INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14 & 15, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Britelife Recovery at Hanover, LLC 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 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in two of fifteen records reviewed.
Client #1 was admitted to the detoxification level of care on January 10, 2026 and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to a pharmacy signed by the client on January 10, 2026, that did not identify the specific information to be released.
Client #15 was admitted to the residential level of care on January 9, 2026 and was still active at the time of the inspection. The record contained an informed and voluntary consent to release information to a pharmacy signed by the client on January 10, 2026, that did not identify the specific information to be released.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were re-trained by Executive Director on 1/21/2026, which also included a training acknowledgement form that staff were required to sign after completion of the training. This form verifies their understanding of informed and voluntary consent, disclosure of information, and specific information to be disclosed. Additionally, the 2 staff members indicated in the improper completion of these documents during inspection were followed up with by the Chief Nursing Officer and Client Care Supervisor with disciplinary action, as they had both received training previously. The Client Care Supervisor and Executive Director will be auditing consent forms weekly moving forward, and the BHT Supervisor will be auditing all consents for new admissions within 48 hours of their admission. Client #1 and #15 have since discharged, so those incorrect ROIs have been revoked. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one out of fifteen records reviewed.
Client #12 was admitted to the residential level of care on November 26, 2025 and discharged on December 23, 2025. The record contained one informed and voluntary consent to release information to a family member signed by the client on December 7, 2025, and one informed and voluntary consent to release information to a family member signed by the client on December 11, 2025, that did not identify the purpose for disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were re-trained by Executive Director on 1/21/2026, which also included a training acknowledgement form that staff were required to sign after completion of the training. This form verifies their understanding of informed and voluntary consent, disclosure of information, and specific information to be disclosed and the purpose of the disclosure. Additionally, the 2 staff members indicated in the improper completion of these documents during inspection were followed up with by the Chief Nursing Officer and Client Care Supervisor with disciplinary action, as they had both received training previously. The Client Care Supervisor and Executive Director will be auditing consent forms weekly moving forward, and the BHT Supervisor will be auditing all consents for new admissions within 48 hours of their admission. |
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 physical plant inspection and a review of the facility ' s files the facility failed to inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State, and local laws and regulations. The facility did not have documentation that the inspections were conducted.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Chief Nursing Officer will be ensuring that the Director of Nursing is completing the drug storage inspection by having the Director of Nursing upload the completed form to a shared Teams drive. The Chief Nursing Officer will be able to ensure completion of this each quarter versus verification at the end of the year that it was completed for all quarters. |