INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 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, Renewal Treatment, Inc. 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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709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services in three of seven records.
Client #1 was admitted on May 7, 2026 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed with the client on May 28, 2026; however, there was no documentation of frequency of services.
Client #2 was admitted on February 12, 2026 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed with the client on February 20, 2026; however, there was no documentation of frequency of services.
Client #3 was admitted on March 9, 2026 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed with the client on March 20, 2026; however, there was no documentation of frequency of services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action: The agency will provide mandatory DDAP treatment plan training to all clinical staff on 9.21.26.
Monitoring/Auditing: Clinical leadership will conduct routine audits of treatment plans to verify that the frequency of all treatment and rehabilitation services is clearly documented and consistent with the individual's identified needs and services provided. Audit results will be reviewed with supervisory staff and used to identify trends or areas requiring additional intervention.
Retraining: Staff identified through audits as not meeting the documentation requirement will receive targeted retraining on DDAP treatment plan requirements. Continued deficiencies will be addressed through additional supervision and follow-up audits.
Completion/Compliance: Specific training to this regulation will be completed for all applicable staff by 10.2.26, and ongoing audits will be conducted to ensure sustained compliance with DDAP requirements.
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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 applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in three of seven records.
Client #1 was admitted on May 7, 2026 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on May 28, 2026. A treatment and rehabilitation plan update was due no later than July 28, 2026; however, this was not completed until July 29, 2026.
Client #2 was admitted on February 12, 2026 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on February 20, 2026. A treatment and rehabilitation plan update was due no later than April 22, 2026; however, this was not completed until May 1, 2026.
Client #4 was admitted on December 22, 2025 and was discharged on May 19, 2026. A treatment and rehabilitation plan update was completed on January 5, 2026. The next treatment and rehabilitation plan update was due no later than March 7, 2026; however, this was not completed until March 9, 2026.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 19, 2025 annual licensing inspection.
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Plan of Correction
Corrective Action: All treatment plans will include clearly documented target dates and end dates in the EHR to allow for electronic tracking and monitoring of required 60-day updates. Clinical staff will be responsible for completing treatment plan updates within the required timeframe.
Monitoring: The Clinical Supervisor will develop and maintain a weekly tracking spreadsheet to monitor upcoming and overdue treatment plan updates. The EHR will also be utilized to track target and end dates and ensure timely completion.
This POC will be implemented by 10.2.26
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in five of seven applicable records. The facility policy and procedure manual indicate a case consultation to occur every ninety days.
Client #1 was admitted on May 7, 2026 and was still active at the time of the inspection. A case consultation was due to occur no later than August 7, 2026; however, this was not completed at the time of the inspection.
Client #2 was admitted on February 12, 2026 and was still active at the time of the inspection. A case consultation was due to occur no later than May 12, 2026; however, this was not completed at the time of the inspection.
Client #3 was admitted on March 9, 2026 and was still active at the time of the inspection. A case consultation was due to occur no later than June 9, 2026; however, this was not completed at the time of the inspection.
Client #5 was admitted on January 16, 2026 and was discharged on May 20, 2026. A case consultation was due to occur no later than April 16, 2026; however, this was not completed prior to discharge.
Client #6 was admitted on March 3, 2026 and was discharged on June 9, 2026. A case consultation was due to occur no later than June 3, 2026; however, this was not completed prior to discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action: To ensure timely compliance with DDAP requirements, case consultations will be completed at the time of each 60-day treatment plan update, allowing the consultation to occur prior to the 90-day requirement. Case consultations may be completed during clinical supervision or separately with the psychiatrist, as appropriate.
Monitoring: The Clinical Supervisor will monitor completion of case consultations in conjunction with the 60-day treatment plan review process. Documentation of each consultation will be maintained in the EHR to ensure completion and facilitate ongoing compliance.
Follow-Up: Any missed or approaching consultation deadlines will be addressed promptly with the responsible clinical staff member, with additional supervision or retraining provided as needed.
This POC will be implemented by 10.2.26
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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 applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in two of two records. The policy and procedure manual indicates follow-up contact must be made within ninety days after discharge.
Client #4 was admitted on December 22, 2025 and was discharged on May 19, 2026. The follow-up contact was due to be completed no later than August 19, 2026; however, this was not completed at the time of the inspection.
Client #7 was admitted on October 22, 2025 and was discharged on April 20, 2026. The follow-up contact was due to be completed no later than July 20, 2026; however, this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action: The agency will develop a standardized discharge follow-up letter to be completed and mailed at the time of discharge. The letter will identify the type of discharge and provide appropriate follow-up information and resources, as applicable.
Policy Update: The agency will revise its discharge policy to clearly define follow-up expectations based on the type of discharge. Residents who return to jail or escape from the facility will be excluded from routine post-discharge follow-up due to the circumstances of their discharge. The revised policy will clearly document these exceptions and the rationale for them.
Monitoring: Clinical leadership will monitor discharge documentation to ensure the appropriate follow-up letter is completed and mailed at the time of discharge and that the type of discharge is accurately identified.
This POC will be implemented by 10.16.26
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