INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on October 15, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Lewis Recovery LLC dba Victory Park Recovery Center 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of employee records, client records, and the Group Facilitator job description, the facility failed to ensure clinical groups were conducted by clinicians that meet at least one of the Department's qualifications for the position of counselor. Per the Chief Executive Officer, the Group Facilitators conduct all of the groups the facility offers.Employee # 3 was hired on June 12, 2023, as a Group Facilitator, and still holds that position. Employee # 3 has a Secondary School Diploma and is a Certified Recovery Specialist.Employee # 4 was hired on August 19, 2025, as a Group Facilitator, and still holds that position. Employee # 4 reported having a High School Diploma.Employee # 5 was hired on April 15, 2025, as a Group Facilitator, and still holds that position. Employee # 5 has documentation of having a Certified Recovery Specialist, which expired September 7, 2025.
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Plan of Correction
CCO, CD and CS met and changed job description for employee #3 who meets DDAP regulation 704.7(b)(6) as counselor. Employe #4 and #5 now hold a job description Counselor Assistant under DDAP regulation 704.8(a)(5). Groups are facilitated and co-facilitated by employees who qualify as counselors for clinically run groups.
HR will ensure all new potential employees onboarding documentation is complete upon start date utilizing HR onboarding check list. Director and Clinical Supervisor will ensure all new hire job descriptions are signed by employee who meets DDAP standards for such position and employees will be provided with a signed copy of their job description for their records.
Clinical Director and Clinical Supervisor will ensure counselor group facilitation is scheduled for clinical groups by employees who have counselor job description per DDAP regulation 704.7(b) |
709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
Based on a review of employee records and the Group Facilitator job description, the facility failed to include written verification of qualifying professional credentials in one of five records reviewed. Employee # 4 was hired on August 19, 2025, as a Group Facilitator, and still holds that position. Employee # 4 reported having a High School Diploma as their highest degree. Documentation of a High School Diploma was missing from the employee record.
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Plan of Correction
Employee #4 provided her high school diploma which is in her HR file. Employee #4 signed a job description as a qualified Counselor Assistant under DDAP regulation 704.8(a)(5).
HR will communicate with all new hires requiring all onboarding documents by utilizing an onboarding check list to be presented prior to start date which will include education diplomas and certification verifications.
HR will advise site director when all documents are received and when a new employee is able to start.
Site director will review documents to ensure onboarding has been compoleted. |
709.26 (c) LICENSURE Personnel management.
§ 709.26. Personnel management.
(c) There shall be written job descriptions for project positions.
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Observations
Based on a review of employee records, the facility failed to include a written job description for project positions.Employee # 4 was hired on August 19, 2025, as a Group Facilitator, and still holds that position. Documentation of a Group Facilitator job description was missing from the employee record.Employee # 5 was hired on April 15, 2025, as a Group Facilitator, and still holds that position. Documentation of a Group Facilitator job description was missing from the employee record.
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Plan of Correction
Employe #4 and #5 now hold a job description as Counselor Assistant under DDAP regulation 704.8(a)(5). Signed job descriptions are in their updated HR files
Utilizing onboarding checklist, HR will identify documents needed for employment.
Clinical Director will complete a job description to be signed by a potential new employee during the onboarding process to ensure all new employees have a job description in their HR files and employee will be provided with a copy of the job description for their record.
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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 internal incident reports, the facility failed to file a written unusual incident report with the Department within three business days following an event requiring the presence of police or ambulance personnel.On June 18, 2025, there was an event where the police and ambulance were onsite.On June 30, 2025, there was an event where an ambulance was onsite.On August 28, 2025, there was an event where an ambulance was onsite.
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Plan of Correction
CCO reviewed incident reporting logs and concurred that ambulance(s) were called to facility and an in house report was filed however, the report was not filed with DDAP portal.
All past incidents have been reported through the incident portal.
CCO, ED and CS reviewed the reporting procedure to endure that all incident reports are completed in house and with the reporting portal.
Staff meeting was conducted and ED and CS are to be notified by email of all incidents (state reportable or in house). ED will file in incident reporting binder and will immediately file a report through the state portal with followup communication (email) advising CCO and CS that report has been comnpleted. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to include and document individual counseling sessions were held at least twice weekly in two of four applicable client records reviewed.Client # 1 was admitted to the Partial Hospitalization Program on July 11, 2025. They stepped down to outpatient services on August 3, 2025, and discharged on August 13, 2025. One individual counseling session was documented on July 15, 2025. Documentation of a second individual counseling session for the week of July 13-19, 2025, was missing from the client record. There was no individual counseling sessions documented for the weeks of July 20-26, 2025, and July 27 - August 2, 2025. Client # 4 was admitted to the Partial Hospitalization Program on July 18, 2025, and discharged on August 4, 2025. There was no individual counseling sessions documented for the week of July 27 - August 2, 2025.
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Plan of Correction
It was found that discharged clients #1 and #4 did not have individual sessions and were missing missed session documentation
CCO, CD and CS met with the clinical team and held a training regarding clinical documentation and required services. CD and CS reenforced that Partial Hospitalization Program individuals require 2 weekly individual sessions or missed services documentation and reviewed DDAP regulation 709.82(d)(1). Clinical staff were advised that any sessions need to be documented, and any missed services also need to be documented noting the reason for the missed service.
CD and CS will conduct a weekly chart audit to ensure that all services have been documented including missed services.
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