INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Resolutions Recovery Center, 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on applicable client record reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one record.
Client #2 was admitted to residential treatment on September 26, 2025 and discharged on November 20, 2025. There was no documentation in the client record notifying the client, in writing, of termination from the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action Taken Immediately
RRC has developed and implemented a standardized Involuntary Discharge Notification Form to ensure all clients are formally notified in writing when termination from treatment occurs.
A review of all current and recently discharged client records has been completed to ensure compliance. Any missing documentation has been addressed where possible with late entry documentation and administrative notes.
System Changes to Prevent Recurrence
Policy Update. RRC has revised its Discharge and Termination Policy to include: Mandatory written notification for all involuntary discharges. Required elements: Reason for termination. Effective date. Appeal/grievance rights. Referral/aftercare recommendations. Documentation must be signed by client and placed in the clinical record. Documentation Requirements: The written notification must be: Completed at the time of discharge decision. Uploaded into EMR under discharge documentation Referenced in the discharge summary and progress notes: EMR Workflow Implementation. A required checklist item has been added to the discharge process in Lightning Step: "Written Notification of Involuntary Termination Completed". Discharges cannot be finalized without completion of this step (administrative oversight enforced). Staff Training
All clinical and supervisory staff will receive mandatory training on:
Proper procedures for involuntary discharge. Documentation standards per DDAP and 28 Pa. Code. Use of the new notification form and EMR workflow
Monitoring and Quality Assurance
The Clinical Director/Program Director will: Utilize a discharge documentation checklist to ensure compliance
Responsible Party
Program Director
Clinical Leadership Team
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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 applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in one of two records. The policy and procedure manual indicates follow-up contact must be made within seven and ninety days of discharge.
Client #1 was admitted to residential treatment on July 17, 2025 and was discharged on September 18, 2025. The seven-day follow-up contact was due to be completed no later than September 25, 2025; however, this was not completed until October 8, 2025. Additionally, the ninety-day follow-up contact was due to be completed no later than December 17, 2025; however, this was not completed until December 26, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
System Changes to Prevent Recurrence
Policy Reinforcement. RRC re-educated staff on the requirement that:
Follow-up contact must occur within 1 time in 30 days. Timeframes are now clearly emphasized as non-negotiable compliance standards. Tracking System Implementation. A centralized Follow-Up Tracking Log has been implemented to track all discharged clients. The log includes: Client name. Discharge date. 1 contact time in 30-day follow-up due date. Date completed. Staff responsible
EMR Workflow. Enhancement Calendar reminders and/or tasks are now assigned at discharge for: 30 day follow up.
Responsibility is assigned to designated staff (case manager). Follow-ups must be documented in the EMR under a standardized follow-up note template.
Redundancy Safeguards: A secondary reviewer (Clinical Supervisor/Program Director) will monitor upcoming due dates weekly to ensure completion.
Missed or overdue follow-ups will be flagged immediately for corrective action. Staff Training. All clinical and case management staff will receive training on: Follow-up contact policy and required timelines. Proper documentation procedures
Use of the tracking log and EMR reminders. Responsible Party
Program Director Clinical Team / Case Management Staff
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