12, 19, 26; April 2, 9, 16, and 23, 2026.
3. Monitoring and Oversight:
The Project Director and Governing Body have jointly reviewed the applicable DDAP Regulations, Licensing Alerts, and Sanctuary House Policy and Procedures regarding counselor assistant supervision requirements.
The Project Director will verify weekly that all documentation is current, signed, and retained in the personnel file of Employee #4.
The Governing Body will review compliance with this corrective action at its monthly administrative meeting and document findings in the minutes.
4. Prevention of Recurrence:
The Project Director/Clinical Supervisor will give herself refresher training on 704.8 and 704.9 supervision requirements by November 15, 2025.
The Project Director will conduct quarterly audits of personnel supervision files to ensure continued compliance.
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Person Responsible for Implementation:
Project Director
Completion Date: Ongoing through April 23, 2026
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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 records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one out of seven records reviewed.
Client #3 was admitted on January 16, 2025 and discharged on April 11, 2025. The record contained one informed and voluntary consent to release information to a family member signed by the client on January 16, 2025, that had identified the purpose for disclosure as other, however no information was listed for what the other purpose was.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Regulation Number: § 709.28(c)(3)
Regulation Title: Confidentiality
Deficiency Statement (per 2025 Licensing Survey Results):
Based on a review of client records, the facility did not fully comply with confidentiality requirements regarding informed and voluntary consent for disclosure. Specifically, in one of seven records reviewed, the facility failed to clearly identify the purpose of disclosure as required by §709.28(c)(3).
Client #3 was admitted on January 16, 2025, and discharged on April 11, 2025. The record contained one informed and voluntary consent form authorizing the release of information to a family member, signed by the client on January 16, 2025. The purpose of disclosure was listed as "other," but no explanation or description of the "other" purpose was documented. This issue was discussed with facility staff during the licensing process.
Corrective Action Plan:
Immediate Action:
The Project Director, in conjunction with the governing body, has reviewed the client record, licensing alerts, and the P and P. They have confirmed that all current and future consent forms explicitly state a clear and specific purpose for disclosure.
The consent form template has been reviewed and is appropriate. staff training will be implemented to address this issue. The goal will be to prompt staff to fill in the "other" category with a defined reason before obtaining the client's signature.
A memo outlining this requirement was issued to all staff on October 26, 2025, emphasizing that incomplete or unclear purposes for disclosure are not acceptable. They acknowledged receipt of the memo. The memo indicated that staff are required to carefully review each consent form for completeness before obtaining the client's signature. If the "other" category is selected, staff must clearly specify the reason for disclosure in the space provided before signing and finalizing the form.
Staff Training:
The Project Director will conduct a Confidentiality and Release-of-Information Refresher Training for all staff on November 4th, 2025. It will be a virtual meeting.
The training will review §709.28(c) requirements, proper completion of consent forms, and examples of acceptable "purpose of disclosure" statements.
Attendance will be documented and maintained in the facility's training file.
Ongoing File Review and Oversight:
The assigned counselor will be responsible for conducting a follow-up chart check 10-14 days after each admission and again upon discharge to ensure all consent forms are complete and compliant. They will also check other required documents at these times.
Prevention of Recurrence:
The verification process will remain one of the duties of the counselor will be responsible for as they continue their case management tasks.
Confidentiality compliance will be incorporated into quarterly chart audits and reviewed at the monthly administrative meeting. The project Director will spot-check random files as part of this compliance check.
Any staff found to have incomplete or incorrect releases will receive immediate corrective feedback and re-training.
Person Responsible for Implementation:
Project Director
Initiated: 10/26/2025 via the memo.
Completion Date: November 4, (training)
Ongoing thereafter with random quarterly checks by the project director
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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, the facility failed to document case consultations every thirty days, per facility policy, in three out of seven records reviewed.
Client #3 was admitted on January 16, 2025 and discharged on April 11, 2025. A case consultation was due no later than February 15, 2025; however, it was completed on February 24, 2025.
Client #6 was admitted on August 19, 2025 and was still active at the time of the inspection. A case consultation was due no later than September 18, 2025; however, it was completed on September 29, 2025.
Client #7 was admitted on July 18, 2025 and was still active at the time of the inspection. A case consultation was due no later than August 17, 2025; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regulation Number: § 709.53(a)(8)
Regulation Title: Case Consultation Notes
Deficiency Statement (per 2025 Licensing Survey Results):
Based on a review of client records, the facility failed to document case consultations every thirty (30) days as required by facility policy, in three out of seven records reviewed. This omission resulted in incomplete client records, which did not reflect consistent case consultation documentation as required under §709.53(a)(8).
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1. Policy and Procedure Revision:
The Project Director, along with the governing body, has revised the facility's Policy and Procedure related to case consultations to ensure compliance with §709.53(a)(8).
Effective immediately, the policy now states that case consultations will occur at least every thirty (30) days following the completion of the client's Master Treatment Plan (MTP).
The revised policy will be dated, signed, and distributed to all clinical and supervisory staff.
2. Implementation of Revised Process:
The Project Director will ensure that case consultations are scheduled and documented in accordance with the updated policy.
Case consultation notes will be reviewed and signed by the Project Director or Clinical Supervisor to verify compliance.
3. Staff Notification and Training:
All clinical staff will receive a formal review of the revised policy during the Clinical Team Meeting on November 4, 2025.
The review will include expectations for frequency, content, and documentation standards of case consultations.
Staff attendance will be documented and maintained in the training file.
4. Ongoing Oversight and Quality Assurance:
Designated third-shift technicians, as appointed by the Project Director, will be granted access to the log frequency report. To protect client confidentiality, the technician will conduct weekly audits using only the log frequency report and will not access individual client records or clinical documentation directly.
Using this report in conjunction with a comprehensive checklist of all required client documentation?including due dates for each required entry?the assigned technician will verify that all twelve active client records reflect timely and complete documentation.
The review will confirm the presence and timeliness of all required entries, including but not limited to the case consultation (treatment team meeting) note, progress notes, treatment plan reviews, and other documentation required by regulation or facility policy.
If any required documentation, including the case consultation/treatment team meeting note, is missing, overdue, or not logged within the required timeframe, the technician will promptly notify both the Counselor and the Project Director.
If the documentation remains incomplete or uncorrected during the subsequent weekly review, the technician will issue a second notification to the Counselor and Project Director. The Project Director will then initiate immediate corrective action, including an educational refresher with the Counselor, to ensure compliance with documentation and timeliness standards.
5. Prevention of Recurrence:
The tracking process performed by the 3rd shift tech will remain in place as a permanent quality control measure.
The Project Director will continue to monitor compliance quarterly. This will ensure that consultation documentation reflects the ongoing clinical oversight and coordination of care required by regulation.
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Person Responsible for Implementation:
Project Director
Completion Date:
November 4, 2025 (policy implementation and staff review): |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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, the facility failed to provide a complete client record, which is to include follow-up information within thirty days after discharge, per facility policy, in two out of four applicable records reviewed.
Client #1 was admitted on August 7, 2025 and discharged on August 28, 2025. A follow up contact was due no later than September 27, 2025; however, there is no documentation that one was completed.
Client #3 was admitted on January 16, 2025 and discharged on April 11, 2025. A follow up contact was due no later than May 11, 2025; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction (POC)
Regulation Number: § 709.53(a)(11)
Regulation Title: Follow-Up Information
Deficiency Statement (per 2025 Licensing Survey Results):
Based on a review of client records, the facility failed to provide complete client records that included required follow-up information within thirty (30) days after discharge, as required by §709.53(a)(11).
In two out of four applicable records reviewed, there was no documentation that follow-up contact was completed within the required timeframe.
- Client #1 was admitted on August 7, 2025, and discharged on August 28, 2025. A follow-up contact was due no later than September 27, 2025; however, there is no documentation that one was completed.
- Client #3 was admitted on January 16, 2025, and discharged on April 11, 2025. A follow-up contact was due no later than May 11, 2025; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Corrective Action Plan:
The project director, along with the governing body, has reviewed the DADP licensing alerts and client records. The follow-up policy was reviewed with all staff, and it was clarified that the follow-up contact must be attempted within thirty (30) days of each client's discharge, regardless of the discharge type.
1. Revised Follow-Up Procedure:
Within seven (7) days of the beginning of each month, the Project Director will generate a list of all clients discharged during the previous month.
This list will be forwarded to a specific 2nd-Shift Technician, who's job duty includes being responsible for making follow-up contact attempts by phone or email, using contact information contained in the client record. His access to the client record is limited but does include basic client contact information and the ability to write a follow up note.
Each follow-up attempt and its outcome will be documented in the client's record. If the client cannot be reached due to known/unknown circumstances (e.g., inpatient treatment, incarceration, or other reasons), this must also be documented. If they cannot be reached, this also needs to be listed.
2. Supervisory Oversight and Monitoring:
Once the assigned 2nd-Shift Technician completes the assigned follow-ups and returns the monthly list, the Project Director will verify that all required documentation is complete and properly filed in the client records.
The Project Director will also conduct quarterly spot-checks of discharged client records to confirm compliance with this procedure.
3. Staff Training and Accountability:
A staff refresher training on follow-up procedures and documentation standards will be conducted on November 4, 2025. Only the staff designated by the Project Director will have this responsibility
Training will include review of §709.53(a)(11), documentation requirements, and examples of appropriate follow-up notations. Techs will be assigned this task and given the permissions necessary to fulfill this task by the Project Director as needed.
Attendance will be documented and retained in the facility's training file.
Any future deficiencies identified in this area will result in immediate corrective education per facility policy.
4. Prevention of Recurrence:
The follow-up tracking system will remain a permanent part of Sanctuary House's quality assurance process.
The Project Director will report on compliance during quarterly administrative meetings,
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Person Responsible for Implementation:
Project Director
Completion Date:
November 4, 2025 (training)
Ongoing thereafter |