INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 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, Renewal Treatment Inc. 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 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on the review of the facility's fire drill log for the months of July 2024 through July 2025, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. An overnight fire drill was conducted in August 2024. The next overnight fire drill was due to be conducted by February 2025, but was not conducted until June 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 13, 2024 annual licensing inspection.
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Plan of Correction
Fire drills during sleeping hours will be conducted on a quarterly basis, exceeding the minimum 6-month regulatory requirement, to ensure all residents are familiar with emergency safety procedures. These drills will be documented on fire drill log. Direction/retraining has already been provided. Progressive disciplinary action will be applied to any staff members who fail to comply with the outlined procedures and expectations. The Director of Security will have full oversight and accountability for the implementation and monitoring of this plan of correction. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of facility documentation, the facility failed to provide documentation the inspections of storage areas were completed per program policy. The facility ' s policies and procedures state that inspections are to be completed quarterly.
The facility was unable to provide documentation of the inspections completed from August 2024 through July 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Manager will conduct monthly inspections of all medication rooms to ensure the following:
- Disinfectants and drugs for external use are stored separately from oral and injectable medications.
- Medications requiring special storage conditions to maintain stability are properly stored.
- Outdated medications are identified and promptly removed.
- Copies of relevant drug-related regulations are available and accessible in appropriate areas.
- Controlled substances and other easily abused drugs are stored in accordance with federal, state and program regulations
The Medical Manager will complete a standardized checklist covering all of the above areas and maintain these records in her office. Training on this will occur prior to September 15, 2025 and these checklists will be completed at the end of each month.
Progressive disciplinary action will be implemented for staff members who fail to comply with this plan of correction.
The Clinical Director and the Vice President of Operations will verify that these checklists are completed each month.
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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 records 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 records.
Client #1 was admitted to inpatient on December 10, 2024 and discharged on December 26, 2024. 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
As of September 2, 2025, a new process has been implemented to ensure proper documentation of all unsuccessful discharges from the Inpatient Drug and Alcohol (D&A) Program. The Clinical Supervisors received instruction on this task on 8.22.25. A standardized termination notice has been developed to include all possible reasons a resident may be unsuccessfully discharged. Clinical Supervisors are responsible for completing this notice for each applicable resident. The termination notice will include the resident's name, the date of termination, a clear rationale for the discharge, and the signature of the Clinical Supervisor.
Before the notice is provided to the resident, it must be scanned and uploaded into the Electronic Health Record (EHR) to ensure accurate and timely documentation. This step is essential to maintaining the integrity of the resident's clinical record and ensuring continuity in the facility's reporting and quality assurance processes.
To monitor compliance with this new protocol, the Clinical Director will review all unsuccessful discharges on a weekly basis. During this review, the Clinical Director will confirm that the termination notices have been properly completed and uploaded into the EHR by the Clinical Supervisors.
In instances where staff fail to follow this procedure, progressive disciplinary action will be taken to address noncompliance. This measure is intended to reinforce the importance of consistent documentation and adherence to policy across the clinical team.
This plan of correction has been established to strengthen program accountability, improve documentation practices, and support the clinical team in maintaining high standards of care and recordkeeping.
Clinical Director will have direct oversight of the POC.
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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 a comprehensive treatment plan in three of seven records.
The policy and procedure indicates a comprehensive treatment plan be developed within fifteen days of admission.
Client #1 was admitted to inpatient on December 10, 2024 and was discharged on December 26, 2024. The comprehensive rehabilitation and treatment plan was due by December 25, 2024, however this was not completed prior to discharge.
Client #2 was admitted to inpatient on February 19, 2025 and was discharged on April 21, 2025. The comprehensive rehabilitation and treatment plan was due by March 6, 2025, however this was not completed prior to discharge.
Client #5 was admitted to inpatient on June 18, 2025 and was discharged on August 18, 2025. The comprehensive rehabilitation and treatment plan was due by July 3, 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
Beginning September 8, 2025, Clinical Supervisors will implement revisions to the existing self-audit form used by D&A Counselors. These revisions will include the addition of clearly defined due dates for the completion of initial treatment plans. Clinical Supervisors will ensure are staff are trained by 9.5.25. As part of this correction plan, counselors will be required to meet with their clients prior to day 13 of treatment to complete the initial treatment plan in its entirety. During this meeting, all required signatures?from both the client and the counselor?must be obtained.
Once the treatment plan is completed and signed by the client and counselor, it will be submitted to the Clinical Supervisor for review. The Clinical Supervisor, along with the program's Physician, will review and sign the plan to finalize approval.
To ensure ongoing compliance, Clinical Supervisors will conduct weekly audits of treatment plans. These audits will confirm that treatment plans are completed on time, fully signed, and meet all required standards. In addition, the Clinical Director will meet with the Clinical Supervisor at least twice per month. These supervisory meetings will include a specific review of timelines and overall compliance with treatment plan requirements.
Staff members who do not adhere to the expectations outlined in this plan of correction will be subject to progressive disciplinary action, in accordance with agency policy.
Clinical Supervisors and Clinical Director will have direct oversight of the POC.
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on applicable client records reviewed, the facility failed to provide case consultations in two of six applicable records.
The facility policy and procedure indicate a case consultation to occur every thirty days.
Client #3 was admitted to inpatient on March 5, 2025 and was discharged on May 5, 2025. A case consultation was due to occur no later than April 5, 2025, however this was not completed until April 7, 2025.
Client #5 was admitted to inpatient on June 18, 2025 and was discharged on August 18, 2025. A case consultation was due to occur no later than July 18, 2025, however this was not completed until July 23, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors will revise the existing self-audit form used by D&A Counselors to include specific due dates for case consults. Counselors are required to adhere to the provided deadlines and ensure case consults are completed on time. If a due date falls on a weekend, the consult must be completed prior to that date. Retraining will be completed by 9.5.25 and this POC will begin as of September 8, 2025.
Clinical Supervisors will conduct weekly audits of 100% of clinical charts to verify timely completion of all case consults. Failure to comply with the established timelines will result in progressive disciplinary action, in accordance with the agency's plan of correction.
Clinical Supervisors will have direct oversight of the POC.
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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 three of three records.
The policy and procedure indicates follow-up contact must be made within thirty days after discharge.
Client #1 was admitted to inpatient on December 10, 2024 and was discharged on December 26, 2024. Follow-up contact was due to occur by January 26, 2025, however this was not completed at the time of the inspection.
Client #2 was admitted to inpatient on February 19, 2025 and was discharged on April 21, 2025. Follow-up contact was due to occur by May 21, 2025, however this was not completed at the time of the inspection.
Client #3 was admitted to inpatient on March 5, 2025 and was discharged on May 5, 2025. Follow-up contact was due to occur by June 5, 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 VP of Programs will contact all currently discharged residents who were discharged prior to the inspection to review timelines and ensure this Plan of Correction can begin immediately.
Moving forward, at the time of admission, Clinical Supervisors will enter each resident's anticipated discharge date into their tracking system. They will also be responsible for documenting the date of the follow-up call, which must occur 30 days after discharge.
Clinical Supervisors will make the follow-up calls to all successfully discharged residents. This Plan of Correction will be implemented starting on and after September 26, 2025 (this is the first round of 30 day calls that will need to be made with the new system).
To ensure compliance, the Clinical Director will conduct spot checks on 20% of discharged residents' charts in the EHR to confirm documentation of the aftercare follow-up call. A form for this purpose already exists within the EHR system. Clinical Supervisors have already been trained on this process.
Progressive disciplinary action will be taken for staff who fail to comply with the requirements of this Plan of Correction.
Clinical Director will have direct oversight of the POC.
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