INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 24, 2026 through February 25, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Liberty Pine Recovery LLC dba Lifeline Recovery and Wellness 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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709.28 (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 ensure a copy of all client consent to release information forms documented in the record was offered to the client in fourteen of fourteen client records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Following the survey, Lifeline Recovery and Wellness implemented a corrective action within the electronic medical record (EMR) system to ensure compliance with consent documentation requirements. On February 25, 2026, the EMR was updated so that, as part of the consent process, clients are automatically prompted to indicate whether they wish to receive a hard copy of the consent forms. This field requires a response, and staff must select either "Yes" or "No" before the consent documentation can be completed.
On February 26, 2026, all staff responsible for completing admissions and intake documentation were trained on the updated EMR workflow and the new required consent question. Staff were instructed on the importance of ensuring the client's preference is documented during the consent process. This system change ensures consistent documentation moving forward and prevents the consent from being finalized without capturing the client's preference.
In addition, the facility conducted a review of all active client records to ensure the required consent documentation and client preference regarding receipt of consent forms were properly documented. Corrections were completed for all active client charts by March 2, 2026, ensuring that both current and future client records meet the documentation requirements.
These corrective actions ensure that client preferences regarding consent documentation are consistently captured in the EMR and that staff follow the updated process during admission. Ongoing monitoring will occur through the facility's internal chart audit process to ensure continued compliance. |
709.30 (1) 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.
(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.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgment by the client that the client had been informed of their right to retain civil rights and liberties except as provided by statute in fourteen of fourteen client records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Following the survey, Lifeline Recovery and Wellness implemented a corrective action within the electronic medical record (EMR) system to ensure compliance with client rights documentation requirements. The EMR was updated on February 25, 2026, so that, as part of the Client Rights acknowledgment process, clients are automatically prompted to indicate whether they wish to receive a hard copy of the Client Rights document. This field now requires a response, and staff must select either "Yes" or "No" before the form can be completed.
On February 26, 2026, all staff responsible for completing admissions and intake documentation were trained on the updated EMR workflow and the new required question. Staff were instructed on the importance of reviewing Client Rights with each client during admission and documenting the client's preference regarding receipt of a hard copy.
Additionally, the facility conducted a review of all active client records to ensure the Client Rights acknowledgment and client preference regarding receipt of the document were properly documented. Corrections were completed in all active client charts by March 2, 2026, ensuring compliance for both current clients and future admissions.
This system update ensures consistent documentation of Client Rights acknowledgment and prevents the form from being finalized without recording the client's preference moving forward. Ongoing monitoring will occur through the facility's internal chart audit process to ensure continued compliance with this requirement. |
709.30 (2) 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.
(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.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgement by the client that the client had been informed of their right that 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. On the client rights acknowledgment, "creed, color, and national origin" were missing in fourteen of fourteen client records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Following the survey finding, Lifeline Recovery and Wellness conducted a review of its policies and admission documentation related to client rights and participation in the clinical record. During this review, the facility confirmed that the existing confidentiality documentation did not explicitly include language informing clients of their right to submit rebuttal data or memoranda to their clinical record if they believe information in the record is inaccurate or incomplete.
To correct this deficiency, on February 25, 2026, Lifeline Recovery and Wellness revised the Confidentiality Policy and the Client Confidentiality Acknowledgment Form to include language informing clients of their right to submit written rebuttal data or memoranda to be included in their clinical record when they believe information in the record is inaccurate or incomplete.
Effective February 25, 2026, the updated confidentiality acknowledgment form was implemented for all new admissions, and all clients admitted on or after this date have the updated form completed and maintained in their clinical record. The revised form includes a specific client acknowledgment section confirming that the client has been informed of this right during the admission process.
A retroactive review of all active client records was completed, and the updated confidentiality acknowledgment form was reviewed with and signed by all active clients. As of March 2, 2026, the deficiency was fully corrected in all active client records, and the updated form is now maintained in each client's chart.
On February 26, 2026, all staff responsible for completing admissions and intake documentation were trained on the revised Confidentiality Policy and updated acknowledgment form. Staff were instructed to review the updated language with each client during the admission process and ensure the client's written acknowledgment is completed and maintained in the clinical record.
These corrective actions ensure that all clients are informed of their right to submit rebuttal data or memoranda to their clinical record, and that documentation of this acknowledgment is consistently maintained in the client record moving forward. |
709.30 (3) 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.
(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.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgement by the client that the client had been informed of their right that while inspecting their own record, any portion of the record the project, facility or clinical director may temporarily remove prior to the inspection by the client can be done if the director determines that the information may be detrimental if presented to the client and the reasons for removing sections shall be documented in the record in fourteen of fourteen client records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To correct this deficiency, on February 25, 2026, the Confidentiality Policy and client confidentiality acknowledgment form were updated to include the required Pennsylvania-specific language regarding a client's right to inspect their record and the circumstances under which information may be temporarily withheld. The updated form now includes language explaining the client's right to inspect their clinical record and that the Project Director, Facility Director, or Clinical Director may temporarily remove portions of the record if disclosure may be detrimental to the client. The form also includes language stating that the reason for removing any section of the record will be documented in the clinical record. Additionally, the updated form includes a client acknowledgment section confirming the client has been informed of this right and a required field asking whether the client would like to receive a hard copy of the confidentiality policy, requiring staff to select "Yes" or "No."
On February 26, 2026, all admissions and intake staff were trained on the updated confidentiality policy and acknowledgment form to ensure the required information is reviewed with clients and properly documented at admission.
Additionally, the facility completed a review of all active client records to ensure the updated confidentiality acknowledgment form was added and properly documented. The facility completed corrections to all active client records by March 2, 2026 to ensure compliance with the updated policy requirements.
This corrective action ensures that clients are properly informed of their rights regarding access to their records and that written acknowledgment is consistently documented in the client record moving forward. The facility has implemented ongoing monitoring through its internal chart audit process to ensure continued compliance with this requirement. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgement by the client that the client had been informed of their right to appeal a decision limiting access to their records to the director in fourteen of fourteen client records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To correct this deficiency, on February 25, 2026, the Confidentiality Consent form was revised to include language informing clients of their right to appeal any decision that limits access to their clinical record to the Director. The updated form includes a client acknowledgment section confirming that the client has been informed of this right as part of the confidentiality consent completed at admission.
On February 26, 2026, all staff responsible for completing admissions and intake documentation were trained on the updated confidentiality consent and acknowledgment requirements. Staff were instructed to review the updated language with each client during the admission process and ensure the client's written acknowledgment is obtained and documented in the clinical record.
Additionally, the facility conducted a review of all active client records to ensure the updated confidentiality consent form, including the appeal rights language, was properly included and documented. The facility completed corrections to all active client records by March 2, 2026, ensuring the deficiency was fully corrected in both new admissions and currently active charts.
This finding and the corrective actions were reviewed with facility staff during the licensing process. These changes ensure that clients are properly informed of their right to appeal any limitation on access to their records and that written acknowledgment is consistently documented in the client record moving forward. Ongoing monitoring will occur through the facility's internal chart audit process to ensure continued compliance with this requirement. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgement by the client that the client had been informed of their right to submit rebuttal data or memoranda to their own records in fourteen of fourteen client records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Following the survey finding, Lifeline Recovery and Wellness conducted a review of its policies and admission documentation related to client rights and participation in the clinical record. During this review, the facility confirmed that the existing confidentiality documentation did not explicitly include language informing clients of their right to submit rebuttal data or memoranda to their clinical record if they believe information in the record is inaccurate or incomplete.
To correct this deficiency, on February 25, 2026, Lifeline Recovery and Wellness revised the Confidentiality Policy and the Client Confidentiality Acknowledgment Form to include language informing clients of their right to submit written rebuttal data or memoranda to be included in their clinical record when they believe information in the record is inaccurate or incomplete.
Effective February 25, 2026, the updated confidentiality acknowledgment form was implemented for all admissions, and all clients admitted on or after this date have the updated form completed and maintained in their clinical record. The revised form includes a specific client acknowledgment section confirming that the client has been informed of this right during the admission process.
In addition, a retroactive chart review was completed, and as of 03/02/2026, all current clients had the updated confidentiality acknowledgment form reviewed with them and signed, ensuring the corrected language is present in all active client records.
On February 26, 2026, all staff responsible for completing admissions and intake documentation were trained on the revised Confidentiality Policy and updated acknowledgment form. Staff were instructed to review the updated language with each client during the admission process and ensure the client's written acknowledgment is completed and maintained in the clinical record.
These corrective actions were implemented immediately and ensure that all clients are informed of their right to submit rebuttal data or memoranda to their clinical record, and that documentation of this acknowledgment is consistently maintained in the client record moving forward. |
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 client records, the facility failed to provide counseling on a regular and scheduled basis in two of three applicable client records reviewed.
Client # 11 was admitted into the partial hospitalization activity on October 16, 2025 and was discharged on December 1, 2025. Individual counseling was to be provided at least twice weekly; however, there were no individual counseling sessions documented during the weeks of November 16, 2025 through November 22, 2025 and November 23, 2025 through November 29, 2025.
Client # 12 was admitted into the partial hospitalization activity on October 6, 2025 and was discharged on November 24, 2025. Individual counseling was to be provided at least twice weekly; however, there were no individual counseling sessions documented during the week of November 16, 2025 through November 22, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following the survey findings, Lifeline Recovery and Wellness conducted a review of the client records referenced and the circumstances surrounding the missing documentation of individual counseling sessions. During the licensing review, it was shared with the surveyor that the therapist responsible for these client records had ongoing performance concerns related to documentation compliance and clinical responsibilities.
In November 2025, the facility implemented a weekly chart audit tool to review clinical documentation, including verification that required individual counseling sessions were being completed and documented according to program requirements. Through this audit process, leadership quickly identified concerns related to missing documentation and inconsistent completion of required clinical notes.
The staff member responsible for the referenced charts was placed under review due to continued performance issues related to documentation compliance. Following the appropriate corrective and HR processes, the therapist was terminated on January 2, 2026, due to continued performance deficiencies, specifically related to documentation and failure to meet clinical documentation expectations.
The weekly chart audit process remains in place and includes weekly routine review of client charts to ensure required individual counseling sessions are occurring and being documented according to program standards. Since the termination of the therapist and continued use of the chart audit tool, no additional deficiencies related to missing individual counseling documentation have been identified.
These findings and corrective actions were reviewed with facility staff during the licensing process. This ongoing audit process ensures that required counseling services are both provided and documented consistently moving forward. |
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 on an individual, which is to include documentation of follow-up information, in two of four applicable client records reviewed.
Client # 13 was admitted into the partial hospitalization activity on August 20, 2025 and was discharged on August 22, 2025. There was no follow-up information documented in the record as of the date of the inspection.
Client # 14 was admitted into the partial hospitalization activity on January 26, 2026 and was discharged on February 6, 2026. There was no follow-up information documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following the survey findings, Lifeline Recovery and Wellness reviewed the documentation requirements related to post-discharge follow-up documentation. During this review, it was identified that while follow-up calls were being conducted with discharged clients, the outreach was not consistently documented in the client record.
These findings were reviewed with the licensing surveyor on site. The facility confirmed that follow-up outreach had been occurring; however, the outreach attempts were not being documented within the EMR as required.
To correct this deficiency, the facility reviewed and reinforced its post-discharge follow-up process. The Alumni Coordinator is responsible for conducting follow-up outreach to clients at seven (7) days post-discharge, as well as additional outreach attempts based on the program's identified follow-up process. All follow-up outreach attempts and outcomes are now documented in the EMR under the discharge tab to ensure the client record remains complete.
Additionally, the facility updated its weekly chart audit tool to include verification that follow-up outreach within seven (7) days of discharge has been completed and documented in the EMR. This allows leadership to routinely monitor compliance and ensure the client record remains complete.
On February 27, 2026, the Clinical Team and Alumni Coordinator were trained on the required follow-up documentation process, including where and how to properly document outreach attempts in the EMR.
This corrective action ensures that post-discharge follow-up outreach is both conducted and properly documented in the client record moving forward, maintaining a complete client record in accordance with regulatory requirements. |
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 on an individual, which is to include documentation of follow-up information, in four of four applicable client records reviewed.
Client # 4 was admitted into the outpatient activity on November 13, 2025 and was discharged on December 15, 2025. There was no follow-up information documented in the record as of the date of the inspection.
Client # 5 was admitted into the outpatient activity on July 10, 2025 and was discharged on August 13, 2025. There was no follow-up information documented in the record as of the date of the inspection.
Client # 6 was admitted into the outpatient activity on September 15, 2025 and was discharged on October 1, 2025. There was no follow-up information documented in the record as of the date of the inspection.
Client # 7 was admitted into the outpatient activity on July 23, 2025 and was discharged on September 24, 2025. There was no follow-up information documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following the survey findings, Lifeline Recovery and Wellness reviewed the documentation requirements related to post-discharge follow-up documentation. During this review, it was identified that while follow-up calls were being conducted with discharged clients, the outreach was not consistently documented in the client record.
These findings were reviewed with the licensing surveyor on site. The facility confirmed that follow-up outreach had been occurring; however, the outreach attempts were not being documented within the EMR as required.
To correct this deficiency, the facility reviewed and reinforced its post-discharge follow-up process. The Alumni Coordinator is responsible for conducting follow-up outreach to clients at seven (7) days post-discharge, as well as additional outreach attempts based on the program's identified follow-up process. All follow-up outreach attempts and outcomes are now documented in the EMR under the discharge tab to ensure the client record remains complete.
Additionally, the facility updated its weekly chart audit tool to include verification that follow-up outreach within seven (7) days of discharge has been completed and documented in the EMR. This allows leadership to routinely monitor compliance and ensure the client record remains complete.
On February 27, 2026, the Clinical Team and Alumni Coordinator were trained on the required follow-up documentation process, including where and how to properly document outreach attempts in the EMR.
This corrective action ensures that post-discharge follow-up outreach is both conducted and properly documented in the client record moving forward, maintaining a complete client record in accordance with regulatory requirements. |