INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11, 2025 through September 12, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Promont Recovery 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(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 personnel records, the facility failed to document a written individual training plan for each employee, with the plan being appropriate to that employee's skill level and developed annually with input from both the employee and the supervisor, in three of four applicable personnel records reviewed.Employee # 2 was hired as a counselor on April 9, 2025. There was no current individual training plan documented in the personnel record at the time of the inspection.Employee # 3 was hired as a counselor on March 24, 2025. There was no current individual training plan documented in the personnel record at the time of the inspection.Employee # 4 was hired as a counselor on February 3, 2025. There was no current individual training plan documented in the personnel record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training plans completed for Employees #2, #3, #4 on 10/6/2025.
Plans placed in personnel files.
New hires: training plan completed within 30 days of hire.
All staff: training plans reviewed/updated annually by hire date.
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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 personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment in one of four applicable personnel records reviewed.Employee # 4 was hired as a counselor on February 3, 2025. There was no fire extinguisher training documented in the personnel record at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 is no longer employed with the facility.
All new employees will receive fire extinguisher training during new hire orientation, on or before their first day of work.
Training completion will be documented with employee and trainer signatures and maintained in the personnel file.
The Clinical Director will maintain a new hire onboarding checklist to ensure fire safety training is completed and documented. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's October 2024 through August 2025 fire drill logs, the facility failed to ensure that unannounced fire drills were conducted at least once a month. At the time of the inspection, there were no documentation indicating fire drills were conducted during the months of October 2024, December 2024, February 2025, April 2025, June 2025, and August 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A fire drill was completed on 9/30/2025 to ensure current compliance.
Fire drill logs have been reviewed and updated to verify all documentation is complete and accessible for review.
The staff responsible for fire safety have been retrained on the DDAP requirement to conduct and document unannounced monthly drills.
The Program Director will ensure unannounced fire drills are conducted monthly and documented immediately after each drill. |
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 personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in one of four applicable personnel record reviewed.Employee # 4 was hired as a counselor on February 3, 2025. There was no emergency preparedness training documented in the personnel record at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 is no longer employed with the facility.
All current staff have completed emergency preparedness training as of 10/6/2025, and documentation has been placed in each active personnel file.
All new employees will receive emergency preparedness training during new hire orientation, prior to assuming job duties.
The Clinical Director will maintain a New Hire Orientation Checklist documenting completion of emergency preparedness and fire safety training.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's October 2024 through August 2025 fire drill logs, the facility failed to ensure their written fire drill records included documentation of which exit route was used during the fire drill. Every fire drill log documented, during the reviewed period, did not include the documentation of which exit route was used during the drill.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility's fire drill log form was reviewed and revised on 9/30/2025 to include a required field for documenting the exit route used during each drill.
All staff responsible for conducting fire drills were retrained on proper documentation procedures on 9/30/2025.
The revised fire drill log will be used for all future drills to ensure complete documentation. |
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 client records, the facility failed to document the purpose of disclosure on release of information forms in one of fourteen client records reviewed.Client # 1 was admitted to the partial hospitalization activity on September 4, 2025 and was still active at the time of the inspection. The release of information forms to a funding source and an emergency contact were signed by the client on September 3, 2025; however, both release forms did not include documentation of the purpose of the disclosure. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #1 has since been discharged from the program and therefore the release of information forms could not be updated.
A full audit of all active client records was completed on 10/6/2025 to ensure that all release of information forms include the purpose of disclosure. Any missing information was corrected where applicable.
All staff responsible for completing release of information forms were retrained on 10/6/2025 regarding DDAP confidentiality requirements, emphasizing the need to clearly document the "purpose of disclosure" on all ROIs.
All new employees will receive training on proper completion of release forms during orientation, and all staff will receive annual refresher training beginning October 2025.
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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 client records, the facility failed to document whether a copy of a client consent was offered to the client in one of fourteen client records reviewed. Client # 1 was admitted to the partial hospitalization activity on September 4, 2025 and was still active at the time of the inspection. The release of information form to a funding source was signed by the client on September 3, 2025; however, there was no documentation in the record indicating a copy of the release form was offered to the client.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 has since been discharged from the program; therefore, the release form could not be updated.
All active client records were reviewed on 10/6/2025 to ensure documentation was present indicating that a copy of each signed release form was offered to the client.
Any missing documentation was corrected where applicable.
All clinical staff were retrained on 10/6/2025 regarding the requirement to document whether a copy of the release form was offered, per confidentiality standards.
The Clinical Director will review all new admissions weekly to verify that the updated ROI form has been completed correctly and that the "copy offered" documentation is included.
The Program Director will conduct quarterly quality assurance (QA) audits of at least five randomly selected client records to ensure that all ROI forms contain the "copy offered" notation.
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709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgment by clients that they have been notified of their rights in fourteen of fourteen client records reviewed.In every client record reviewed, there was a client rights acknowledgement form, signed by each client; however, all the regulatory-required client rights were not included on the acknowledgement form and there was no other documentation in the record indicating the client rights were presented to the client. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of October 7, 2025, the facility revised the Client Rights Acknowledgment Form to include all rights required under §709.30, including the following:
(1) A client receiving care or treatment under section 7 of the act (71 P.S. §1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion.
(3) Clients have the right to inspect their own records. The project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
A copy of the revised Client Rights policy and acknowledgment form has been incorporated into the facility's Policy and Procedure Manual as of October 7, 2025.
The revised Client Rights Acknowledgment Form will be presented to every new client during the intake and admission process, effective October 7, 2025. |
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 the decision to involuntarily terminate the client's treatment at the project, which is to also include the reason for termination, in one of one applicable client records reviewed.Client # 13 was admitted to the outpatient activity on December 2, 2024 and was administratively discharged on February 21, 2025. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project. This is a repeat citation from the September 11, 2024 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #13 is no longer active in the program; therefore, written notification could not be provided retroactively.
Staff responsible for client terminations were retrained on 10/6/2025 regarding the requirement to provide written notice of involuntary termination, including the reason for termination, as per §709.33(a).
The facility's termination notification policy and procedure was reviewed and updated on 10/6/2025 to emphasize documentation of written notice and reasons for termination in the client record.
All future involuntary terminations will include a written notice to the client, documenting the reason for termination, and a copy will be filed in the client record.
The Clinical Director will review all involuntary termination records monthly to confirm proper documentation.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's September 2024 through September 2025 unusual incident reports, the facility failed to file a written unusual incident report with the Department, within 3 business days, following an event that required the presence of police and/or ambulance personnel at the facility on February 21, 2025. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All active unusual incident reports from September 2024 through September 2025 were reviewed to ensure timely submission and completion of required documentation.
Staff responsible for incident reporting were retrained on 10/6/2025 regarding DDAP requirements for timely filing of unusual incident reports within 3 business days.
A standardized unusual incident reporting protocol has been implemented, including a tracking system to ensure all incidents requiring police, fire, or ambulance response are submitted to the Department within 3 business days.
The Clinical Director will review all unusual incidents immediately upon occurrence to ensure proper documentation and timely submission.
Staff training on unusual incident reporting will be included in new hire orientation and reinforced annually during staff development training.
Per the deficiency, The February 21, 2025 unusual incident report will be filed on 10/9/2025.
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709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, a preliminary treatment and rehabilitation plan in four of six client records reviewed. The facility policy and procedure manual states that the preliminary treatment plan will be completed within 3 days of admission. Client # 1 was admitted to the partial hospitalization activity on September 4, 2025 and was still active at the time of the inspection. There was no preliminary treatment plan documented in the record at the time of the inspection. Client # 2 was admitted to the partial hospitalization activity on November 15, 2024 and was discharged on December 18, 2024. The preliminary treatment plan was due to be completed by November 18, 2024; however, the plan was completed on November 20, 2025. Client # 6 was admitted to the partial hospitalization activity on November 29, 2024 and was discharged on January 3, 2025. The preliminary treatment plan was due to be completed by December 2, 2024; however, the plan was completed on December 5, 2024. Client # 7 was admitted to the partial hospitalization activity on March 20, 2025 and was discharged on April 10, 2025. The preliminary treatment plan was due to be completed by March 23, 2025; however, the plan was completed on April 2, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Preliminary treatment plans for all active clients were reviewed and completed as of 10/6/2025.
Historical records for discharged clients were reviewed to acknowledge and document late submissions, and corrective steps were noted in their records.
Staff responsible for admissions and treatment planning were retrained on 10/6/2025 regarding the requirement to complete preliminary treatment plans within 3 days of admission.
A Preliminary Treatment Plan Tracking Log has been implemented as of 10/1/2025 to monitor completion within 3 days for all new admissions.
The Clinical Director will review all new admissions daily to ensure preliminary treatment plans are completed on time.
Any delays will be addressed immediately, with retraining provided to responsible staff. |
709.83(a)(11) LICENSURE Client records
709.83. 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 maintain a complete client record, which is to include the documentation of follow-up information, in three of six applicable client records reviewed.The facility policy and procedure manual states that follow-up information is to be documented 7 days, 1 month, 2 months, 6 months, 1 year and 2 years after discharge. Client # 2 was admitted to the partial hospitalization activity on November 15, 2024 and was discharged on December 18, 2024. There was only follow-up information documented in the record 1 month after discharge at the time of the inspection. Client # 3 was admitted to the partial hospitalization activity on February 25, 2025 and was discharged on April 1, 2025. There was only follow-up information documented in the record 1 month after discharge at the time of the inspection.Client # 6 was admitted to the partial hospitalization activity on November 29, 2024 and was discharged on January 3, 2025. There was only follow-up information documented in the record 1 month after discharge at the time of the inspection.This is a repeat citation from the September 11, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow-up information for all active and recently discharged clients was reviewed and updated as of 10/6/2025, documenting all follow-ups completed at 1 month and 6 months per the updated policy.
Staff responsible for discharge and follow-up documentation were retrained on 10/6/2025 regarding the revised follow-up schedule.
For clients who are no longer active and missing follow-ups, a note has been placed in the record acknowledging the missing follow-ups and documenting corrective steps taken.
The facility policy has been updated to require follow-up documentation at 1 month and 6 months after discharge.
A Follow-Up Tracking Log has been implemented to monitor completion of these follow-ups for all clients.
The Clinical Director will review the log monthly to ensure follow-ups are completed on schedule.
Any missed follow-ups will be addressed immediately, and responsible staff will receive retraining. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, a preliminary treatment and rehabilitation plan in two of five applicable client records reviewed. The facility policy and procedure manual states that the preliminary treatment plan will be completed within 3 days of admission. Client # 8 was admitted to the outpatient activity on July 3, 2025 and was still active at the time of the inspection. The preliminary treatment plan was due to be completed by July 6, 2025; however, the plan was completed on July 7, 2025. Client # 13 was admitted to the outpatient activity on December 2, 2024 and was discharged on February 21, 2025. The preliminary treatment plan was due to be completed by December 5, 2024; however, the plan was completed on December 12, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Preliminary treatment plans for all active clients were reviewed and completed as of 10/6/2025.
Historical records for discharged clients were reviewed to document late submissions, with corrective notes added to their records.
Staff responsible for intake and treatment planning were retrained on 10/6/2025 regarding the requirement to complete preliminary treatment plans within 3 days of admission.
A Preliminary Treatment Plan Tracking Log has been implemented as of 10/6/2025 to monitor timely completion of all new preliminary treatment plans.
The Clinical Director will review all new admissions daily to ensure plans are completed within 3 days.
Any delays will be addressed immediately, and responsible staff will receive additional training. |
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 maintain a complete client record, which is to include the documentation of follow-up information, in four of four applicable client records reviewed.The facility policy and procedure manual states that follow-up information is to be documented 7 days, 1 month, 2 months, 6 months, 1 year and two years after discharge. Client # 11 was admitted to the outpatient activity on February 25, 2025 and was discharged on May 23, 2025. There was only follow-up information documented in the record 1 month after discharge at the time of the inspection.Client # 12 was admitted to the outpatient activity on December 10, 2024 and was discharged on February 9, 2025. There was only follow-up information documented in the record 1 month after discharge at the time of the inspection.Client # 13 was admitted to the outpatient activity on December 2, 2024 and was discharged on February 21, 2025. There was follow-up information documented in the record 2 months and 3 months after discharge at the time of the inspection.Client # 14 was admitted to the outpatient activity on January 15, 2025 and was discharged on February 24, 2025. There was follow-up information documented in the record 2 months and 3 months after discharge at the time of the inspection.This is a repeat citation from the September 11, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow-up information for all active and recently discharged clients was reviewed and updated as of 10/6/2025, completing follow-ups per the updated policy at 1 month and 6 months after discharge.
Staff responsible for follow-up documentation were retrained on 10/6/2025 regarding the revised schedule.
For discharged clients with incomplete follow-up documentation, a note was added to acknowledge missing follow-ups and describe corrective actions taken.
Facility policy has been revised to require follow-up documentation at 1 month and 6 months after discharge.
A Follow-Up Tracking Log has been implemented to ensure all follow-ups are completed on schedule.
The Clinical Director will review the log monthly to verify timely follow-up completion.
Any missed follow-ups will be addressed immediately, and responsible staff will receive retraining.
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