INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on February 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, SpiritLife, Inc. 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project in one of one applicable record.
Client #11 was admitted to the inpatient level of care on May 23, 2025 and was discharged June 4, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Deficiency Cited & Plan of Correction:
ASAM aligned policies and procedures already exist for issuing written notifications of involuntary termination. (SL 2.6 Discharge Policy & SL 4.14 Involuntary Discharge)
Upon investigation it appears the deficiency resulted from failure to upload the completed documentation to the client's chart.
To Prevent Recurrence:
- Clinical staff will be re trained on the policies including the expectation of uploading all termination notices into the EHR at the time of discharge.
- The training date for the Clinical team has been scheduled for 4/2/26 at 12PM.
- The Clinical Supervisor will verify that all involuntary discharge packets?including the written notice?are uploaded during weekly chart reviews for the next 60 days.
Persons Responsible: Counselors and Clinical Supervisor
Completion Date: Full compliance will be achieved within 30 days of implementation.
Implementation date: 4/2/26
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