INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 26, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Recovery Cove 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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704.11(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.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of two applicable personnel records reviewed.
Employee # 4 was hired as a counselor on October 7, 2024 and was due to complete the HIV/AIDS training and the TB/STD training no later than October 10, 2025. The HIV/AIDS training was completed late on January 7, 2026 and the TB/STD training was not completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 completed the TB/STD training on 4/2.
New employees will be reminded by the program director to complete TB/STD within the first year of employment. This will be monitored by the program director . |
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 client records, the facility failed to obtain a written informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in one of fourteen client records reviewed.
Client # 2 was admitted to the partial hospitalization activity on November 20, 2025 and was discharged on December 11, 2025. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form documented in the client's record prior to any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/3/2024 during supervision, Program Director reviewed the clients that there was no consent to release information form documented in the client's record prior to any of the disclosures, and how these need to be entered in the clients chart. Program director will complete monthly audits to ensure these are compliant. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent will expire on consent to release information forms in one of fourteen client records reviewed.
Client # 13 was admitted to the outpatient activity on October 8, 2025 and was discharged on February 20, 2025. The release of information form to the funding source was signed by the client on October 8, 2025; however, the release form did not indicate the date, event, or condition upon which the consent would expire.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/3/2024 during supervision, Program Director reviewed the clients releases that did not indicate the date,event,or condition upon which the consent will expire, and how these need to be entered in the client's chart. Program director will complete monthly audits to ensure these are compliant. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in three of three applicable client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on October 3, 2025 and was discharged on December 8, 2025. The individual treatment and rehabilitation plan was completed on October 3, 2025 and the first update was due no later than November 3, 2025; however, the update was not completed at the time of discharge.
Client # 3 was admitted to the partial hospitalization activity on September 30, 2025 and was discharged on November 26, 2025. The individual treatment and rehabilitation plan was completed on September 30, 2025 and the first update was due no later than October 30, 2025; however, the update was not completed at the time of discharge.
Client # 6 was admitted to the partial hospitalization activity on August 28, 2025 and was discharged on November 5, 2025. The individual treatment and rehabilitation plan was completed on September 26, 2025 and the first update was due no later than October 26, 2025; however, the update was not completed at the time of discharge.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/3/2024 during supervision, Program Director reviewed Treatment plans with clinical team to identify frequency and type of services, and the need to complete within 30 days. Program Director provided examples for clinical team and treatment plan shall identify LOC, Frequency and type in objectives. Program Director will complete monthly audits to ensure treatment plans are updated every 30 days. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in four of five applicable client records reviewed.
Client # 8 was admitted to the outpatient activity on December 8, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 16, 2025 and the first update was due no later than February 16, 2026; however, the update was not completed until February 27, 2026.
Client # 10 was admitted to the outpatient activity on September 16, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 15, 2025 and the first update was due no later than November 15, 2025; however, the update was not completed until January 8, 2026.
Client # 13 was admitted to the outpatient activity on October 8, 2025 and was discharged on February 20, 2026. The individual treatment and rehabilitation plan was completed on October 8, 2025 and the first update was due no later than December 8, 2025; however, the update was not completed until January 8, 2026.
Client # 14 was admitted to the outpatient activity on June 27, 2025 and was discharged on October 27, 2025. The individual treatment and rehabilitation plan was completed on July 2, 2025 and the first update was due no later than September 2, 2025; however, the update was not completed until September 29, 2025.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/3/2024 during supervision, Program Director reviewed Treatment plans with clinical team to identify frequency and type of services and the need to complete within 60 days . Program Director provided examples for clinical team and treatment plan shall identify LOC, Frequency and type in objectives. Current client's treatments plans were updated. Program Director will complete monthly audits to ensure treatment plans are updated every 60 days. |