INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 8, 2026 through January 9, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, UHS Recovery Foundation, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor met the educational qualifications for the position in one of five applicable personnel records reviewed.
Employee # 13 was hired as a counselor on April 20, 2025 and was still in this position at the time of inspection. The personnel record verified the employee had an associate's degree in general studies, which is not a qualifying major. There was no other documentation in the record indicating the employee has a qualifying degree/major; therefore, the employee did not meet the educational degree requirements for the position upon hire.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Human Resources was reeducated on 704.7(b) regulations on 1/12/2026.
Employee #13 was stepped down to a counselor aide on 1/12/2026.
Ongoing, Director of Human Resources will audit and check each new hire for appropriate placement in job duty prior to start date. Compliance of new hire position control per appropriate qualifications will be reported to the Performance Improvement Committee monthly. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
At the time of the inspection, the fire extinguishers located in the kitchen and near rooms 123, 203, and 204 had blank inspection tags, which did not include any dates inspected by either the local fire department or fire extinguisher company. Additionally, there was no other documentation provided indicating these extinguishers were annually inspected.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Plant Operations was reeducated on 1/9/2026 for the regulation 705.10(c)(3).
During the inspection, the out of compliance fire extinguishers were all placed with correct tags.
Ongoing, the Director of Plant Operations will audit 100% of the fire extinguishers for the monthly inspection to be placed on the correct year's tag. The compliance of the audit will be reported to the Performance Improvement Committee monthly. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable records reviewed.
The facility policy regarding against medical advice (AMA) discharges of a client is that the emergency contact will be called within twelve hours of the client leaving treatment.
Client # 8 was admitted to the inpatient non-hospital activity on September 22, 2025 and was discharged against medical advice on October 3, 2025. There was no documentation in the record indicating the emergency contact was notified of the client's AMA treatment status.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services and Director of Quality Assurance reeducated all therapists of the AMA discharge requirements for emergency contact outreach. Documentation or AMA form was implemented to ensure that the outreach contains thorough information.
Ongoing, the Director of Clinical Services and Director of Quality Assurance will audit 5 AMA discharge charts per month for the compliance of the appropriate documentation in the chart. The documentation compliance will be reported monthly in the Performance Improvement Committee. |
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, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable client record reviewed.
Client # 9 was admitted to the inpatient non-hospital activity on October 1, 2025 and was involuntarily terminated on October 13, 2025. There was no documentation, in the record, indicating the client received written notice of the involuntary termination from treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Quality Assurance provided reeducation to the Director of Risk Management to ensure that a copy of the therapeutic discharge letter remains in the medical record.
Ongoing, The Director of Risk Management will audit 100% of all therapeutic discharge records to ensure that all necessary documents remain in the medical record. The compliance of the therapeutic discharge documentation in the medical record will be reported monthly in Performance Improvement Committee. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide the client with an opportunity to request reconsideration of a decision terminating treatment in one of one applicable client record reviewed.
Client # 9 was admitted to the inpatient non-hospital activity on October 1, 2025 and was involuntarily terminated on October 13, 2025. There was no documentation, in the record, indicating the client was given an opportunity to request reconsideration of being involuntarily terminated from treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Quality Assurance provided reeducation to the Director of Risk Management to ensure that a copy of the therapeutic discharge letter remains in the medical record.
Ongoing, The Director of Risk Management will audit 100% of all therapeutic discharge records to ensure that all necessary documents remain in the medical record. The compliance of the therapeutic discharge documentation in the medical record will be reported monthly in Performance Improvement Committee. |