INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lenape Wellness Center 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of administrative records and staff interview, the facility failed to ensure a written individual training plan for each employee was developed in 46 out of 52 applicable records.
Facility policy and procedure states that each year in June all drug and alcohol program employees will complete an individualized training plan for the coming fiscal year.
Staff #1 was hired to the position of Project Director on December 17, 2025 and was in this position at the time of review. Staff #1 did not have an individual training plan developed in June 2026.
Staff #2 was hired to the position of Clinical Supervisor on December 17, 2025 and was in this position at the time of review. Staff #2 did not have an individual training plan developed in June 2026.
Staff #3 was hired to the position of counselor on December 17, 2025 and was in this position at the time of review. Staff #3 did not have an individual training plan developed in June 2026.
Staff #4 was hired to the position of counselor on December 17, 2025 and was in this position at the time of review. Staff #4 did not have an individual training plan developed in June 2026.
Staff #5 was hired to the position of counselor on December 17, 2025 and was in this position at the time of review. Staff #5 did not have an individual training plan developed in June 2026.
Staff #6 was hired to the position of counselor on December 17, 2025 and was in this position at the time of review. Staff #6 did not have an individual training plan developed in June 2026.
Staff #7 was hired to the position of counselor on February 6, 2026 and was in this position at the time of review. Staff #7 had an individual training plan completed on February 14, 2026. However, staff #7 did not have an individual training plan developed in June 2026
Staff #8 was hired to the position of counselor on December 17, 2025 and was in this position at the time of review. Staff #8 did not have an individual training plan developed in June 2026.
38 out of 44 other staff did not have an individual training plan developed in June 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Lenape Wellness Center acknowledges the finding regarding the absence of annual written Individual Training Plans for applicable employees. Upon identification of the deficiency, the facility initiated corrective action to ensure compliance with DDAP requirements and facility policy. Employee start dates within the training/compliance tracking system have been updated to align with the issuance of the facility's license to ensure accurate tracking of training requirements. All department supervisors have been educated regarding the requirement to develop and maintain an individualized written training plan for each employee under their supervision. Supervisors are meeting individually with their respective staff to develop training plans based on each employee's position, responsibilities, experience, identified training needs, and professional development needs. Individual Training Plans will be completed for 100% of applicable staff no later than August 31, 2026.
The facility has also clarified its annual training cycle to establish June as the beginning of each training year. Moving forward, Individual Training Plans will be reviewed and updated annually each June for all applicable employees, with the next annual review occurring in June 2027. The Director of Human Resources will maintain overall responsibility for monitoring compliance with this requirement, while each department supervisor will be responsible for ensuring that Individual Training Plans are developed and reviewed for the employees under their supervision. The Director of Human Resources will verify completion of all current plans by August 31, 2026, and will conduct an annual review each June thereafter to ensure that 100% of applicable employees have a current Individual Training Plan on file. Any deficiencies identified through this monitoring process will be referred to the applicable supervisor for immediate correction. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill log and staff interview, the facility failed to conduct fire drills at least once a month.
The fire drill log was reviewed from January 2026 through July 2026. No fire drill was completed for July 2026.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Lenape Wellness Center acknowledges the finding regarding the absence of documentation demonstrating completion of the required fire drill for July 2026. Compliance met with the Facility Director to review the deficiency and determine the cause. The Facility Director reported that a fire drill occurred during July; however, the drill was not properly documented on the facility's fire drill log. The facility recognizes that an undocumented drill cannot demonstrate compliance with the monthly fire drill requirement and has implemented corrective measures to prevent recurrence.
Lenape Wellness Center has contacted the local fire department as of 8/21/26 and established a process for conducting and documenting fire drills at least monthly. During each monthly fire drill, the facility's fire alarm will be activated and the local fire department will respond in accordance with the established process. The Facility Director is responsible for ensuring that the required fire drill is conducted each month and that the fire drill form and log are completed accurately and maintained as evidence of compliance. As an additional monitoring measure, the Compliance Manager will review fire drill compliance during the facility's monthly Quality Assurance meeting. This review will verify that the drill occurred during the applicable month, evaluate the facility and staff response to the drill, and review the completed fire drill documentation for accuracy and completeness. Any missed drill or documentation deficiency identified through the Quality Assurance process will be addressed immediately with the Facility Director and corrective action implemented as necessary to maintain ongoing compliance. |
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 fire drill log, the facility failed to ensure to maintain a written fire drill record that includes problems encountered.
Fire drill logs were reviewed from January 2026 through July 2026.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
As of August 21, 2026, Lenape Wellness Center has implemented corrective action regarding the failure to maintain fire drill records that adequately document problems encountered. The Compliance Department met with facility leadership and reviewed the required elements of the fire drill record. During this review, it was identified that staff had been documenting "pass" rather than providing a clear narrative describing any problems encountered during the drill. Leadership was educated that each fire drill record must include a clear narrative describing any problems encountered or specifically state that no problems were encountered, when applicable. A mock fire drill form was completed with leadership as a training exercise to demonstrate the documentation expectations and confirm understanding of the requirement.
Effective August 21, 2026, the Facility Director is responsible for ensuring that each monthly fire drill record is completed accurately and includes a narrative addressing problems encountered. The Compliance Department will audit the completed fire drill documentation monthly to verify compliance with all required elements. Any deficiencies identified during the monthly review will be immediately addressed with facility leadership, with additional education and corrective action provided as necessary to ensure continued compliance. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility fire drill log and staff interview, the facility failed to set off a fire alarm or smoke detector during each fire drill.
Fire drill logs were reviewed from January 2026 through July 2026.
The facility fire drill log indicated fire drills were conducted in January 2026, February 2026, March 2026, and June 2026. For January 2026, February 2026, and June 2026, the fire drill log indicates that the fire alarm was not activated, and how the drill was announced is described as " walkie-talkie " . The March 2026 fire drill does not indicate whether the fire alarm was activated or not, and how the drill was announced is described as " walkie-talk announcement and chat " . Staff interview confirmed that no fire alarm or smoke detector was set off during these fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of August 21, 2026, Lenape Wellness Center has implemented corrective action regarding the failure to activate a fire alarm or smoke detector during each required fire drill. The Compliance Department met with facility leadership and reviewed the requirement that fire drills include activation of the facility's fire alarm or smoke detector and that notification through walkie-talkie or other internal communication methods does not satisfy this requirement. Facility leadership acknowledged the prior practice and was educated regarding the required procedure moving forward.
Lenape Wellness Center has contacted the local fire department and established a process for conducting monthly fire drills in which the facility's fire alarm will be activated. The local fire department has been made aware of the facility's monthly fire drill process and is agreeable to the activation of the fire alarm and their resulting response as part of these drills. Effective August 21, 2026, the Facility Director is responsible for ensuring that a fire alarm or smoke detector is activated during every monthly fire drill and that the method of alarm activation is clearly documented on the corresponding fire drill record. The Compliance Department will review the completed fire drill documentation during the monthly Quality Assurance process to verify that the drill occurred, the required alarm was activated, staff response was appropriately documented, and all required elements of the fire drill form were completed. Any identified deficiency will be immediately addressed with facility leadership to ensure ongoing compliance. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent shall be offered to the client in seven of seven records.
All seven records reviewed contained client consents, however clients were not offered a copy of the client consent. This was confirmed by facility staff.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility reviewed the identified deficiency and determined that the existing client consent forms included an option for clients to accept or decline a copy; however, the Release of Information (ROI) forms did not include documentation demonstrating that the client had been offered a copy.
The Release of Information form was corrected in real time on site during the licensing survey to include a designated section documenting that the client was offered a hard copy and allowing the client to indicate whether they accept or decline the copy.
As of 8/12/2026, all active client records were reviewed and updated to ensure that Release of Information forms reflect that clients are offered a hard copy and document whether the client accepts or declines the copy.
All applicable staff were trained on the revised process and documentation requirements as of 8/21/2026. Moving forward, the facility will ensure that clients are offered a copy of all applicable consents and Releases of Information and that the client's acceptance or declination is documented in the record.
Compliance will review a sample of charts monthly during the quality assurance chart review and identify that these is being checked off on all consents and releases. |
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 administrative records and staff interview, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
The fire drill log from May 22, 2026 stated that the fire department arrived at the facility following the fire alarm being pulled. A written unusual incident report was due to be submitted with the Department no later than May 25, 2026. No written unusual incident report for this incident had been received as of the date of inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Lenape Wellness Center acknowledges the finding regarding the failure to submit a written Unusual Incident Report to the Department within three business days following the May 22, 2026 incident involving the presence of fire department personnel at the facility. As of August 21, 2026, the facility's leadership and Compliance Department met to review the deficiency, identify the breakdown in the reporting process, and implement an enhanced protocol to ensure reportable incidents are submitted to the Department timely and accurately.
Moving forward, Lenape Wellness Center will continue to follow its internal incident reporting policy for the documentation, review, and management of all incidents. In addition, as of August 21, 2026, a new escalation protocol has been implemented for incidents that may meet DDAP unusual incident reporting requirements. Whenever a potentially reportable incident occurs, including any event requiring the presence of police, fire, or ambulance personnel at the facility, facility leadership must immediately notify the Compliance Department via email and provide all available incident information.
The Compliance Department will review the incident for reportability and ensure that any required written Unusual Incident Report is completed and submitted to the Department within three business days of the incident. This process establishes clear accountability between facility leadership and the Compliance Department and will be utilized to ensure ongoing compliance with DDAP unusual incident reporting requirements.
As an additional corrective action, on August 26, 2026, Lenape Wellness Center will submit an Unusual Incident Report to the Department for the May 22, 2026 incident involving the presence of fire department personnel on campus. This submission addresses the previously unreported incident and, together with the enhanced reporting and escalation protocol, supports the facility's ongoing efforts to prevent recurrence. |