INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, R3 Recovery Services 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee in the required time frame, appropriate to that employee's skill level in six out of six employee records reviewed. The training plans documented were not signed or dated.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
To correct the deficiency cited under 704.11(b)(1) regarding the lack of timely, signed, and dated individual training plans (ITPs) for staff, R3 Recovery Services has implemented a comprehensive corrective action plan. Although all training plans were completed during the last review period, we recognize that they must also be signed and dated by both the employee and supervisor to demonstrate mutual agreement. Moving forward, all ITPs will be signed at the time of review to ensure compliance. All existing employee records will be reviewed, and any missing signatures will be obtained no later than 6/30/2025. A standardized ITP template has been created to ensure consistency, with clearly designated areas for required signatures and dates. New hires will complete an ITP within 30 days of hire, and annual training plans will be updated each calendar year or on the employee's anniversary date. The Clinical Director will oversee the completion of all ITPs, and the Office Manager will maintain a tracking system to ensure timely updates. A quarterly internal audit will be conducted to monitor ongoing compliance. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for Project Directors.Employee #1 was hired as a Project Director on August 1, 2022 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from May 2023, through May, 2024. Employee # 1's record did not document any training hours for the training year reviewed.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
To correct the deficiency cited under 704.11(d)(2) regarding the lack of documentation of the required 12 annual training hours for the Project Director, R3 Recovery Services has implemented a corrective action plan to ensure full compliance moving forward. The Project Director will complete a total of 12 clock hours of training in the approved DDAP categories by December 31, 2025, and all completed training hours will be documented with certificates of completion and stored in the employee's personnel file.
To ensure timely tracking and completion of these hours, the Office Manager will conduct quarterly audits of the Project Director's training progress and maintain a master training log. Any deficiencies identified during these audits will be immediately addressed and corrected. The Clinical Director will oversee compliance and provide support to ensure training topics align with regulatory expectations. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to maintain hot water not exceeding 120 degrees. The lobby bathroom's hot water was at 140 degrees.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency cited under 705.6(3) regarding the hot water temperature exceeding 120°F was corrected the same day of the licensing inspection. The Project Director immediately adjusted the water heater settings to ensure the temperature does not exceed 120°F. This adjustment was confirmed at the time of correction. The hot water heater has been calibrated to maintain compliance with regulatory temperature requirements and will not be altered moving forward. The facility maintenance team has been informed that any changes to the water heater settings must be approved by the Project Director to ensure ongoing compliance. The Project Director will test the water temperature in the facility once per month to ensure compliance. |
705.25 (5) LICENSURE Food service.
705.25. Food service.
A nonresidential facility may provide meals to clients through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers. A nonresidential facility which operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure cold food was at or below 40 degrees and frozen food at or below 0 degrees. The facility did not have a mechanism to ensure the temperature of cold food or frozen food. This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
To correct the deficiency cited under 705.25(5) regarding the lack of a mechanism to ensure proper food storage temperatures, R3 Recovery Services ordered and implemented the use of refrigerator, freezer, and food thermometers as of April 20, 2025. These thermometers are now in place in all applicable storage units and are used to verify that cold food is kept at or below 40°F, hot food at or above 140°F, and frozen food at or below 0°F. The Project Director will review the temperatures once per month to ensure compliance. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment. Employee #3 was hired on February 1, 2025 as a counselor and was still in the position as of the date of the inspection. The training was completed on April 5, 2025.Employee #4 was hired on October 14, 2024 as a counselor and was still in the position as of the date of the inspection. The training was completed on April 4, 2025. Employee #5 was hired on September 3, 2024 as a counselor and was still in the position as of the date of the inspection. The training was completed on April 3, 2025.Employee #6 was hired on October 12, 2024 as a counselor and was still in the position as of the date of the inspection. The training was completed on April 4, 2025.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
To correct the deficiency cited under 705.28(c)(4) regarding fire extinguisher training upon staff employment, R3 Recovery Services confirms that all staff did complete the required fire extinguisher training; however, it was not completed within the required time frame as outlined in regulations. As of April 23 2025, training has been completed and documented for all relevant employees. To prevent future delays, fire extinguisher training will now be incorporated into the onboarding process and completed within the first week of employment. The Office Manager will maintain a training log and monitor completion dates to ensure timely compliance. Regular quarterly audits will be conducted to confirm that all documentation is completed in accordance with licensing standards. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies. Training logs for the training were not dated.Employee #3 was hired on February 1, 2025 as a counselor and was still in the position as of the date of the inspection. Employee #4 was hired on October 14, 2024 as a counselor and was still in the position as of the date of the inspection. Employee #5 was hired on September 3, 2024 as a counselor and was still in the position as of the date of the inspection. Employee #6 was hired on October 12, 2024 as a counselor and was still in the position as of the date of the inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
To correct the deficiency cited under 705.28(d)(3) regarding incomplete documentation of fire drill training, R3 Recovery Services confirms that all staff members were trained to perform their assigned tasks during emergencies; however, training logs were not consistently signed or dated by employees to verify completion. All training logs will be updated and signed by the appropriate staff no later than June 30, 2025. Moving forward, all new employees will receive fire drill training during onboarding, and documentation will include employee signatures and dates at the time of training. The Office Manager will oversee this process and conduct quarterly audits to ensure continued compliance and timely documentation. This procedure will align with our broader corrective action plan for training documentation to ensure full compliance with licensing standards. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from June, 2024- April, 2025, the facility failed to prepare alternative exit routes to be used during fire drills, as all drills utilized the same exit route, the front door.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
To correct the deficiency cited under 705.28(d)(5) regarding the use of alternate exit routes during fire drills, R3 Recovery Services will begin utilizing all available exit routes in a rotating schedule for future drills. Effective immediately, fire drills will alternate between the front doo and rear exit, to ensure all staff and clients are familiar with multiple evacuation paths. Fire drill documentation logs will include the exit route used during each drill to demonstrate compliance. The Office Manager will oversee implementation and ensure a monthly audit of drill procedures and records is completed to confirm that alternate exits are being used consistently. This measure will enhance emergency preparedness and align our facility with regulatory requirements. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document what specific information could be disclosed on consent to release forms in six out of ten records reviewed.Client #1 was admitted on December 13, 2024 and discharged on March 12, 2025. A consent form dated January 13, 2025 to a government agency had " other" checked for information to be disclosed without specifying what additional information was permitted to be released. In addition, a consent form dated December 13, 2024 to a funding source did not list specific information permitted to be released.Client #2 was admitted on September 5, 2024 and was still active at the time of the inspection. A consent form dated September 5, 2024 to a funding source did not list specific information permitted to be released.Client #3 was admitted on September 13, 2024 and was still active at the time of the inspection. A consent form dated September 13, 2024 to a funding source did not list specific information permitted to be released.Client #4 was admitted on October 16, 2024 was still active at the time of the inspection. A consent form dated October 16, 2024 to a funding source did not list specific information permitted to be released.Client #9 was admitted on September 12, 2024 and was discharged on January 14, 2025. A consent form dated September 12, 2024 to a funding source did not list specific information permitted to be released. Additionally, a consent dated September 13, 2024 to another agency had " other" checked for information to be disclosed without specifying what additional information was permitted to be released.Client #10 was admitted on November 6, 2024 and was still active at the time of the inspection. A consent form dated November 6, 2024 to a funding source did not list specific information permitted to be released.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To correct the deficiency cited under § 709.28(c)(2) regarding the failure to document specific information disclosed on consent forms, R3 Recovery Services will provide targeted training to all clinical and administrative staff on the proper completion of Release of Information (ROI) forms. While the ROI form currently in use remains unchanged, it has been identified that staff were not consistently completing the "specific information disclosed" section in full detail. A training will be conducted by 6/30/2025 to review regulatory expectations, walk through best practices, and clarify the importance of accurately listing all types of information permitted for disclosure. Supervisors will monitor ongoing ROI compliance through regular chart audits, and the Office Manager will conduct monthly audits to ensure all ROIs are fully completed. Staff found to be out of compliance will be re-educated promptly. |
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 the review of client records, the facility failed to document a completed consent to release information form to include a purpose of disclosure in one out of ten records reviewed. Client #2 was admitted on admitted on September 5, 2024 and was still active at the time of the inspection. A consent form was dated November 18, 2024 to another treatment facility. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To correct the deficiency cited under § 709.28(c)(3) regarding the lack of documented "purpose of disclosure" on a consent to release information form, R3 Recovery Services will implement targeted corrective training to ensure full compliance with confidentiality regulations. While the current ROI form includes a section for listing the purpose of disclosure, the licensing inspection revealed inconsistent completion of this field. All clinical and administrative staff will receive mandatory training by June 30, 2025, emphasizing the regulatory importance of documenting a clear and specific purpose for each disclosure. Examples of compliant language and common errors will be reviewed. Supervisors will reinforce this standard during clinical documentation reviews, and the Office Manager will include this criterion in monthly audits of client records. Any forms missing required elements will be corrected and staff will be retrained as needed. |
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 outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in nine out of ten records reviewed.Client #2 was admitted on September 5, 2024 and was still active at the time of the inspection. A treatment plan update was completed on November 11, 2024 and the next update was due no later than January 11, 2025; however, it was not completed until March 12, 2025.Client #3 was admitted on September 13, 2024 and was still active at the time of the inspection. A treatment plan update was completed on January 9, 2025 and the next update was due no later than March 9, 2025; however, none was completed.Client #4 was admitted on October 16, 2024 and was still active at the time of the inspection. A treatment plan update was completed on December 19, 2024 and the next update was due no later than February 19, 2025; however, none was completed. Client #5 was admitted on July 1, 2024 and was discharged on November 20, 2024. A treatment plan update was completed on September 4, 2024 and an update was due no later than November 4, 2024; however, it was not completed until November 13, 2024. Client #6 was admitted on July 2, 2024 and was discharge on January 13, 2025. A treatment plan update was completed on September 3, 2024 and an update was due no later than November 3, 2024; however, it was not completed until November 27, 2024.Client #7 was admitted on July 17, 2024 and was discharge on January 15, 2025. A treatment plan update was completed on August 27, 2024 and the next update was due no later than October 27, 2024; however, it was not completed until November 12, 2024.Client #8 was admitted on August 28, 2024 and was discharged on January 22, 2025. A treatment plan update was completed on October 2, 2024 and an update was due no later than December 2, 2024; however, none was completed.Client #9 was admitted on September 12, 2024 and was discharged on January 14, 2025. A treatment plan update was completed on October 10, 2024 and the next update was due no later than December 10, 2024; however, it was not completed until December 18, 2024.Client #10 was admitted on November 6, 2024 and was still active at the time of the inspection. A treatment plan update was completed on January 2, 2025 and the next update was due no later than March 3, 2025; however, none was completed.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To address the deficiency cited under 709.92(b) related to treatment plan updates not being completed within the required 60-day timeframe, R3 Recovery Services has implemented a new electronic medical record (EMR) system as of March 20, 2025. This EMR system includes integrated alerts and reporting functions that flag upcoming and overdue treatment plan review dates for each client. Weekly compliance reports are reviewed by the Clinical Director and Office Manager to ensure all treatment plans are updated timely in accordance with DDAP regulations. Staff have been trained on the new tracking tools and are expected to complete updates on or before the 60-day due date. Ongoing internal audits will be conducted to monitor adherence, and supervisory oversight has been strengthened to maintain regulatory compliance and quality of care. |
709.93(a)(11) LICENSURE Client records
709.93. 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 document follow up information within guidelines established by the facility's policy and procedures manual in five out of five applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed seven days following discharge.Client #5 was admitted on July 1, 2024 and was discharged on November 20, 2024. The follow up was completed on December 19, 2024Client #6 was admitted on July 2, 2024 and was discharge on January 13, 2025. The follow up was completed on January 23, 2025.Client #7 was admitted on July 17, 2024 and was discharge on January 15, 2025. The follow up was completed on January 23, 2025.Client #8 was admitted on August 28, 2024 and was discharged on January 22, 2025. The follow up was completed on February 6, 2025Client #9 was admitted on September 12, 2024 and was discharged on January 14, 2025. No follow up was completed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To correct the deficiency cited under 709.93(a)(11) regarding failure to complete follow-up documentation within the seven-day timeframe following discharge, R3 Recovery Services has implemented a new electronic medical record (EMR) system as of March 20, 2025. This upgraded system allows for more effective tracking of discharges and follow-up timelines. The EMR now generates automated discharge reports, and the Clinical Director and Office Manager review these reports weekly to ensure that all follow-up contacts and letters are completed and documented within seven days of discharge, in accordance with the facility's policy. Staff have been trained on the updated EMR functionalities and expectations surrounding timely follow-up documentation. Continued oversight through regular audits will ensure ongoing compliance with 28 PA Code § 709.93(a)(11). |