INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 30, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Wellness Recovery 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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709.25 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 last audit completed was for year ending December 31, 2023, and was reviewed at the April 4, 2024, inspection. There was no audit provided for year ending December 31, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project has contracted with a new independent certified public
accountant to complete the required annual financial audit, including
reference to drug and alcohol treatment activities.
This procedure will go into effect on June 8, 2026. Moving forward,
the annual financial audit will be completed at the end of each fiscal
year in accordance with generally accepted accounting principles.
The Project Director will monitor completion of the annual audit and
maintain documentation for review.
Responsible Party: Project Director
Implementation Date: June 8, 2026
Monitoring: Annual fiscal audit review |
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 obtain an informed and voluntary consent from the client which includes name of the person, agency, or organization to whom disclosure is made in one of fourteen records.
Client #1 was admitted to the detox level of care on September 13, 2025, and discharged on September 20, 2025. A release of information form was signed September 13, 2025, and did not include name of the person, agency, or organization to whom disclosure is made.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Director revised the electronic intake packet to require
the name of the person, agency, or organization receiving disclosed
information on all Release of Information forms. Staff will not be
able to proceed without completing this required field.
The updated procedure will go into effect on June 8, 2026. Front
office and intake staff will be re-educated on confidentiality and
Release of Information requirements.
The Clinical Director and Project Director will complete weekly
quality assurance reviews of intake packets to monitor compliance.
Any errors will be corrected promptly, and additional staff training
will be provided as needed.
Responsible Parties: Clinical Director and Project Director
Implementation Date: June 8, 2026
Monitoring: Weekly QA review |
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 review of administrative information, the facility failed to inspect storage areas as required.
The policy and procedures state that all medication storage areas are inspected weekly.
There were no inspections documented from May 2025 through September 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Medication storage inspection policies will be updated to require
documented quarterly inspections of all medication storage areas,
including verification of proper storage, separation of external-use
products, removal of outdated medications, and availability of drug-
related regulations.
The updated policy will go into effect on June 8, 2026. Nursing staff
will be trained on the revised inspection procedure and
documentation requirements.
The Project Director will review medication storage inspection logs
quarterly to monitor compliance and address any deficiencies.
Responsible Party: Project Director
Implementation Date: June 8, 2026
Monitoring: Quarterly review of medication storage inspection logs |
709.62(c)(2)(iii) LICENSURE Orientation - Fee Schedule
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project which included familiarization with the fee schedule in seven of seven records.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The fee schedule will be added to the intake packet and reviewed with
clients during orientation. The fee schedule will also be included in the
client handbook.
The updated procedure will go into effect on June 8, 2026. Clients will
sign documentation confirming they were informed of the fee schedule
along with their informed consent, client rights, and privacy practices.
The Clinical Director and Project Director will review intake packets
during quality assurance checks to monitor compliance.
Responsible Parties: Clinical Director and Project Director
Implementation Date: June 8, 2026
Monitoring: Intake packet QA review |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in six of six discharged records.
The facility's policy and procedures state that follow-up contact is to be completed within 7 and 30 days of discharge.
Client #1 was admitted to the detox level of care on September 13, 2025, and discharged on September 20, 2025. The 7-day follow-up was due no later than September 27, 2025, and the 30-day follow-up was due no later than October 20, 2025; however, both were completed on March 4, 2026.
Client #2 was admitted to the detox level of care on November 10, 2025, and discharged on November 17, 2025. The 7-day follow-up was due no later than November 24, 2025, and the 30-day follow-up was due no later than December 17, 2025; however, both were completed on April 13, 2026.
Client #3 was admitted to the detox level of care on January 9, 2026, and discharged on January 13, 2026. The 7-day follow-up was due no later than January 20, 2026, and the 30-day follow-up was due no later than February 13, 2026; however, both were completed on April 26, 2026.
Client #4 was admitted to the detox level of care on December 26, 2025, and discharged on January 1, 2026. The 7-day follow-up was due no later than January 8, 2026, and the 30-day follow-up was due no later than February 1, 2026; however, both were completed on April 26, 2026.
Client #5 was admitted to the detox level of care on July 8, 2025, and discharged on July 15, 2025. The 7-day follow-up was due no later than July 22, 2025, and the 30-day follow-up was due no later than August 15, 2025; however, both were completed on November 11, 2025.
Client #6 was admitted to the detox level of care on May 14, 2025, and discharged on May 25, 2025. The 7-day follow-up was due no later than June 1, 2025, and the 30-day follow-up was due no later than June 25, 2025; however, both were completed on February 3, 2026.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The follow-up form has been revised to include separate signature, date, and time fields for both the 7-day and 30-day follow-up contacts.
The updated procedure will go into effect on June 8, 2026. Clinical
staff will be re-educated on completing and documenting follow-up
contacts within the required 7-day and 30-day timeframes.
The Clinical Director and Project Director will review discharged
client records during quality assurance checks to monitor timely
completion and documentation of follow-up information.
Responsible Parties: Clinical Director and Project Director
Implementation Date: June 8, 2026
Monitoring: Discharge record QA review |
709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project which included familiarization with the fee schedule in seven of seven records.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The fee schedule will be added to the intake packet and reviewed with
clients during orientation. The fee schedule will also be included in the
client handbook.
The updated procedure will go into effect on June 8, 2026. Clients will
sign documentation confirming they were informed of the fee schedule
along with their informed consent, client rights, and privacy practices.
The Clinical Director and Project Director will review intake packets
during quality assurance checks to monitor compliance.
Responsible Parties: Clinical Director and Project Director
Implementation Date: June 8, 2026
Monitoring: Intake packet QA review |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 in four of four discharged records.
The facility's policy and procedures state that follow-up contact is to be completed within 7 and 30 days of discharge.
Client #8 was admitted to the residential level of care on July 18, 2025, and discharged on July 29, 2025. The 7-day follow-up was due no later than August 5, 2025, and the 30-day follow-up was due no later than August 29, 2025; however, both were completed on April 26, 2026.
Client #9 was admitted to the residential level of care on December 29, 2025, and discharged on January 29, 2026. The 7-day follow-up was due no later than February 5, 2026, and the 30-day follow-up was due no later than March 1, 2026; however, both were completed on April 26, 2026.
Client #10 was admitted to the residential level of care on March 5, 2026, and discharged on April 3, 2026. The 7-day follow-up was due no later than April 10, 2026, and the 30-day follow-up was due no later than May 3, 2026; however, both were completed on April 29, 2026.
Client #11 was admitted to the residential level of care on October 14, 2025, and discharged on October 24, 2025. The 7-day follow-up was due no later than October 31, 2025, and the 30-day follow-up was due no later than November 24, 2025; however, both were completed on March 24, 2026.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The follow-up form has been revised to include separate signature, date, and time fields for both the 7-day and 30-day follow-up contacts.
The updated procedure will go into effect on June 8, 2026. Clinical
staff will be re-educated on completing and documenting follow-up
contacts within the required 7-day and 30-day timeframes.
The Clinical Director and Project Director will review discharged
client records during quality assurance checks to monitor timely
completion and documentation of follow-up information.
Responsible Parties: Clinical Director and Project Director
Implementation Date: June 8, 2026
Monitoring: Discharge record QA review |