INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on Septemberr 1-2, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site investigation, Cove Forge Behavioral Health System at Williamsburg 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 investigation:
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Plan of Correction
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on September 1, 2026, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
Knepp House had window blinds with missing or broken slats in room 3, room 4 and in the bathroom.
YSF had window blinds with missing or broken slats in room 1, 2 and 3. The chairs in the lounge area had a leather-like material that was worn, cracked, and duct-taped on the seat cushions. The vinal plank flooring in the lounge area had the laminant overlay missing around some of the edges of the planks, causing a tripping hazard.
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Plan of Correction
Knepp house blinds were replaced on 9/3/26.
YSF blinds were replaced on 9/3/26.
YSF chair was removed and replaced on 9/7/26.
The flooring in the lounge area was replaced on 9/22/26.
Managers have been reminded to report any broken or damaged item(s) during the weekly leadership rounds so repair/replacement can occur.
Maintenance has been reminded to replace worn and broken items during their rounding so repair/replacement can occur. Maintenance rounding occurs weekly.
The facility director will ensure broken and damaged items are replaced and/or repaired and that rounding occurs. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on September 1, 2026, the facility failed to maintain each bathroom in a clean and sanitary manner at all times.
The bathroom in Knepp House had a black mold-like substance where the top and bottom sections of the shower walls meet.
The upstairs bathroom in YSF had a black and brown colored mold-like substance in the grout around the shower pan and on the tiles in the corner of the shower.
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Plan of Correction
The bathroom in Knepp was cleaned with a new cleaning product on 9/3/26 and no mold like substance is evident.
The bathroom in YSF was cleaned with a new cleaning product on 9/3/26 and no mold like substance is evident.
Housekeeping has added cleaning shower grout to the check off list on their cleaning sheets for all patient bathrooms. Grout cleaning will occur weekly.
If the grout does not come clean with cleaning products, maintenance will re-grout the area that has any brown or black substance(s).
The housekeeping supervisor will ensure weekly grout cleaning occurs by checking facility bathrooms and cleaning sheets on a weekly basis.
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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 and the Notification of Termination of Treatment: Administrative Discharges policy, the facility failed to provide documentation of a termination letter notifying a client, in writing, of a decision to involuntarily terminate treatment.
Per the Notification of Termination of Treatment: Administrative Discharges policy, a notice, which will include the reason for termination, will be maintained in the client record.
Client # 3 was admitted on June 26, 2026, and discharged on July 13, 2026. Documentation of a termination letter was missing from the client record.
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Plan of Correction
The CEO re-educated the clinical supervisors on the importance of completing the administrative discharge form/letter when an individual is administratively discharged from treatment.
The re-education occurred in the Monday morning program meeting on 9/14/26.
The quality coordinator will audit 10 administrative discharge charts for the next 4 months to ensure the administrative discharge form/documentation of the discharge is in the client record. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan.
Client # 3 was admitted on June 26, 2026, and discharged on July 13, 2026. Per the treatment plan dated June 30, 2026, the client was to have one individual session per week. Documentation of an individual session was missing for the week of July 5, 2026.
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Plan of Correction
The residential clinical supervisors re-educated the residential counseling staff on the importance of having a minimum of one individual session per week with patients in the residential program.
This re-education took place during shift report and in clinical staffing.
Each residential clinical supervisor will monitor 20 charts per week for the next three months to ensure there is a minimum of one individual session per week. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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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 a discharge summary.
Client # 1 was admitted on June 11, 2026, and discharged on July 1, 2026. Documentation of a discharge summary was missing in this client record.
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Plan of Correction
Clinical Supervisors will track discharges through supervision meetings at beginning and ending of each week to identify clients that are discharging throughout the week.
Clinical supervisors will identify priority discharge summaries during these meetings.
After identifying priority discharge summaries, Clinical Supervisor will disperse information to clinicians they supervise to ensure completion of the discharge summary within 7 days.
Clinical supervisors will continue to track all daily discharges and announce expectations during morning and afternoon shift reports as to which discharge summaries are due within 7 days.
Medical records will keep track of timely discharge summary completion and email findings to clinical staff. |