INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, R3 Recovery Services 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 a review of the Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that 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 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.
Employee #4 was hired as a counselor on October 14, 2024. His training was due no later than October 14, 2025; however, the TB/STD training was not completed.
Employee #9 was hired as a counselor on May 19, 2025. Her training was due no later than May 19, 2026; however, her TB/STD training was not completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
To correct the deficiency cited under 704.11(c)(1) regarding mandatory communicable disease training, R3 Recovery Services has implemented a corrective action plan to ensure all staff complete the required 6 hours of HIV/AIDS training and 4 hours of tuberculosis, sexually transmitted diseases, and other health-related topics training using a Department-approved curriculum within the required timeframe. As of 6/8/2026, staff who did not have the required TB/STD training completed at the time of the audit have either completed the training or have been scheduled to complete the training. Proof of completion will be placed in each employee's training file once received.
Moving forward, R3 Recovery Services will revise the onboarding process to ensure that all new staff are registered for required communicable disease trainings during onboarding to avoid delays in completion. A mandatory training checklist will be used for all new hires and will include required training topics, due dates based on position and date of hire, registration status, completion dates, and documentation of certificates in the personnel file. A training tracker will also be maintained to monitor ongoing compliance. The Clinical Director will oversee completion of required trainings, and the Office Manager or assigned administrative staff will maintain the tracker and employee training records. The training tracker will be reviewed quarterly to ensure ongoing compliance. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #8 was hired on May 1, 2025 as a counselor and was still in the position as of the date of the inspection. The training was completed on January 6, 2026.
Employee #9 was hired on May 19, 2025 as a counselor and was still in the position as of the date of the inspection. The training was completed on September 4, 2025.
Employee #10 was hired on August 11, 2025 as a counselor and was still in the position as of the date of the inspection. The training was completed on December 16, 2025.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the April 16, 2025 licensing inspection.
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Plan of Correction
To correct the deficiency cited under 705.28(c)(4) regarding staff instruction in the use of fire extinguishers upon employment, R3 Recovery Services has implemented a corrective action plan to ensure all staff receive and document fire extinguisher training at the time of hire. Although Employees #8, #9, and #10 completed the required fire extinguisher training, the training was not completed upon employment as required. R3 Recovery Services recognizes that this is a repeat citation from the April 16, 2025 licensing inspection and has taken additional steps to strengthen the onboarding process and prevent further recurrence.
Moving forward, fire extinguisher training will be completed as part of the new hire onboarding process before staff begin working independently. The onboarding checklist has been updated to include this training. The Office Manager or assigned administrative staff will be responsible for ensuring this training is completed and documented during onboarding, and the Clinical Director will provide oversight to confirm compliance. A training tracker will be maintained and reviewed quarterly to ensure required onboarding trainings are completed timely. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies.
Employee #7 was hired on September 1, 2025 as a counselor and was still in the position as of the date of the inspection. The training was completed on September 11, 2025.
Employee #8 was hired on May 1, 2025 as a counselor and was still in the position as of the date of the inspection. The training was completed on January 6, 2026.
Employee #9 was hired on May 19, 2025 as a counselor and was still in the position as of the date of the inspection. The training was completed on September 4, 2025.
Employee #10 was hired on August 11, 2025 as a counselor and was still in the position as of the date of the inspection. The training was completed on December 16, 2025.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the April 16, 2025 licensing inspection.
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Plan of Correction
To correct the deficiency cited under 705.28(d)(3) regarding ensuring that all personnel on all shifts are trained to perform assigned tasks during emergencies, R3 Recovery Services has implemented a corrective action plan to ensure emergency task training is completed and documented upon employment. Although Employees #7, #8, #9, and #10 completed the required emergency procedures training, the training was not completed upon employment as required. R3 Recovery Services recognizes that this is a repeat citation from the April 16, 2025 licensing inspection and has taken additional steps to strengthen the onboarding process and prevent further recurrence.
Moving forward, emergency task training will be completed as part of the new hire onboarding process before staff begin working independently. The onboarding checklist has been updated to include training on assigned emergency tasks. The Office Manager or assigned administrative staff will be responsible for ensuring this training is completed and documented during onboarding, and the Clinical Director will provide oversight to confirm compliance. A training tracker will be maintained and reviewed quarterly to ensure required onboarding trainings are completed timely. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan within guidelines established by the facility's policy and procedures manual in two out of three applicable records reviewed. The facility's policy and procedures manual states that the aftercare plan must be completed within two weeks prior to discharge.
Client #5 was admitted on July 10, 2025 and was discharged on April 23, 2026. No aftercare plan was completed.
Client #7 was admitted on October 20, 2025 and was discharged on March 26, 2026. No aftercare plan was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
R3 Recovery Services acknowledges the identified deficiency related to 709.93(a)(9), indicating that aftercare plans were not properly signed in accordance with documentation requirements. While aftercare plans were completed, the required client signatures were not obtained in the records reviewed. In response, the agency has reinforced with clinical staff the requirement that all aftercare plans must be reviewed with the client and signed prior to discharge. Staff have been re-educated to ensure that, if a client is unable or unwilling to sign the aftercare plan, a clear note will be documented in the record explaining the reason the signature was not obtained. Supervisors will review discharge documentation to ensure compliance with this requirement, and ongoing chart audits will be conducted to monitor adherence. These actions have been implemented to ensure compliance with regulatory requirements and prevent recurrence of this issue. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in three out of three applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed seven days following discharge.
Client #5 was admitted on July 10, 2025 and was discharged on April 23, 2026. No follow up was completed.
Client #6 was admitted on October 8, 2025 and discharged on April 20, 2026. No follow up was completed.
Client #7 was admitted on October 20, 2025 and was discharged on March 26, 2026. No follow up was completed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 16, 2025 licensing inspection.
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Plan of Correction
R3 Recovery Services acknowledges the identified deficiency related to 709.93(a)(11), indicating that follow-up information was not completed within the required timeframe of seven days following discharge, as outlined in the agency's policy and procedures. The agency also recognizes that this is a repeat citation from the April 16, 2025 licensing inspection. In response, all clinical staff have been re-educated as of June 10, 2026 regarding the requirement to complete follow-up contact and documentation within seven days of discharge. Staff have been instructed that follow-up must be attempted and documented within the required timeframe, and that all attempts, including unsuccessful contact, must be clearly documented in the client record. Clinical supervisors are responsible for reviewing discharges and ensuring that follow-up documentation is completed within policy guidelines. Moving forward, the agency will conduct chart audits of recently discharged clients to verify that follow-up documentation is completed within seven days, and any instances of noncompliance will be addressed immediately through supervision and corrective action. These corrective measures have been implemented to ensure compliance with regulatory requirements and to prevent recurrence of this deficiency. |