INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 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, Sunlight Recovery Solutions LLC DBA Sunlight Wellness & Recovery 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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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon staff employment in six of six applicable personnel record reviewed.
Employee # 1 was hired as the project director on March 1, 2025; however, the training in the use of the fire extinguisher was not completed until September 25, 2025.
Employee # 2 was hired as the facility director on March 1, 2025; however, the training in the use of the fire extinguisher was not completed until September 26, 2025.
Employee # 3 was hired as the clinical supervisor on August 5, 2025; however, the training in the use of the fire extinguisher was not completed until September 24, 2025.
Employee # 4 was hired as a counselor on July 7, 2025; however, the training in the use of the fire extinguisher was not completed until September 24, 2025.
Employee # 5 was hired as a counselor on July 22, 2025; however, the training in the use of the fire extinguisher was not completed until September 24, 2025.
Employee # 6 was hired as a counselor on July 21, 2025; however, the training in the use of the fire extinguisher was not completed until September 24, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
A comprehensive staff orientation training has been developed to include Fire Safety and Fire Extinguisher Training.
All newly hired staff are scheduled for new hire orientation training within two weeks of hire.
Each new employee will sign off on having completed the training and the training record placed in the employee's HR file.
An orientation training checklist is utilized upon hire to ensure that all required training is complete prior to finalization of new employee onboarding. HR files will be audited on a quarterly basis to ensure compliance as part of the annual training compliance plan. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 personnel records, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies in six of six applicable personnel record reviewed.
Employee # 1 was hired as the project director on March 1, 2025; however, the training to perform assigned tasks during emergencies was not completed until September 25, 2025.
Employee # 2 was hired as the facility director on March 1, 2025; however, the training to perform assigned tasks during emergencies was not completed until September 26, 2025.
Employee # 3 was hired as the clinical supervisor on August 5, 2025; the training to perform assigned tasks during emergencies was not completed until September 24, 2025.
Employee # 4 was hired as a counselor on July 7, 2025; however, the training to perform assigned tasks during emergencies was not completed until September 24, 2025.
Employee # 5 was hired as a counselor on July 22, 2025; however, the training to perform assigned tasks during emergencies was not completed until September 24, 2025.
Employee # 6 was hired as a counselor on July 21, 2025; however, the training to perform assigned tasks during emergencies was not completed until September 24, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A comprehensive staff orientation training has been developed to include Fire Safety, Emergency Response and Fire Drill Training.
All newly hired staff are scheduled for new hire orientation training within two weeks of hire.
Each new employee will sign off on having completed the training and the training record placed in the employee's HR file.
An orientation training checklist is utilized upon hire to ensure that all required training is complete prior to finalization of new employee onboarding. HR files will be audited by the Project Director on a quarterly basis to ensure compliance as part of the annual training compliance plan. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 April 2025 through September 2025 fire drill logs, the facility failed to ensure their written fire drill logs included documentation of the exit route used, the number of persons in the facility at the time of the drill, and whether the fire alarm or smoke detector was operative at the time of the drill.
Every monthly fire drill log completed during the reviewed period did not include the documentation of the exit route used, the number of persons in the facility at the time of the drill, and whether the fire alarm or smoke detector was operative at the time of the drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Written fire drill logs documentation has been updated to include the exit route used, the number of persons in the facility at the time of the drill, and whether the fire alarm or smoke detector was operative at the time of the drill.
Staff have been re-trained on how to complete the fire drill log correctly.
Every monthly fire drill log completed from the date of the review now include documentation of the exit route used, the number of persons in the facility at the time of the drill, and whether the fire alarm or smoke detector was operative at the time of the drill.
Monthly fire drill completion will be adding as a standing leadership meeting agenda item to confirm drills have been completed and ensure ongoing compliance. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in two of fourteen client records reviewed.
Client # 13 was admitted to the outpatient activity on March 10, 2025 and was discharged on June 30, 2025. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 14 was admitted to the outpatient activity on April 22, 2025 and was discharged on August 15, 2025. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An intake checklist has been developed and is in use to ensure that all appropriate documentation is completed at time of client intake, including ensuring all disclosure consents. The intake checklist includes a list of potential type of disclosures to ensure all necessary disclosures are completed and signed by the client.
Intake and clinical staff have been re-trained on the intake checklist and re-reviewed the process of ensuring that all appropriate aspects of the consent have been filled in including the purpose of the disclosure and the name of the person to whom the disclosure is being made.
Staff have been re-trained on the appropriate process to confirm the necessary releases are complete prior to disclosure per policy and law.
Executive Director of operations runs a quarterly report out of the EMR to ensure ROI forms are signed as expected and conducts monthly spot audits to review ROI forms and compare to disclosures.
Staff are coached and re-trained as indicated based on findings of spot audits.
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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 is made on consent to release information forms in two of fourteen client records reviewed.
Client # 7 was admitted to the partial hospitalization activity on May 19, 2025 and was discharged on June 23, 2025. There were two blank release of information forms signed by the client on May 2, 2025; however, both release forms did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.
Client # 11 was admitted to the outpatient activity on June 23, 2025 and was discharged on August 18, 2025. There were two blank release of information forms signed by the client on May 2, 2025; however, both release forms did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An intake checklist has been developed and is in use to ensure that all appropriate documentation is completed at time of client intake, including ensuring all disclosure consents. Intake and clinical staff have been re-trained on the intake checklist and re-reviewed the process of ensuring that all appropriate aspects of the consent have been filled in including the purpose of the disclosure and the name of the person to whom the disclosure is being made.
Intake and clinical staff have been re-trained on the intake checklist and re-reviewed the process of ensuring that all appropriate aspects of the consent have been filled in including the purpose of the disclosure and the name of the person to whom the disclosure is being made.
Executive Director of operations runs a quarterly report out of the EMR to ensure ROI forms are signed as expected and conducts monthly spot audits of ROI forms to ensure all necessary documentation fields are complete.
Staff are coached as indicated based on findings of spot audits.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on release of information forms in eleven of fourteen client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on September 16, 2025 and was still active at the time of the inspection. There were release of information forms to a recovery house, another treatment provider, an emergency contact, a funding source, and a family member signed by the client on September 16, 2025; however, none of the release forms included documentation of the purpose of the disclosure.
Client # 2 was admitted to the partial hospitalization activity on September 23, 2025 and was still active at the time of the inspection. There were release of information forms to a lawyer, another treatment provider, an emergency contact, a funding source, and a family member signed by the client on September 16, 2025; however, none of the release forms included documentation of the purpose of the disclosure.
Client # 3 was admitted to the partial hospitalization activity on September 24, 2025 and was still active at the time of the inspection. There were release of information forms to a recovery house, another treatment provider, an emergency contact, a funding source, and a family member signed by the client on September 16, 2025. Additionally, a release of information form to another recovery house was signed by the client on October 20, 2025. None of the release forms included documentation of the purpose of the disclosure.
Client # 4 was admitted to the partial hospitalization activity on June 13, 2025 and was discharged on July 28, 2025. There was a release of information form to another treatment provider signed by the client on June 13, 2025; however, the release form did not include documentation of the purpose of the disclosure.
Client # 5 was admitted to the partial hospitalization activity on July 1, 2025 and was discharged on August 13, 2025. There was a release of information form to a recovery house signed by the client on July 1, 2025; however, the release form did not include documentation of the purpose of the disclosure.
Client # 6 was admitted to the partial hospitalization activity on May 28, 2025 and was discharged on June 25, 2025. There were release of information forms to an emergency contact, a funding source, a recovery house, and a friend signed by the client on May 28, 2025; however, none of the release forms included documentation of the purpose of the disclosure.
Client # 7 was admitted to the partial hospitalization activity on May 19, 2025 and was discharged on June 23, 2025. There was a release of information form to a recovery house signed by the client on May 2, 2025; however, the release form did not include documentation of the purpose of the disclosure.
Client # 8 was admitted to the outpatient activity on July 28, 2025 and was still active at the time of the inspection. There was a release of information form to another treatment provider signed by the client on June 13, 2025; however, the release form did not include documentation of the purpose of the disclosure.
Client # 9 was admitted to the outpatient activity on August 13, 2025 and was still active at the time of the inspection. There was a release of information form to a recovery house signed by the client on July 1, 2025; however, the release form did not include documentation of the purpose of the disclosure.
Client # 10 was admitted to the outpatient activity on June 25, 2025 and was still active at the time of the inspection. There were release of information forms to an emergency contact, a funding source, a recovery house, and a friend signed by the client on May 28, 2025; however, none of the release forms included documentation of the purpose of the disclosure.
Client # 11 was admitted to the outpatient activity on June 23, 2025 and was discharged on August 18, 2025. There was a release of information form to a recovery house signed by the client on May 2, 2025; however, the release form did not include documentation of the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An intake checklist has been developed and is in use to ensure that all appropriate documentation is completed at time of client intake, including ensuring all disclosure consents. Intake and clinical staff have been re-trained on the intake checklist and re-reviewed the process of ensuring that all appropriate aspects of the consent have been filled in including the purpose of the disclosure and the name of the person to whom the disclosure is being made.
Executive Director of operations runs a quarterly report out of the EMR to ensure ROI forms are signed as expected and conducts monthly spot audits of ROI forms to ensure all necessary documentation fields are complete.
Staff are coached as indicated based on findings of spot audits.
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in one of two applicable client records reviewed.
Client # 4 was admitted to the partial hospitalization activity on June 13, 2025 and was discharged on July 28, 2025. The individual treatment and rehabilitation plan was completed on June 17, 2025 and the first update was due no later than July 17, 2025; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff have been re-educated on the requirements of updating treatment plans per policy and best practice.
Clinical Director has implemented a tracking schedule which alerts clinicians when treatment plan updates are due.
Clinical Director conducts a weekly audit report to track completion of treatment plan updates.
This is reviewed in weekly clinical supervision and 1:1 in clinician individual supervision. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. 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 assure that counseling services were provided according to the individual treatment and rehabilitation plan in two of five applicable client records reviewed.
Client # 2 was admitted to the partial hospitalization activity on September 23, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on September 29, 2025, indicated the client was to receive two individual therapy sessions per week. The record of services and progress notes indicated the client received one individual session per week during each week of the client's treatment.
Client # 4 was admitted to the partial hospitalization activity on June 13, 2025 and was discharged on July 28, 2025. The individual treatment and rehabilitation plan, completed on June 17, 2025, indicated the client was to receive two individual therapy sessions per week. The record of services and progress notes indicated that the client received one individual session during the week of June 22, 2025 through June 28, 2025, and no individual sessions during the each week from June 29, 2025 through July 12, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff have been re-educated on the requirement to provide individual sessions per treatment plan and regulations and the timelines and requirements of updating treatment plans per policy and best practice.
Clinical staff were additionally re-educated on how to document sessions that were offered and missed/declined by the client.
Clinical Director has implemented a weekly chart review and audit tracking process to ensure clinical team is scheduling and completing individual sessions as indicated.
Clinical Director has implemented a tracking schedule which alerts clinicians when treatment plan updates are due.
This is reviewed in weekly clinical supervision. |
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 review of client records, the facility failed to ensure clients, who were admitted to the partial hospitalization program, received individual counseling at least twice per week in four of seven client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on September 16, 2025 and was still active at the time of the inspection. There were less than two individual sessions documented in the record during the week of September 21, 2025 through September 27, 2025 and also during each week from October 5, 2025 through October 18, 2025.
Client # 2 was admitted to the partial hospitalization activity on September 23, 2025 and was still active at the time of the inspection. There were less than two individual sessions documented in the record during each week from September 28, 2025 through October 18, 2025.
Client # 4 was admitted to the partial hospitalization activity on June 13, 2025 and was discharged on July 28, 2025. There were less than two individual sessions documented in the record during each week from May 5, 2025 through June 8, 2025 and also during the week of June 16, 2025 through June 22, 2025.
Client # 5 was admitted to the partial hospitalization activity on July 1, 2025 and was discharged on August 13, 2025. There were less than two individual sessions documented in the record during the week of July 6, 2025 through July 12, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff have been re-educated on the requirement to provide individual sessions per treatment plan and regulations and the timelines and requirements of updating treatment plans per policy and best practice.
Clinical staff were additionally re-educated on how to document sessions that were offered and missed/declined by the client.
Clinical Director has implemented a weekly chart review and audit tracking process to ensure clinical team is scheduling and completing individual sessions as indicated.
Clinical Director has implemented a tracking schedule which alerts clinicians when treatment plan updates are due.
This is reviewed in weekly clinical supervision. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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, the facility failed to ensure individual treatment and rehabilitation plans were completed, per facility policy, and developed with the client in three of seven applicable client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within 10 days of admission.
Client # 10 was admitted to the outpatient activity on June 25, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by July 5, 2025; however, the plan was not completed until August 14, 2025.
Client # 11 was admitted to the outpatient activity on June 23, 2025 and was discharged on August 18, 2025. The individual treatment and rehabilitation plan was due to be completed by July 3, 2025; however, the plan was not completed until July 8, 2025.
Client # 13 was admitted to the outpatient activity on March 10, 2025 and was discharged on June 30, 2025. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff have been re-educated on the requirement to provide individual sessions per treatment plan and regulations and the timelines and requirements of updating treatment plans per policy and best practice.
Clinical staff were additionally re-educated on how to document sessions that were offered and missed/declined by the client.
Clinical Director has implemented a weekly chart review and audit tracking process to ensure clinical team is scheduling and completing individual sessions as indicated.
Clinical Director has implemented a tracking schedule which alerts clinicians when treatment plan updates are due.
This is reviewed in weekly clinical supervision. |
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 maintain a complete client record, which is to include documentation of an aftercare plan, in two of three applicable client records reviewed.
Client # 13 was admitted to the outpatient activity on March 10, 2025 and was discharged on June 30, 2025. There was no aftercare plan documented in the record at the time of the inspection.
Client # 14 was admitted to the outpatient activity on April 22, 2025 and was discharged on August 15, 2025. There was no aftercare plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff have been re-educated on the requirements for aftercare, including complete documentation of the aftercare plan or, if applicable, where an aftercare plan has been offered but refused by the client.
A comprehensive discharge checklist was created, all clinical staff have been educated on the checklist and instructed to use it to ensure discharges are completed per policy and regulated.
Clinical Director has implemented a policy in which all discharge charts are to be audited for completion of all required activities prior to the completion of the discharge and close of the chart. |
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 maintain a complete client record, which is to include documentation of follow-up information, in four of four applicable client records reviewed.
Client # 11 was admitted to the outpatient activity on June 23, 2025 and was discharged on August 18, 2025. There was no documentation of follow-up information in the record at the time of the inspection.
Client # 12 was admitted to the outpatient activity on April 24, 2025 and was discharged on July 1, 2025. There was no documentation of follow-up information in the record at the time of the inspection.
Client # 13 was admitted to the outpatient activity on March 10, 2025 and was discharged on June 30, 2025. There was no documentation of follow-up information in the record at the time of the inspection.
Client # 14 was admitted to the outpatient activity on April 22, 2025 and was discharged on August 15, 2025. There was no documentation of follow-up information in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Coordinator has been tasked with following up with all discharged clients per policy at 30, 60, 90 days utilizing EMR auto-task creation.
Program Coordinator is utilizing a standard questionnaire to capture standard outcomes.
Referrals and resources are provided as indicated by the results of the follow up.
Executive Director will run and review EMR reports monthly, results will be reviewed during monthly leadership meeting and in 1:1 supervision with Program Coordinator. |