INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19, 2025 through November 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, Pennsylvania Recovery Center, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of one applicable personnel record reviewed.
Employee # 2 was hired as a counselor on August 2, 2024 and was due to have the HIV/AIDS training and the TB/STD training completed no later than August 2, 2025. The HIV/AIDS training was completed within the timeframe; however, the TB/STD training was not completed as of the date of the inspection.
This is a repeat citation from the October 8, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Along with the Clinical Director, all staff's training requirements and progress will be tracked on an ongoing basis by the Director of Compliance. Two months before a training is required, the Director of Compliance will notify both the responsible party and their direct Supervisor. The Director of Compliance will follow up again regarding completion one month before the training is due, then weekly. The Clinical Director, or direct supervisor, of the staff member will take corrective action if the required training is not completed as scheduled. Human Resource personnel will continue to complete quarterly audits to ensure training requirements are met. This process began on December 1, 2025.
It was discovered on 12/4/25 that Employee #2 had completed 4 hours of TB/STD/Hepatitis training on July 19, 2017 as evidenced by Certificate of Training they provided to Clinical Director. Employee also provided copy of their DDAP Training Management System Transcript listing the training as completed. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training, during the facility's January 31, 2024 through December 31, 2024 training year, in one of one applicable personnel record reviewed.
Employee # 11 was hired as a counselor on August 25, 2020. The personnel record documented 15 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Along with the Clinical Director, all staff's training requirements and progress will be tracked on an ongoing basis by the Director of Compliance. During the Clinical Meeting on December 11, 2025, all counselors will be informed that 6-7 training hours will be due every three months throughout the year (March 30th, June 30th, September 30th, December 30th). The Director of Compliance will send reminders to any counselor that has not completed their hours on the first of the month that those hours are due. The Clinical Director will take corrective action if any counselor does not meet the appropriate deadline(s). Tracking of training hours by Director of Compliance has begun on December 1, 2025. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's December 2024 through October 2025 fire drill logs, the facility failed to maintain a complete written fire drill record, which is to include the documentation of the time of the fire drill.
At the time of the inspection, the written log for the fire drill completed in October 2025 did not include the time the drill was conducted.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Safety Officer and the Director of Compliance will both review all Fire/Emergency Drills upon completion to ensure all necessary information is included. Both individuals will begin reviewing completed drills immediately, starting with the fire drill that will occur on December 10, 2025. |
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 was to be made to on a consent to release information form in one of fourteen client records reviewed.
Client # 10 was admitted to the outpatient activity on September 1, 2025 and was active at the time of inspection. A release of information form to a government agency was signed and dated by the client on September 26, 2025; however, the consent form did not include the name of the person, agency, or organization to whom the disclosure was to be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/26/25 a new copy of the incorrect Release of Information has been created and signed by the client with all necessary information. To avoid this issue in the future, all program staff will be re-educated individually by their direct supervisor how to properly complete Releases of Information and what information is required. A ROI example sheet with necessary information required will be provided to all staff during the individual coaching session. Staff will be encouraged to place in a location they can easily reference, to ensure this is followed through on a consistent basis. Additionally, during the monthly chart audits (beginning with December 2025) completed by the Director of Compliance, Releases of Information will be reviewed for necessary information. If an issue is discovered the responsible party and their supervisor will be notified immediately, via email, to correct the issue. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment and rehabilitation plan, during the intake and admission period, in four of seven client records reviewed.
The facility policy and procedure manual stated that the preliminary treatment and rehabilitation plan is to be completed within 48 hours from the date of admission.
Client # 8 was admitted to the outpatient activity on May 29, 2025 and was still active at the time of the inspection. The preliminary treatment and rehabilitation plan was due to be completed no later than May 31, 2025; however, the preliminary plan was not completed until June 9, 2025.
Client # 11 was admitted to the outpatient activity on January 20, 2025 and was discharged on September 18, 2025. The preliminary treatment and rehabilitation plan was due to be completed no later than September 20, 2025; however, the preliminary plan was not completed until January 31, 2025.
Client # 13 was admitted to the outpatient activity on April 18, 2025 and was discharged on June 10, 2025. There was no preliminary treatment and rehabilitation plan documented in the record at the time of the inspection.
Client # 14 was admitted to the outpatient activity on September 8, 2025 and was discharged on November 14, 2025. The preliminary treatment and rehabilitation plan was due to be completed no later than September 10, 2025; however, the preliminary plan was not completed until October 21, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All intake staff will be re-educated via email on December 5, 2025 to ensure that preliminary treatment plans are signed by all newly admitting clients. Additionally, the Director of Admissions will review all charts of newly admitted clients to ensure that the preliminary treatment plan is signed within 48 hours of admission, and if needed communicate the need to support staff to obtain signature. |
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 updated and reviewed at least every sixty days in two of five applicable client records reviewed.
Client # 11 was admitted to the outpatient activity on January 20, 2025 and was discharged on September 18, 2025. The individual treatment and rehabilitation plan was completed on January 31, 2025 and the first update was due no later than March 31, 2025; however, the update was not completed until April 23, 2025. Additionally, a treatment plan update was completed on June 18, 2025 and the next update was due no later than August 18, 2025; however, the update was not completed until August 26, 2025.
Client # 12 was admitted to the outpatient activity on February 7, 2025 and was discharged on August 1, 2025. A treatment and rehabilitation plan update was completed on April 28, 2025 and the next update was due no later than June 28, 2025; however, the update was not completed until July 8, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Outpatient clinical staff will be re-educated on the required frequency of Master Treatment Plan Updates in the weekly staff meeting on Thursday December 4, 2025. A compliance reference sheet for the therapists will be provided to staff during the meeting. Additionally, during monthly chart audits, Treatment Plans will be reviewed for frequency of reviews and pending due dates will be communicated to the responsible party and the Clinical Director. |