INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 17, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Recovery Works - PA 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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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the facility failed to develop, and make available to the public, an annual report which is to include, but not be limited to, a statement disclosing the names of officers, directors and principal shareholders.This finding was discussed with facility staff during the licensing process.
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Plan of Correction
The Annual Public Report was completed, including disclosure of the owner. Acknowledgment of and how to request the report has been posted on the Recovery Works‑PA website and is available to the public upon request. A copy has been placed the team Share Drive for review.
A standardized Annual Public Report template that includes all required elements under §709.22(c), including ownership disclosure. The report will be completed by the project director annually each January for the prior fiscal year. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.At the time of the inspection, there was no financial audit completed for the project's fiscal year ending December 31, 2024.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Letter permitting exception was received 3/10/26. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made to on consent to release information forms in one of seven client records reviewed. Client # 5 was admitted on September 19, 2025 and was discharged on January 6, 2026. The release of information form to an emergency contact was signed by the client; however, the release form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
We have discontinued the use of paper ROI forms for clients who do not use the client portal. All ROIs completed outside of the portal will now be completed and digitally signed through an online platform. The digital ROI includes required fields that cannot be submitted unless completed, including: specific information to be disclosed, purpose of disclosure, name of the individual or organization receiving the information, expiration date, and client signature and date. Each ROI is automatically time‑stamped and uploaded to the client chart.
All staff will complete training by 3/19/26 on the updated ROI process and the requirement that all ROIs must include to whom the specific information is to be disclosed. The project director will conduct quarterly audits of ROIs to ensure compliance with §709.28(c)(2). Any incomplete forms identified during audits will be corrected immediately and reviewed with staff. |
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 client records, the facility failed to document the specific information to be disclosed on consent to release information forms in one of seven client records reviewed. Client # 7 was admitted on August 22, 2025 and was discharged on January 6, 2026. The release of information form to an emergency contact was signed by the client on August 28, 2025; however, the release form did not include the specific information to be disclosed.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
We have discontinued the use of paper ROI forms for clients who do not use the client portal. All ROIs completed outside of the portal will now be completed and digitally signed. The digital ROI includes required fields that cannot be submitted unless completed, including: specific information to be disclosed, purpose of disclosure, name of the individual or organization receiving the information, expiration date, and client signature and date. Each ROI is automatically time‑stamped and uploaded to the client chart.
All staff will complete training by 3/19/26 on the updated ROI process and the requirement that all ROIs must include the specific information to be disclosed. The project director will conduct quarterly audits of ROIs to ensure compliance with §709.28(c)(2). Any incomplete forms identified during audits will be corrected immediately and reviewed with staff. |
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 client records, the facility failed to document the purpose of the disclosure on consent to release information forms in five of seven client records reviewed.Client # 1 was admitted on July 22, 2025 and was still active at the time of the inspection. The release of information form to an emergency contact was signed by the client on October 21, 2025; however, the release form did not include the purpose of the disclosure. Client # 3 was admitted on August 11, 2025 and was still active at the time of the inspection. The release of information form to an emergency contact was signed by the client on August 11, 2025; however, the release form did not include the purpose of the disclosure. Client # 4 was admitted on July 14, 2025 and was discharged on December 10, 2025. The release of information form to a family member was signed by the client; however, the release form did not include the purpose of the disclosure. Client # 5 was admitted on July September 19, 2025 and was discharged on January 6, 2026. The release of information form to a recovery house was signed by the client; however, the release form did not include the purpose of the disclosure. Client # 7 was admitted on August 22, 2025 and was discharged on January 6, 2026. The release of information form to an emergency contact was signed by the client on August 28, 2025; however, the release form did not include the purpose of the disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A formatting issue in the EMR allowed clients to bypass the required "Purpose of Disclosure" field. This issue has been corrected, and the field can no longer be skipped. In addition, the facility has discontinued the use of paper ROIs for clients who do not use the client portal. All ROIs completed outside of the portal are now created and digitally signed, which includes required fields that cannot be submitted unless completed. Each ROI is automatically time‑stamped and uploaded to the client chart.
All staff will be trained on the corrected EMR form and the updated ROI process 3/19/2026. The facility director will conduct quarterly audits of ROIs to ensure that the purpose of disclosure is documented on every form in compliance with §709.28(c)(3). Any incomplete forms identified during audits will be corrected immediately and reviewed with staff. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on a release of information form in two of seven client records reviewed.Client # 4 was admitted on July 14, 2025 and was discharged on December 10, 2025. The release of information form to a family member was signed by the client; however, the date of the client's signature was not documented. Client # 5 was admitted on July September 19, 2025 and was discharged on January 6, 2026. The release of information forms to an emergency contact, the funding source, and a recovery house were signed by the client; however, the date of the client's signatures was not documented. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Paper ROIs have been discontinued. All ROIs completed outside of the portal are now created and digitally signed, which includes required fields that cannot be submitted unless completed. Each ROI is automatically time‑stamped and uploaded to the client chart.
All staff will be trained by 3/19/2026 on the corrected EMR form and the updated ROI process. The facility director will conduct quarterly audits of ROIs to ensure that the purpose of disclosure is documented on every form in compliance with §709.28(c)(3). Any incomplete forms identified during audits will be corrected immediately and reviewed with staff. |
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 document the written acknowledgement by clients that they have been notified of all their rights, including that 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 and the reasons for removing sections shall be documented in the record, in four of seven applicable records reviewed. Client # 2 was admitted on July 16, 2025 and was still active at the time of the inspection. There was no written documentation that the client was notified of this client right in the record at the time of the inspection. Client # 5 was admitted on July September 19, 2025 and was discharged on January 6, 2026. There was no written documentation that the client was notified of this client right in the record at the time of the inspection.Client # 6 was admitted on October 15, 2025 and was discharged on December 17, 2025. There was no written documentation that the client was notified of this client right in the record at the time of the inspection.Client # 7 was admitted on August 22, 2025 and was discharged on January 6, 2026. There was no written documentation that the client was notified of this client right in the record at the time of the inspection.This is a repeat citation from the February 7, 2025 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We identified that paper copies of the Client Rights form did not consistently print all required lines, including the section describing the client's right to inspect their record and the conditions under which portions may be temporarily removed. To prevent omissions, we have discontinued the use of paper Client Rights forms. All Client Rights Acknowledgements are now completed electronically through the client portal or digitally, both of which contain required fields that cannot be bypassed. The full rights document is always presented in its complete form, and the electronic signature is automatically time‑stamped and uploaded to the client chart.
All staff will be trained by 3/19/2026 on the updated electronic Client Rights Acknowledgement process and the requirement that clients must receive and sign the complete rights document, including the section related to record inspection and temporary removal of information. The project director will conduct quarterly audits of Client Rights Acknowledgements to ensure all required elements are present. Any incomplete forms identified during audits will be corrected immediately and reviewed with staff. |
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 document the written acknowledgement by clients that they have been notified of all their rights, including that clients have the right to appeal a decision limiting access to their records to the director, in four of seven applicable records reviewed.Client # 2 was admitted on July 16, 2025 and was still active at the time of the inspection. There was no written documentation that the client was notified of this client right in the record at the time of the inspection. Client # 5 was admitted on July September 19, 2025 and was discharged on January 6, 2026. There was no written documentation that the client was notified of this client right in the record at the time of the inspection.Client # 6 was admitted on October 15, 2025 and was discharged on December 17, 2025. There was no written documentation that the client was notified of this client right in the record at the time of the inspection.Client # 7 was admitted on August 22, 2025 and was discharged on January 6, 2026. There was no written documentation that the client was notified of this client right in the record at the time of the inspection.This is a repeat citation from the February 7, 2025 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We identified that paper copies of the Client Rights form did not consistently print all required lines, including the section describing that clients have the right to appeal a decision limiting access to their records to the director. To prevent omissions, we have discontinued the use of paper Client Rights forms. All Client Rights Acknowledgements are now completed electronically through the client portal or digitally, both of which contain required fields that cannot be bypassed. The full rights document is always presented in its complete form, and the electronic signature is automatically time‑stamped and uploaded to the client chart.
All staff will be trained by 3/19/2026 on the updated electronic Client Rights Acknowledgement process and the requirement that clients must receive and sign the complete rights document, including the section related to record inspection and temporary removal of information. The project director will conduct quarterly audits of Client Rights Acknowledgements to ensure all required elements are present. Any incomplete forms identified during audits will be corrected immediately and reviewed with staff. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of seven applicable client records reviewed. Client # 1 was admitted on July 22, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 23, 2025 and an update was due no later than October 23, 2025; however, the update was not completed until December 4, 2025. Additionally, another update was due no later than February 4, 2026; however, the update was not completed at the time of the inspection. Client # 4 was admitted on July 14, 2025 and was discharged on December 10, 2025. A treatment plan update was completed on October 1, 2025 and another update was due no later than December 1, 2025; however, the update was not completed until December 10, 2025. Client # 7 was admitted on August 22, 2025 and was discharged on January 6, 2026. The individual treatment and rehabilitation plan was completed on September 5, 2025 and an update was due no later than November 5, 2025; however, the update was not completed until November 22, 2025. This is a repeat citation from the February 7, 2025 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The expired treatment plan for client #1 was updated and reviewed by the Project Director.
Because the EMR does not support automated alerts for treatment plan deadlines, the facility implemented a standardized workflow using the EMR's Task feature. Clinicians are now required to create a Task at the time each treatment plan is completed, with the due date set for one week prior to the 60‑day deadline. This ensures that the clinician receives a visible reminder within the EMR and has adequate time to complete the update before the regulatory deadline. Staff have been trained on this workflow by 3/19/2026.
The project director will conduct monthly audits of treatment plans and associated Tasks to verify that due dates are being entered correctly and that updates are completed on time. Any overdue or incomplete updates identified during audits will be corrected immediately and reviewed with staff. Audit results will be documented and maintained for review during future licensing inspections. |