INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 20, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lewis Recovery LLC Victory Park Recovery Center 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of personnel records, the facility failed to ensure that the clinical supervisor completed a core curriculum in clinical supervision within a timely fashion.Employee #3 was promoted to a clinical supervisor position on August 15, 2024 and was still in that position at the time of the inspection. She has not completed the core curriculum training at the time of the inspection.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Chief Clinical Officer and Clinical Director met with employee #3. Employee #3 has begun core curriculum supervisor training at time of the submission of this POC. Any new employee promoted to the position of clinical supervisor will complete the core clinical supervisor training within their first 90 days in this position. Chief Clinical Officer and Clinical Director will review any potential promotions or new hire in the role of Clinical Supervisor to ensure that core curriculum supervisor training has already been completed or needs to be completed. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document that each counselor met both the education and experiential qualifications for the position.Employee #7, who was hired as a Certified Recovery Specialist on June 14, 2023, did not meet the experience or educational requirements to be a counselor. He has a GED. While his title was Certified Recovery Specialist, he performed the duties of a counselor. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Director and Clinical Supervisor have reviewed the personnel file of employee #7. The job description for Employee #7 was changed to Counselor Assistant to comply with regulation 704.7 (b) on 11/20/2025. Clinical Director and Clinical Supervisor will ensure at the time of hire that all future counselor assistants will meet both the educational and experiential qualifications of the position in accordance to regulation 704.7(b). Clinical Director will be the direct supervisor for all Counselor Assistants. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's staff development program, the facility failed to develop a comprehensive staff development program for the current training year, December 1, 2024 through November 31, 2025. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
A comprehensive staff development program for the training year has been developed in accordance with regulation 704.11(a)(2).
The program will include: An annual training needs assessment for all personnel. An overall training plan addressing identified needs, required DDAP trainings, time frames for completion, and responsible staff. To prevent recurrence, Clinical Director will complete and approve the annual staff development plan at least 30 days prior to the start of each new training year. A reminder system will be added to the facility's compliance calendar to prompt review, update, and completion of the plan annually. The staff development plan will be reviewed quarterly during administrative meetings held by Clinical Director and Clinical Supervisor to ensure it remains current and comprehensive. Project Director and Clinical Supervisor will present the quarterly staff development plan to Chief Clinical Officer during scheduled supervision meetings.
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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 onw out of nine employee records reviewed.Employee #4 was hired on May 6, 2025 as a counselor and was still in the position as of the date of the inspection. No plan was documented.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
During our most recent DDAP audit, it was determined that facility did not consistently maintain a written, annually updated Individual Training Plan (ITP) for each employee with documented input from the employee and the supervisor.
Corrective action related to employee #4 involved a review and completion of their ITP for training year 2024/2025 .
Facility-wide corrective action includes implementing a formalized ITP template which aligns with DDAP 704.11 (b)(1). Each employee's ITP will be placed in their personnel file and reviewed with their supervisor at their annual performance evaluation. Each employee's ITP will be appropriate to the employee's specific position and skill level. Clinical Director will meet with Chief Clinical Officer monthly to review findings. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. There were cameras in each of the three group counseling rooms.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pursuant to regulation 705.23(3) regarding visual only cameras, Chief Clinical Officer requested an exception to Department's regulations at 28 Pa Code Chapter 705 Physical Plant Standards. Facility received approval for the exception on 12/2/2025.
Per the exception, the cameras are visual only and the following staff will have access to these feeds; CCO, CFO, Executive Director and Clinical Supervisor.
The exception letter will be placed in the Policy & Procedure binder in the Clinical Director's office.
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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 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 #4 was hired on May 6, 2025 as a counselor and was still in the position as of the date of the inspection. No training was completed. Employee #5 was hired on August 21, 2025 as a counselor and was still in the position as of the date of the inspection. No training was completed.Employee #6 was hired on September 18, 2025 as a counselor and was still in the position as of the date of the inspection. No training was completed.Employee #8 was hired on October 27, 2025 as a counselor assistant and was still in the position as of the date of the inspection. No training was completed.Employee #9 was hired on October 27, 2025 as a counselor assistant and was still in the position as of the date of the inspection. No training was completed.These findings were reviewed with the facility staff during the licensing process.This is a repeat citation from the October 18, 2024 annual licensing inspection.
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Plan of Correction
Pursuant to 705.28 (c) (4), employees #\4, #5, #6, #8 & #9 completed use of fire extinguisher training by 12/16/2025. Leadership reviewed onboarding documentation and have included Fire Extinguisher Training in new hire orientation documentation packet. Clinical Director added Fire Extinguisher Training to new hire orientation checklist. This will be completed with new hired staff conducted by Clinical Director. Chief Clinical Officer, Clinical Director and Clinical Supervisor will continue to meet weekly for Clinical Supervisor supervision team meeting and review any new staff hired to ensure compliance to regulation 705.28(c)(4). |
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. Employee #4 was hired on May 6, 2025 as a counselor and was still in the position as of the date of the inspection. No training was completed. Employee #5 was hired on August 21, 2025 as a counselor and was still in the position as of the date of the inspection. No training was completed.Employee #6 was hired on September 18, 2025 as a counselor and was still in the position as of the date of the inspection. No training was completed.Employee #8 was hired on October 27, 2025 as a counselor assistant and was still in the position as of the date of the inspection. No training was completed.Employee #9 was hired on October 27, 2025 as a counselor assistant and was still in the position as of the date of the inspection. No training was completed.These findings were reviewed with the facility staff during the licensing process.This is a repeat citation from the October 18, 2024 annual licensing inspection.
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Plan of Correction
Pursuant to 705.28 (d) (3), it was found that employees #4, #5, #6, #8 & #9 were not trained upon hire. This training was completed for employees #4, #5, #6, #8 & #9 by 12/16/2025 Leadership reviewed onboarding documentation and have included Fire Safety Training including Fire Drills in new hire orientation documentation packet to ensure new staff are trained to perform assigned tasks during emergencies. Clinical Director added Fire Safety Training to new hire orientation checklist. This will be completed with new hired staff conducted by Clinical Director. Chief Clinical Officer, Clinical Director and Clinical Supervisor will continue to meet weekly for Clinical Supervisor supervision team meeting and review any new staff hired to ensure compliance to regulation 705.28(d)(3). |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
709.25 - Based on a review of administrative documents and an interview with the facility director, the project failed to document an annual financial audit for the fiscal year ending December 31, 2023. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO and CFO have secured a certified public accounting firm to complete annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities as the annual audit for fiscal year 2024 had not been completed at the time of annual survey which was still in process. The selected independent certified public accounting firm or any future independent certified public accounting firm will be contractually engaged to prepare annual audits within six months of the conclusion of the previous fiscal year.
The CFO will ensure that the annual financial audit is completed for the fiscal year of 2025 within 6 months of the conclusion of the fiscal year. CFO and CEO have added update and status of the fiscal audit to the monthly leadership agenda to ensure compliance of regulation 709.25.
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709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document case consultations within guidelines established by the facility's policy and procedures manual in three out of three applicable records reviewed. The facility's policy and procedures manual states that the case consultations must be completed at least once prior to discharge.Client #12 was admitted on July 14, 2025 and was discharged on August 29, 2025.Client #13 was admitted on July 14, 2025 and was discharged on August 29, 2025.Client #14 was admitted on June 30, 2025 and was discharged on August 8, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the most recent DDAP audit, it was determined that clients #12, #13 & #14 did not have a case consultation prior to discharge. Chief Clinical Officer, Clinical Director and Clinical Supervisor changed verbiage in the Policy & Procedure Manual to require a "case consultation within 90 days of admission." Clinical Director and Clinical supervisor met with staff during weekly treatment team meeting to advise all clinical staff of the case consultation new timeframe. A tab is in the existing electronic health record to complete between day 1 and day 90 for each client to ensure compliance with regulation 709(a)(4). Clinical Director and Clinical Supervisor will complete weekly chart audits to include case consultations. |
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 partial hospitalization client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in three out of three applicable records reviewed. The facility's policy and procedures manual states that the follow-up must be completed seven days following discharge.Client #12 was admitted on July 14, 2025 and was discharged on August 29, 2025.Client #13 was admitted on July 14, 2025 and was discharged on August 29, 2025.Client #14 was admitted on June 30, 2025 and was discharged on August 8, 2025.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 18, 2024 annual licensing inspection.
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Plan of Correction
Pursuant to regulation 709.83(a)(11), it was found that follow up contact was not documented for clients #12, #13 & #14 discharged from Partial Hospitalization Program.
Leadership team met and designated that all follow up contacts to be completed and logged by Alumni Coordinator overseen by Clinical Director. Chief Clinical Officer, Clinical Director and Clinical Supervisor changed verbiage in the Policy and Procedure Manual that follow up calls are to be made within 30 days of discharge.
Clinical Director and Clinical Supervisor will review all partial hospitalization discharges weekly and audit EMR of partial hospitalization discharged clients to ensure follow up contacts are made by Alumni Coordinator. Clinical Director and Clinical Supervisor will report weekly contacts reports to Chief Clinical Officer to safeguard that facility is within compliance of regulation 709.83(a)(11).
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of outpatient client records, the facility failed to document case consultations within guidelines established by the facility's policy and procedures manual in three out of six applicable records reviewed. The facility's policy and procedures manual states that the case consultations must be completed at least once prior discharge.Client #5 was admitted on May 28, 2025 and discharged on July 24, 2025. No case consultation was completed.Client #6 was admitted on May 12, 2025 and discharged on July 25, 2025. No case consultation was completed.Client #7 was admitted on September 10, 2025 and discharged on November 5, 2025. No case consultation was completed.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 18, 2024 annual licensing inspection.
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Plan of Correction
During the most recent DDAP audit, it was determined that clients #5, #6 & #7 did not have a case consultation prior to discharge. Chief Clinical Officer, Clinical Director and Clinical Supervisor changed verbiage in the Policy & Procedure Manual to require a "case consultation within 90 days of admission." Clinical Director and Clinical supervisor met with staff during weekly treatment team meeting to advise all clinical staff of the case consultation new timeframe. A tab is in the existing electronic health record to complete between day 1 and day 90 for each client to ensure compliance with regulation 709(a)(4). Clinical Director and Clinical Supervisor will complete weekly chart audits to include case consultations. |
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 outpatient client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in three out of three 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 May 28, 2025 and was discharged on July 25, 2025.Client #6 was admitted on May 12, 2025 and was discharged on July 25, 2025.Client #7 was admitted on September 10, 2025 and was discharged on November 5, 2025.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 18, 2024 annual licensing inspection.
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Plan of Correction
Pursuant to regulation 709.93(a)(11), it was found that follow up contact was not documented for clients #5, #6 & #7 discharged from treatment.
Leadership team met and designated that all follow up contacts to be completed and logged by Alumni Coordinator overseen by Clinical Director. Chief Clinical Officer, Clinical Director and Clinical Supervisor changed verbiage in the Policy and Procedure Manual that follow up calls are to be made within 30 days of discharge.
Clinical Director and Clinical Supervisor will review all discharges weekly and audit EMR of discharged clients to ensure follow up contacts are made by Alumni Coordinator. Clinical Director and Clinical Supervisor will report weekly contacts reports to Chief Clinical Officer to safeguard that facility is within compliance of regulation 709.83(a)(11).
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