INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 10-11, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Her Safe Haven 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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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers 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 provide documentation of all staff being instructed on the use of the fire extinguisher upon employment in one of twelve records. Staff #3 was hired as a counselor on June 6, 2025 and was still in this position at the time of the inspection. There was no documentation of fire extinguisher training in the personnel record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and Facility Director will ensure that all new staff are completing the "Fire Emergency Protocol" training as part of their onboarding process using the personnel file and training checklist.
Once the fire extinguisher training explained in the policy is completed, the Facility Director and the new staff person will then sign off on a certificate of completion that will be kept in the staff person's file.
All current staff files will be reviewed to ensure they are properly trained in use of fire extinguishers. If they are not, they will be instructed to complete the training.
The Project Director will conduct a quarterly audit of staff files to ensure ongoing compliance.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 provide documentation of all staff are trained to perform assigned tasks during emergencies in one of twelve records. Staff #3 was hired as a counselor on June 6, 2025 and was still in this position at the time of the inspection. There was no documentation Staff #3 was trained to perform assigned tasks during emergencies in the personnel record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and Facility Director will ensure that all new staff are completing the "Fire Emergency Protocol" training as part of their onboarding process using the personnel file and training checklist.
Included in the policy is the instruction to ensure all personnel on all shifts are trained to perform assigned tasks during emergencies.
Once the assigned tasks training explained in the policy is completed, the Facility Director and the new staff person will then sign off on a certificate of completion that will be kept in the staff person's file.
All current staff files will be reviewed to ensure they are properly trained in assigned tasks during emergencies. If they are not, they will be instructed to complete the training.
The Project Director will conduct a quarterly audit of staff files to ensure ongoing compliance.
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility fire drill log for the months of June 2025 through January 2026, the facility failed to prepare alternate exit routes to be used during fire drills. All fire drill indicated use of the " front exit. "These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will review all fire drill requirements with the Facility Director and staff at the staff meeting in March.
The Project Director will conduct a quarterly audit of fire drill logs to ensure ongoing compliance.
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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 applicable client record reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one record.Client #4 was admitted on September 10, 2025 and discharged on October 29, 2025. There was no documentation in the client record notifying the client, in writing, of termination from the project.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will create a new "Resident Termination Letter" that will cover all types of discharge, including completion, voluntary and involuntary discharges. The letter will include a checkoff for the type of discharge, the reason for termination, termination criteria, timeline for discharge, and other termination/discharge requirements under DDAP regulations.
The resident will be offered a copy and have an opportunity to sign the letter. If the resident refuses, it will be noted on the termination letter.
The "Discharge Policy" will be updated by the Project Director to reflect the new processes.
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709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against facility advice in one of one applicable record.The facility's inpatient non-hospital residential policy and procedure states the client ' s emergency contact will be notified within twenty-four hours of the client ' s decision to leave against facility advice, providing there is consent given in writing for Her Safe Haven to contact the emergency contact.Client #7 was admitted to the residential level of care on June 23, 2025 and discharged on July 14, 2025. There was a consent for the emergency contact in client #7 ' s record.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The "Discharge Policy" will be updated by the Project Director and reviewed with staff at the March meeting to ensure that the procedures regarding the contacting of the resident's Emergency Contact within 24 hours when a resident makes the decision to leave against staff advice is completed and documented.
The Project Director will conduct monthly audits of the residents' files to ensure Clinical Staff are completing the notification.
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709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on applicable client records reviewed, the facility failed to provide a preliminary treatment plan in accordance with the facility policy and procedure in four of five applicable records. The facility policy and procedure indicated a preliminary treatment plan to be completed within seventy-two hours of admission.Client #1 was admitted on November 10, 2025 and was still active at the time of the inspection. The preliminary treatment plan was to be completed on November 13, 2025; however, this was not completed at the time of the inspection. Client #2 was admitted on December 10, 2025 and was still active at the time of the inspection. The preliminary treatment plan was to be completed on December 13, 2025; however, this was not completed at the time of the inspection.Client #4 was admitted on September 10, 2025 and was discharged on October 29, 2025. The preliminary treatment plan was to be completed on September 13, 2025; however, this was not completed prior to discharge.Client #7 was admitted on June 23, 2025 and was discharged on July 14, 2025. The preliminary treatment plan was to be completed on June 26, 2025; however, this was not completed prior to discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will update the "Intake Assessment" to include a Preliminary Treatment Plan which would indicate whether the resident is recommended for treatment in a level 3.5 residential program.
The Facility Director will review the updated form with staff.
The Project Director will conduct monthly audits of the residents' files to ensure Clinical Staff are completing the Preliminary Treatment Plan.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 applicable client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client and in accordance to the facility ' s policy and procedure in four of seven records. The facility policy and procedure indicated an initial comprehensive treatment and rehabilitation plan be completed within fourteen days of admission into the program.Client #1 was admitted on November 10, 2025 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed on November 14, 2025 did not include documentation of the plan being developed with the client.Client #5 was admitted on June 12, 2025 and was discharged on November 3, 2025. The comprehensive treatment and rehabilitation plan developed on June 13, 2025 did not include documentation of the plan being developed with the client.Client #6 was admitted on July 8, 2025 and was discharged on September 25, 2025. The comprehensive treatment and rehabilitation plan developed on July 11, 2025 did not include documentation of the plan being developed with the client.Client #7 was admitted on June 23, 2025 and was discharged on July 14, 2025. The initial comprehensive treatment plan was due no later than July 7, 2025; however this was not completed prior to discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will conduct monthly audits of the residents' files to ensure Clinical Staff are completing the individual treatment plans with the residents according to timeline requirements, and with the resident's dated signature.
These audit findings will be reviewed with the Facility Director on a monthly basis.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services in six of six records. Client #1 was admitted on November 10, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed on November 14, 2025; however, there was no documentation of frequency of services.Client #2 was admitted on December 10, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on December 16, 2025; however, there was no documentation of frequency of services.Client #3 was admitted on February 2, 2026 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on February 10, 2026; however, there was no documentation of frequency of services.Client #4 was admitted on September 10, 2025 and was discharged on October 29, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on September 19, 2025; however, there was no documentation of frequency of services.Client #5 was admitted on June 12, 2025 and was discharged on November 3, 2025. A comprehensive treatment and rehabilitation plan was developed on June 13, 2025; however, there was no documentation of frequency of services.Client #6 was admitted on July 8, 2025 and was discharged on September 25, 2025. A comprehensive treatment and rehabilitation plan was developed on July 11, 2025; however, there was no documentation of frequency of services.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The treatment and rehabilitation plan template will be revised to include a clearly designated section for the type and frequency of treatment and rehabilitation services. Current client records will be reviewed and updated as needed to ensure compliance. Relevant staff will be re-educated on documentation requirements under 709.52(a)(2), including the requirement that treatment plans developed with the client must specify the type and frequency of services. The Facility Director will monitor newly completed and updated treatment plans through routine chart audits to ensure ongoing compliance. |
709.52(a)(3) LICENSURE Support service type
709.52. 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:
(3) Proposed type of support service.
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Observations
Based on a review of applicable client records, the facility failed to document proposed type of support service on individual treatment plans in six of six records.Client #1 was admitted on November 10, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed on November 14, 2025; however, there was no documentation of proposed type of support service.Client #2 was admitted on December 10, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on December 16, 2025; however, there was no documentation of proposed type of support service.Client #3 was admitted on February 2, 2026 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on February 10, 2026; however, there was no documentation of proposed type of support service.Client #4 was admitted on September 10, 2025 and was discharged on October 29, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on September 19, 2025; however, there was no documentation of proposed type of support service.Client #5 was admitted on June 12, 2025 and was discharged on November 3, 2025. A comprehensive treatment and rehabilitation plan was developed on June 13, 2025; however, there was no documentation of proposed type of support service.Client #6 was admitted on July 8, 2025 and was discharged on September 25, 2025. A comprehensive treatment and rehabilitation plan was developed on July 11, 2025; however, there was no documentation of proposed type of support service.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility will revise the treatment and rehabilitation plan template to include a clearly defined section for documenting the proposed type of support service. All current client records will be reviewed and updated as needed to ensure inclusion of this information.
The facility will implement a standardized treatment plan format requiring completion of all regulatory elements under 709.52(a), including support services. Staff responsible for treatment planning will receive re-education on documentation requirements, with emphasis on identifying and documenting appropriate support services, including but not limited to case management, life skills development, medical and psychiatric coordination, and peer support.
The Project Director will conduct routine audits to ensure all treatment plans include the proposed type of support service. Any deficiencies identified will be addressed through supervision and corrective action as needed.
The Facility Director will be responsible for implementation and ongoing compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every thirty days in five of five applicable records.Client #1 was admitted on November 10, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on November 14, 2025. A treatment and rehabilitation plan update was due no later than December 14, 2025; however, this was not completed until January 20, 2026.Client #2 was admitted on December 10, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on December 16, 2025. A treatment and rehabilitation plan update was due no later than January 16, 2026; however, this was not completed at the time of the inspection.Client #4 was admitted on September 10, 2025 and was discharged on October 29, 2025. A treatment and rehabilitation plan was developed on September 19, 2025. A treatment and rehabilitation plan update was due no later than October 19, 2025; however, this was not completed until October 24, 2025.Client #5 was admitted on June 12, 2025 and was discharged on November 3, 2025. A treatment and rehabilitation plan was developed on June 13, 2025. A treatment and rehabilitation plan update was due no later than July 13, 2025; however, this was not completed until July 22, 2025.Additionally, a treatment and rehabilitation plan update was completed on August 19, 2025. The next treatment and rehabilitation plan update was due no later than September 19, 2025; however, this was not completed prior to discharge.Client #6 was admitted on July 8, 2025 and was discharged on September 25, 2025. A treatment and rehabilitation plan update was completed on August 19, 2025. The next treatment and rehabilitation plan update was due no later than September 19, 2025; however, this was not completed prior to discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and Facility Director will review the treatment plan requirements at the Clinical Staff meeting in March.
There will also be a training scheduled in March to review the clinical documentation guides that were created to ensure staff are knowledgeable on documentation and service requirements.
Treatment Plan review dates will be discussed in case consultation meetings led by the Facility Director. Review dates will be scheduled on the shared clinical calendar based on the resident's intake date and completion of the initial treatment plan. This will assist the Facility Director in maintaining accountability with clinical staff.
Facility Director will also support the therapist in creating their own internal tracking system to ensure timeline requirements are met.
The Project Director will conduct monthly audits of the residents' files to ensure Clinical Staff are completing the individual treatment plans with the residents according to timeline requirements, and with the resident's dated signature.
These audit findings will be reviewed with the Facility Director on a monthly basis.
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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 applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure in two of four records. The policy and procedure indicates a discharge summary will be completed within two days of discharge.Client #4 was admitted on September 10, 2025 and was discharged on October 29, 2025. The discharge summary was due to be completed no later than October 31, 2025; however, this was not completed at the time of the inspection.Client #7 was admitted on June 23, 2025 and was discharged on July 14, 2025. The discharge summary was due to be completed no later than July 16, 2025; however, this was not completed at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The "Discharge Policy" will be updated by the Project Director to change the completion timeline of the Discharge Summary from 2 days to 2 weeks.
This will be reviewed with staff at the March meeting.
The Facility Director is creating a new comprehensive Discharge Summary form to be completed.
The Project Director will conduct monthly audits of the residents' files to ensure Clinical Staff are completing the Discharge Summary.
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure in four of four records. The policy and procedure indicates follow-up contact must be made within one week and within one month after discharge.Client #4 was admitted on September 10, 2025 and was discharged on October 29, 2025. The one-week follow-up contact was due to be completed no later than November 5, 2025; however, this was not completed at the time of the inspection. Additionally, the one-month follow-up contact was due to be completed no later than November 29, 2025; however, this was not completed at the time of the inspection.Client #5 was admitted on June 12, 2025 and was discharged on November 3, 2025. The one-month follow-up contact was due to be completed no later than December 3, 2025; however, this was not completed at the time of the inspection.Client #6 was admitted on July 8, 2025 and was discharged on September 25, 2025. The one-month follow-up contact was due to be completed no later than October 25, 2025; however, this was not completed at the time of the inspection.Client #7 was admitted on June 23, 2025 and was discharged on July 14, 2025. The one-week follow-up contact was due to be completed no later than July 21, 2025; however, this was not completed at the time of the inspection. Additionally, the one-month follow-up contact was due to be completed no later than August 14, 2025; however, this was not completed at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The "Discharge Policy" will be updated by the Project Director to change the guidelines of the follow up procedures.
The current policy states there will be a minimum of 2 follow-up contacts: 1 week and 1 month post discharge.
The new policy will reflect a minimum of 1 follow up contact to be completed within 1 week post discharge.
The follow up contact will include the termination letter and any other summary documentation the resident may need.
This policy and procedure update will be reviewed with staff at the March meeting.
The Project Director will conduct monthly audits of the residents' files to ensure Clinical Staff are completing the follow up procedures.
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of applicable client records, the facility failed to provide verification that any work done by the client at the project is an integral part of his treatment and rehabilitation plan, in six of six residential records reviewed. Client #1 was admitted on November 10, 2025 and was still active at the time of the inspection. Client #2 was admitted on December 10, 2025 and was still active at the time of the inspectionClient #3 was admitted on February 2, 2026 and was still active at the time of the inspection. Client #4 was admitted on September 10, 2025 and was discharged on October 29, 2025. Client #5 was admitted on June 12, 2025 and was discharged on November 3, 2025. Client #6 was admitted on July 8, 2025 and was discharged on September 25, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed this regulation with the therapist.
Chores are a part of a resident's Daily Living Skills Development and will be included in the Treatment Plan.
The Project Director will conduct monthly audits of the residents' files to ensure that any Daily Living Skills Development done by the client in the program is an integral part of their treatment plan and is documented as such in their resident file.
These audit findings will be reviewed with the Facility Director on a monthly basis.
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