INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 20, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Resurrection House LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records and the Treatment Planning policy, the facility failed to develop an individual treatment and rehabilitation plan per the facility policy in three of eight records reviewed.The Treatment Planning policy indicates that an initial treatment plan will be completed upon admission, and a Master Treatment Plan will be created within 7 days.Client # 2 was admitted on November 24, 2025, and discharged on December 23, 2025. A master treatment plan should have been completed on or before 12/1/25. The master treatment plan was dated 12/8/25.Client # 3 was admitted on November 18, 2025, and discharged on December 7, 2025. A master treatment plan should have been completed on or before 11/25/25. There was no master treatment plan documented in this client record.Client # 8 was admitted on July 8, 2025, and discharged on October 27, 2025. A master treatment plan should have been completed on or before 7/15/25. The master treatment plan was dated 7/23/25.
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Plan of Correction
Executive Director and Director of HR & Compliance were hired on 12/15/2025 and will be responsible for ensuring the treatment planning policy is followed. The clinical supervisor will conduct weekly chart audits to ensure initial treatment plans are documented and executed within 24 hours of a client's admission and the master comprehensive treatment plan is documented and executed within 7 days of a client's admission. The clinical supervisor will send the chart audit report to the executive director and director of HR and Compliance each week.
A progress note has been documented in all client's chart's whose treatment plans have not been executed within the designated timeframes identified in the facility policies. All treatment plans are documented at this time.
Executive Director and Director of HR and Compliance will be responsible for developing corrective action plans for any staff that demonstrates difficulty executing documentation within the timeframes outlined in the facility's policies. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to include the type and frequency of treatment and rehabilitation services on a treatment plan in one of eight records reviewed. Client # 1 was admitted on September 8, 2025, and discharged on December 10, 2025. The treatment plan dated 9/8/25 did not include the frequency of which group sessions were to be offered.
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Plan of Correction
Executive Director and Director of HR & Compliance were hired on 12/15/2025 and will be responsible for ensuring the initial treatment plan and individual comprehensive treatment plan are executed in full completion, with a specific focus on the frequency of clinical services.
The clinical supervisor will complete a weekly chart audit to ensure all treatment plans are completed in their entirety. The clinical supervisor will send the chart audit report to the Executive Director and Director of HR and Compliance weekly.
All treatment plans have been reviewed, and the frequency of services have been added in the treatment plans that were missing.
The Executive Director and Director of HR and Compliance will be responsible for developing corrective action plans for any staff members that demonstrate difficulty in following the standards of documentation identified in the facility's policies. |
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 a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 30 days in three of eight records reviewed. Client # 1 was admitted on September 8, 2025, and discharged on December 10, 2025. A comprehensive treatment plan was dated 9/8/25. Documentation of treatment plan updates due on or before 10/8/25, 11/8/25, and 12/8/25 were missing from the client record.Client # 4 was admitted on August 14, 2025, and discharged on November 14, 2025. The comprehensive treatment plan was dated 8/18/25. Documentation of treatment plan updates due on or before 9/18/25, and 10/18/25 were missing from the client record.Client # 7 was admitted on August 20, 2025, and discharged on October 8, 2025. The comprehensive treatment plan was dated 8/27/25. Documentation of a treatment plan update due on or before 9/27/25, was missing from the client record.
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Plan of Correction
Executive Director and Director of HR & Compliance were hired on 12/15/2025 and will be responsible for ensuring the comprehensive treatment plan review policy is followed. The clinical supervisor will conduct weekly chart audits to ensure treatment plan reviews are documented on the comprehensive treatment plan every thirty days from the date the comprehensive treatment plan was initiated. The clinical supervisor will send the chart audit report to the executive director and director of HR and Compliance each week.
All treatment plan reviews are documented at this time.
Executive Director and Director of HR and Compliance will be responsible for developing corrective action plans for any staff that demonstrates difficulty executing documentation within the timeframes outlined in the facility's policies. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in seven of eight records reviewed.Client # 1 was admitted on September 8, 2025, and discharged on December 10, 2025. A treatment plan dated 9/8/25 indicated the client was to have weekly individual sessions. There are no individual sessions documented for the weeks beginning 10/26, 11/2, 11/9, 11/16, 11/23, 11/30, or 12/7/25.Client # 2 was admitted on November 24, 2025, and discharged on December 23, 2025. A treatment plan dated 12/8/25 indicated the client was to have weekly individual sessions. There are no individual sessions documented in this client record.Client # 4 was admitted on August 14, 2025, and discharged on November 14, 2025. A treatment plan dated 8/18/25 indicated the client was to have weekly individual sessions. There are no individual sessions documented for the weeks beginning 11/2/25 and 11/9/25.Client # 5 was admitted on July 17, 2025, and discharged on October 23, 2025. A comprehensive treatment plan dated 7/21/25 and treatment plan updates dated 8/21/25 and 9/21/25 indicated the client was to have weekly individual sessions. There are no individual sessions documented in this client record.Client # 6 was admitted on August 19, 2025, and discharged on October 24, 2025. A treatment plan dated 8/27/25 and a treatment plan updated dated 9/27/25 indicated the client was to have weekly individual sessions. There are no individual sessions documented in this client record.Client # 7 was admitted on August 20, 2025, and discharged on October 8, 2025. A treatment plan dated 8/27/25 indicated the client was to have weekly individual sessions. There are no individual sessions documented in this client record.Client # 8 was admitted on July 8, 2025, and discharged on October 27, 2025. A treatment plan dated 7/23/25 and treatment plan updates dated 8/23/25 and 9/23/25 indicated the client was to have weekly individual sessions. There are no individual sessions documented for the weeks beginning 10/5, 10/12, and 10/19/2025.
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Plan of Correction
Executive Director and Director of HR & Compliance were hired on 12/15/2025 and will be responsible for ensuring that individual therapy notes will be documented weekly in accordance with the facility's policies. The clinical supervisor will conduct weekly chart audits to ensure all individual therapy notes are documented weekly. The clinical supervisor will send the chart audit report to the executive director and director of HR and Compliance each week.
All missing individual notes have been documented in the electronic medical record at this time.
Executive Director and Director of HR and Compliance will be responsible for developing corrective action plans for any staff that demonstrates difficulty adhering to the documentation standards outlined in the facility's clinical policies. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record which is to include a discharge summary, in one of eight records reviewed.Client # 4 was admitted on August 14, 2025, and discharged on November 14, 2025. The client record contained a discharge summary dated 11/14/25; however, the document was blank.
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Plan of Correction
Executive Director and Director of HR & Compliance were hired on 12/15/2025 and will be responsible for ensuring that all clients have a discharge summary fully executed within 7 days of their discharge. The clinical supervisor will conduct weekly chart audits to ensure discharge summaries are fully executed within 7 days of the clients discharge. The clinical supervisor will send the chart audit report to the executive director and director of HR and Compliance each week.
All discharge summaries have been completed at this time.
Executive Director and Director of HR and Compliance will be responsible for developing corrective action plans for any staff that demonstrates difficulty executing documentation within the timeframes outlined in the facility's policies. |