INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 5-6, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Fellowship House LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from April 2025 through January 2026, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the months of April 2025 through January 2026.
These findings were reviewed with facility staff during the complaint investigation inspection.
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Plan of Correction
The clinical facility will conduct unannounced fire drills during hours of operation at least once per month. All fire drills will be documented in accordance with licensure fire safety regulation 705.10(d)(1). Staff responsible for ensuring that unannounced fire drills are conducted include Jessica Long (Clinical Supervisor) and Joseph Van Wie (Facility Project Director). |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of partial client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual.
The facility's policy and procedures manual states the comprehensive treatment plan must be completed within seven days following admission.
Client #1 was admitted on August 22, 2025, and was discharged on December 30, 2025. A comprehensive treatment plan was due no later than August 29, 2025, the treatment plan was completed September 5, 2025.
Client #2 was admitted on August 18, 2025, and was discharged on January 9, 2026. A comprehensive treatment plan was due no later than August 25, 2025, the treatment plan was completed August 29, 2025.
These findings were reviewed with facility staff during the complaint investigation process.
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Plan of Correction
The clinical supervisor (Jessica Long) has implemented documentation tracking for clinical staff to ensure compliance with comprehensive treatment plans and signature timeframes. The clinical supervisor will conduct chart audits weekly to ensure that all comprehensive treatment plans are completed in accordance with licensure regulation 709.82(a). |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of partial client records, the facility failed to document treatment plan updates within the regulatory timeframe.
Client #1 was admitted on August 22, 2025, and was discharged on December 30, 2025. A treatment plan was completed on September 5, 2025, the next treatment plan update was due no later than October 5, 2025. There was no additional treatment plans documented in the client record.
Client #2 was admitted on August 18, 2025, and was discharged on January 9, 2026. A treatment plan was completed on August 29, 2025, the next treatment plan update was due no later than September 29, 2025. There was no additional treatment plans documented in the client record.
These findings were reviewed with facility staff during the complaint investigation process.
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Plan of Correction
The clinical supervisor (Jessica Long) has implemented documentation tracking for clinical staff to ensure compliance with 30-day comprehensive treatment plan updates and signature timeframes. The clinical supervisor will conduct chart audits weekly to ensure that all comprehensive treatment plan updates are completed in accordance with licensure regulation 709.82(b). |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of partial client records, the facility failed to provide counseling to a client on a regular and consistent basis. The following services shall be included and documented: individual counseling at least twice weekly.
Client #1 was admitted on August 22, 2025, and was discharged on December 30, 2025. It was observed by DDAP staff that during the week of August 24-August 30, 2025, no individual sessions were documented in the client record.
This finding was reviewed with facility staff during the complaint investigation process.
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Plan of Correction
The clinical supervisor (Jessica Long) has implemented documentation tracking for clinical staff to ensure compliance with weekly individual sessions and signature timeframes. The clinical supervisor will conduct chart audits weekly to ensure that weekly individual sessions are completed in accordance with licensure regulation 709.82(d)(1). |
709.83(a)(6) 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of partial client records, the facility failed to provide a complete client record, which is to include aftercare information.
Client #1 was admitted on August 22, 2025, and was discharged on December 30, 2025. There was no aftercare plan documented in the client record.
This finding was reviewed with facility staff during the complaint investigatin process.
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Plan of Correction
The clinical supervisor (Jessica Long) has implemented documentation tracking for clinical staff to ensure compliance with documented aftercare plans and signature timeframes. The clinical supervisor will conduct chart audits weekly to ensure that aftercare plans are completed in accordance with licensure regulation 709.83(a)(6). |
709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of partial client records, the facility failed to provide a complete client record, which is to include a discharge summary.
The facility's " Policy 5.38FH " notes " the discharge summary will be completed within 7 days of termination. "
Client #1 was admitted on August 22, 2025, and was discharged on December 30, 2025. There was no discharge summary documented in this client's record.
This finding was reviewed with facility staff during the complaint investigation process.
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Plan of Correction
The clinical supervisor (Jessica Long) has implemented documentation tracking for clinical staff to ensure compliance with the completion of discharge summaries within seven days of discharge and signature timeframes. The clinical supervisor will conduct chart audits weekly to ensure that all discharge summaries are completed within seven days of discharge in accordance with licensure regulation 709.83(a)(10). |
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 client records, the facility failed to provide a complete client record, which is to include follow-up information.
The facility's policy " 5.43FH Client Follow-Up " notes " all discharged clients, including AMA and Admin DC will be followed up and monitored through telephone contact at 7 days and 30 days post discharge. "
Client #1 was admitted on August 22, 2025, and was discharged on December 30, 2025. There was no follow-up contacts documented in the client's record.
Client #2 was admitted on August 18, 2025, and was discharged on January 9, 2026. There was no follow-up contacts documented in the client's record.
These findings were reviewed with facility staff during complaint investigation process. .
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Plan of Correction
The clinical supervisor (Jessica Long) has created a documentation tracking system and assigned the case manager (Michael Burkholder) with conducting follow up contacts regardless of discharge status at 7 days and 30 days post discharge. The discharge follow-up will be documented in the client's chart. The clinical supervisor will conduct weekly audits to ensure that the discharge follow-up is documented in compliance with licensure regulation 709.83(a)(11). |