INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 2, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Philhaven 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 May, 2024 through April, 2025 fire drill logs, the facility failed to document the number of persons in the facility at the time of the drill and exit route used.
Fire drills May, 2024-December, 2025 and February, 2025 - April, 2025 did not have number of persons in the facility documented.
Fire drills May and June, 2024 and February - April., 2025 did not document exit route used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director or designee will revise current Fire Drill form to include all required elements within 705.28 (d)(4) by June 1, 2025.
Facility Director or designee will reeducate staff on the new Fire Drill form by June 1, 2025.
Any team member who is on extended leave of absence, such as FMLA and return after June 1, 2025 will be re-educated to the new fire drill form prior to their next assigned shift. Any newly hired team member will be educated to the new fire drill form as part of their onboarding orientation.
Facility will start to use new form beginning in June 2025.
Facility Director or designee will monitor compliance.
Data will be reported monthly to the Quality Management Council until 100% compliance is achieved for 3 consecutive months demonstrating sustained success. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from May, 2024 through April, 2025, the facility failed to prepare alternative exit route to be used during fire drills, as all drills utilized the same exit routes July, 2024 - January, 2025.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director or designee will revise current Fire Drill form to include all required elements within 705.28 (d)(5) by June 1, 2025.
Facility Director or designee will reeducate staff to the new fire drill form by June 1, 2025.
Facility will start to use new form beginning in June 2025.
Any team member who is on extended leave of absence, such as FMLA and return after June 1, 2025 will be re-educated to the new fire drill form prior to their next assigned shift. Any newly hired team member will be educated to the new fire drill form as part of their onboarding orientation.
Facility Director or designee will monitor compliance.
Data will be reported monthly to the Quality Management Council until 100% compliance is achieved for 3 consecutive months demonstrating sustained success. |
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 obtain a completed informed and voluntary consent which included the purpose of the disclosure in one out of seven records reviewed.
Client #5 was admitted on October 2, 2024 and was discharged April 9, 2025. A consent form dated November 20, 2024 to a government agency did not list the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director or designee will reeducate staff by June 1, 2025 on 709.28(c)(3) confidentiality regulations and use of consent to release of information form, including that this must be obtained prior to entering SUD services.
Any team member who is on extended leave of absence, such as FMLA and return after June 1, 2025 will be re-educated to the process of obtaining and documenting informed and voluntary consent of the patient.Any newly hired team member responsible for obtaining informed and voluntary consent of the patient will be educated to the process as part of their onboarding oreintation.
Facility Director or designee will monitor compliance.
Data will be reported monthly to the Quality Management Council until 100% compliance is achieved for 3 consecutive months demonstrating sustained success.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director or designee will provide education to team members responsible for the completion of Intake Assessment/Formulation requirements present in 709.91(b)(6), including Clinical Impression by June 1, 2025.
Team members responsible for the completion of the Intake Assessment/Formulation will be re-educated to the process to include the Clinical Impression requirement by June 1, 2025. Any team member who is on extended leave of absence, such as FMLA will be re-educated to the process of documenting the Intake Assessment/Formulation to include Clinical Impression prior to their next assigned shift. Any newly hired team member responsible for the completion of completing the patient's Intake Assessment/Formulation to include Clinical Impression will be educated to the process as part of their onboarding orientation.
Facility Director or designee will monitor compliance.
Data will be reported monthly to the Quality Management Council until 100% compliance is achieved for 3 consecutive months demonstrating sustained compliance. |
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 a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in four out of seven client records reviewed.
Client #2 was admitted on February 7, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on February 13, 2025 with no type or frequency identified.
Client #4 was admitted on November 11, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 22, 2024 with no type or frequency identified.
Client #5 was admitted on October 2, 2024 and discharged on April 9, 2025. A comprehensive treatment plan was developed on October 2, 2024 with no type or frequency identified.
Client #7 was admitted on November 29, 2024 and discharged on April 17, 2025. A comprehensive treatment plan was developed on November 29, 2024 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director or designee will provide education by June 1, 2025 to clinician on incorporating type and frequency of treatment, which includes education on the individual treatment plan and review requirement of 709.92(a)(2).
Team members responsible for documenting the type and frequency of treatment in the patient's individualized treatment plan who is on an extended leave of absence, such as FMLA who return after June 1, 2025 will be re-educated to the requirement prior to their next assigned shift. Newly hired team members who are responsible for the documentation of the type and frequency of treatment as part of the patient's treatment plan will be educated to the requirement as part of their onboarding orientation.
Facility Director or designee will monitor compliance.
Data will be reported monthly to the Quality Management Council until 100% compliance is achieved for 3 consecutive months demonstrating sustained compliance.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 ensure that the clients received counseling services according to their individual treatment plan in three out of three applicable records reviewed.
Client #1 was admitted on February 3, 2025 and was still active at the time of the inspection. The treatment plan dated February 17, 2025 indicated one group therapy session per week for 12 weeks. There was no documentation of the client receiving group during these 12 weeks.
Client #3 was admitted on February 17, 2025 and was still active at the time of the inspection. The treatment plan dated March 4, 2025 indicated weekly group sessions. The only group session documented was a no show on March 26, 2025.
Client #6 was admitted on November 26, 2024 and was discharged on April 9, 2025. The treatment plan dated November 26, 2024 indicated group sessions weekly. There was no documentation that the client received group therapy during the weeks of December 9, 2024, December 16, 2024, and December 23, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director or designee will provide education by June 1, 2025 to those team members responsible for the documentation of Treatment and Rehabilitation Services: 709.92.
Team members who are responsible for the documentation of Treatment and Rehabilitation services, to include individual and group therapies who are on extended leave of absence, such as FMLA and return after June 1, 2025 will be re-educated to the standard prior to their next assigned shift. Newly hired team members who are responsible for the documentation of Treatment and Rehabilitation services to include individual and group therapies will be educated to the requirement as part of their onboarding orientation.
Facility Director or designee will monitor compliance.
Data will be reported monthly to the Quality Management Council until 100% compliance is achieved for 3 consecutive months demonstrating sustained success. |