INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on 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, Good Works Life Recovery House 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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709.25 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 project 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. The project had an exception to the regulation requiring an audit if the project's gross income is less than $500,000. However, the project provided a copy of their 2025 tax filing indicating that the gross income exceeded $500,000 for the project's previous fiscal year; therefore, the exception is no longer valid, and a financial audit must be completed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.25 Fiscal management
Good Works Life Recovery House Project Director will be responsible for ensuring that annual financial audit inspection will be completed yearly by an independent certified public accountant for an annual financial audit of activities associated with the project's drug and alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
Project Director contacted William T. Grimm & Associates, P.C. agency on 1/8/2026 to schedule a financial audit. Stacey E. Szewczyk will be the engagement partner that will be responsible for supervising the engagement (audit) and signing the report or authorizing another individual to sign. The audit will begin approximately on August 1, 2026, for review of 2025 financial audit. The end date of completion for 2025 and report issued is expected to be on November 15, 2026. If the plan is completed on or around November 15, 2026, then Project Direct will submit the report December 1, 2026, or at next state licensing review.
Ongoing audits
At the end of each audit review, Project Director will schedule for the next year's financial audit review on or around the month of August, exact date and month will depend on the availability of the independent certified public accountant.
The financial audit will be made available for public review by contacting the Board of Directors President in writing requesting to review Good Works Life Recovery House annual financial audit. Audit will be made available for DDAP to review during inspections or when requested.
This will be monitored yearly by Project Director through Board of Director meetings.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of administrative records, the facility failed to report an event at the facility requiring the presence of ambulance personnel to the Department within three business days.The facility has documented reports of the presence of ambulance personnel on April 7, 2025; April 19, 2025; May 8, 2025; July 1, 2025; July 6, 2025; August 4, 2025; August 6, 2025; August 7, 2025; August 20, 2025; September 15, 2025; September 23, 2025; October 2, 2025; October 21, 2025; October 24, 2025; November 7, 2025; November 23, 2025; November 27, 2025; December 1, 2025; December 1, 2025; and December 28, 2025. These events were not reported to the Department within three business days.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The cited unusual incidents reports were inputted in the Event Report to be reviewed. In addition, the Project Director placed the unusual incident report procedure in the staff notes on 1/15/2026 and distributed a memorandum to all staff on 1/16/2026 addressing the reporting of an unusual incident report. Also, the Project Director will review the protocol in the mandatory staff meeting on 1/23/26.
The protocol for completing an unusual incident report that pertains to regulation 709.34 is that staff will report the unusual incident by fully completing the unusual incident (paper form) report and place the completed paper form in the project director's mailbox. The Project Director will review the information and submit the report to DDAP online unusual incident reporting within 3 business days of the unusual incident, which is 72 hours.
This will be monitored monthly by the Project Director during clinical team meetings. |
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 two of six applicable records.Client #2 was admitted on April 23, 2025 and was discharged on November 4, 2025. A treatment and rehabilitation plan was developed on April 23, 2025. A treatment and rehabilitation plan update was due no later than May 23, 2025; however, this was not completed until May 28, 2025.Client #6 was admitted on September 5, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on December 2, 2025. The next treatment and rehabilitation plan update was due no later than January 2, 2026; 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
709.52 Treatment plan update
All treatment plans will be reviewed and updated, with the client's participation and presence, every 30 days after the original treatment plan is completed and signed by all parties. If day thirty falls on an off day of the counselor, then counselor will complete the treatment plan update with the client before day thirty. If the primary counselor is on vacation when an update is due, then the counselor overseeing the primary counselor's caseload will complete the treatment plan update with the client.
This will be monitored by Project Director during monthly supervisions with counselors
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