INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Sarah Jane Bentley Foundation 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 personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a counselor on January 17, 2024 and was due to have the communicable disease training no later than January 17, 2025. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Project Director will meet Employee #3 to register and complete TB/STD Training by August 31, 2025
2. Project Director will facilitate training at Sarah Jane Bentley Foundation with Human Resource Manager and Clinical Supervisor on accessing and monitoring Staff Training Needs to ensure that employees received at least four hours of TB/STD and other health related topics within the regulatory timeframe.
3. Project Director will complete training at Sarah Jane Bentley Foundation with Human Resource Manager and Clinical Supervisor on accessing and monitoring Staff Training Needs by August 31, 2025. |
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 document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in three out of nine records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed between within 30 days following admission.
Client #2 was admitted on February 19, 2025 and discharged on April 25, 2025. A comprehensive treatment plan was due no later than March 19, 2025; however, there was no treatment plan documented in the client's record.
Client #5 was admitted on March 6, 2025 and discharged on April 29, 2025. A comprehensive treatment plan was due no later than April 6, 20245; however, there was no treatment plan documented in the client's record.
Client #8 was admitted on January 21, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 21, 2025; however, there was no treatment plan documented in the client's record.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Clinical Supervisor will facilitate "Clinical Documentation Training" with all Counselors on implementing and completing comprehensive and updated treatment plans within guidelines established by the Sarah Jane Bentley Foundation's policy and procedures manual.
2. Clinical Supervisor will conduct a biweekly audit on all client charts and meet with primary counselor to discuss any documentation issues. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in six out of six records reviewed.
Client #1 was admitted on October 22, 2024 and discharged on May 2, 2025. A comprehensive treatment plan was completed on October 29, 2024 and an update was due no later than December 29, 2024; however, the next update was completed on February 26, 2025. In addition, the following update was due on April 26, 2025; however, no more updates were documented in the client's record.
Client #3 was admitted on November 22, 2024 and discharged on May 30, 2025. A comprehensive treatment plan was completed on December 11, 2024 and an update was due no later than February 11, 2025; however, the update was completed on February 26, 2025.
Client #4 was admitted on November 26, 2024 and discharged on June 25, 2025. A comprehensive treatment plan was completed on December 2, 2024 and an update was due no later than February 2, 2025; however, no updates were documented in the client's record.
Client #6 was admitted on January 14, 2025 and discharged on April 29, 2025. A comprehensive treatment plan was completed on January 15, 2025 and an update was due no later than March 15, 2025; however, no updates were documented in the client's record.
Client #8 was admitted on January 21, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 21, 2025 with updates due no later than April 21, 2025 and June 21, 2025. There were no treatment plan updates documented in the client's record.
Client #9 was admitted on March 25, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 2, 2025 and an update was due no later than June 2, 2025; however, the update was completed on June 10, 2025.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Clinical Supervisor will facilitate "Clinical Documentation Training" with all Counselors on implementing and completing comprehensive and updated treatment plans within guidelines established by the Sarah Jane Bentley Foundation's policy and procedures manual by August 31, 2025.
2. Clinical Supervisor will conduct a biweekly audit on all client charts and meet with primary counselor to discuss any documentation issues.
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