INITIAL COMMENTS
|
This report is a result of an off-site telehealth-only licensure renewal inspection conducted on May 15, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the off-site inspection, Recovery Unplugged Pennsylvania 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:
|
Plan of Correction
|
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
Based on the review of client records, the facility failed to follow their written plan for intake and admission to complete a medical history within three days of admission, per facility policy, in one out of one record reviewed.
Client #1 was admitted on April 23, 2026, and was still active at the time of the inspection. A medical history was due no later than April 26, 2026; however, it was not completed until April 30, 2026.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Recovery Unplugged PA acknowledges the finding related to the completion of the medical history for Client #1. We have reviewed the admission and intake process and identified a need to clarify the timeframe for completion of the medical history and the definition of the client's start date.
Effective 8/12/2026, our policy has been revised to require completion of the client's medical history within one week of the client's start date. The policy will also be updated to clearly define the "start date" as the date the client first attends a scheduled group, rather than the date of admission.
Staff will be educated on the revised policy and the updated definition of the client's start date. The Executive Director is responsible for implementing the updated policy, and this update will be monitored monthly in our Performance Improvement Committee meetings by our Compliance team. Any identified deficiencies will be addressed promptly through staff education and corrective action as appropriate. These changes are being implemented to ensure consistent compliance with the facility's written intake and admission procedures and to prevent recurrence of this finding.
|
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Based on the review of client records, the facility failed to follow their written plan for intake and admission to complete a drug and alcohol history within three days of admission, per facility policy, in one out of one record reviewed.
Client #1 was admitted on April 23, 2026, and was still active at the time of the inspection. A drug and alcohol history was due no later than April 26, 2026; however, it was not completed until April 30, 2026.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Recovery Unplugged PA acknowledges the finding regarding the untimely completion of the drug and alcohol history for Client #1. The facility has reviewed its intake and admission procedures and identified the need to clarify both the timeframe for completing the drug and alcohol history and the definition of the client's start date.
Effective 8/12/2026, our policy has been revised to require completion of the client's drug and alcohol history within one week of the client's start date. The policy has also been updated to clearly define the "start date" as the date the client first attends a scheduled group, rather than the date of admission.
Staff will be educated regarding the revised policy and the updated definition of the client's start date. The Executive Director is responsible for implementing the updated policy, and compliance with this requirement will be monitored monthly through Performance Improvement Committee meetings by our Compliance team. Any identified deficiencies will be addressed promptly through additional staff education and corrective action, as appropriate.
These corrective actions are being implemented to ensure staff have a clear understanding of the revised requirements, promote timely completion of required drug and alcohol histories, maintain compliance with the facility's intake and admission procedures, and prevent recurrence of this finding.
|
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on the review of client records, the facility failed to follow their written plan for intake and admission to complete a personal history within three days of admission, per facility policy, in one out of one record reviewed.
Client #1 was admitted on April 23, 2026, and was still active at the time of the inspection. A personal history was due no later than April 26, 2026; however, it was not completed until April 30, 2026.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Recovery Unplugged PA acknowledges the finding regarding the untimely completion of the personal history for Client #1. The facility has reviewed its intake and admission procedures and identified the need to clarify both the timeframe for completing the personal history and the definition of the client's start date.
Effective 8/12/2026, our policy has been revised to require completion of the client's personal history within one week of the client's start date. The policy has also been updated to clearly define the "start date" as the date the client first attends a scheduled group, rather than the date of admission.
Staff will be educated regarding the revised policy and the updated definition of the client's start date. The Executive Director is responsible for implementing the updated policy, and compliance with this requirement will be monitored monthly through Performance Improvement Committee meetings by our Compliance team. Any identified deficiencies will be addressed promptly through additional staff education and corrective action, as appropriate.
These corrective actions are being implemented to ensure staff have a clear understanding of the revised requirements, promote timely completion of required personal histories, maintain compliance with the facility's intake and admission procedures, and prevent recurrence of this finding.
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation within three days of admission, per the facility policy, in one out of one record reviewed.
Client #1 was admitted on April 23, 2026, and was still active at the time of the inspection. A complete psychosocial was due no later than April 26, 2026; however, it was not completed until April 30, 2026.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Recovery Unplugged PA acknowledges the finding regarding the untimely completion of the psychosocial evaluation for Client #1. The facility has reviewed its intake and admission procedures and identified the need to clarify both the timeframe for completing the psychosocial evaluation and the definition of the client's start date.
Effective 8/12/2026, our policy has been revised to require completion of the client's psychosocial evaluation within one week of the client's start date. The policy has also been updated to clearly define the "start date" as the date the client first attends a scheduled group, rather than the date of admission.
Staff will be educated regarding the revised policy and the updated definition of the client's start date. The Executive Director is responsible for implementing the updated policy, and compliance with this requirement will be monitored monthly through Performance Improvement Committee meetings by our Compliance team. Any identified deficiencies will be addressed promptly through additional staff education and corrective action, as appropriate.
These corrective actions are being implemented to ensure staff have a clear understanding of the revised requirements, promote timely completion of psychosocial evaluations, maintain compliance with the facility's intake and admission procedures, and prevent recurrence of this finding.
|
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:
|
Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within seven days of admission, per facility policy, in one out of one record reviewed.
Client #1 was admitted on April 23, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 30, 2026; however, it was not completed until May 6, 2026.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Recovery Unplugged PA acknowledges the finding regarding the untimely completion of the comprehensive treatment plan for Client #1. The facility has reviewed its intake and treatment planning procedures and identified the need to clarify both the timeframe for completing the comprehensive treatment plan and the definition of the client's start date.
Effective 8/12/2026, our policy has been revised to require completion of the client's comprehensive treatment plan within seven days of the client's start date. The policy has also been updated to clearly define the "start date" as the date the client first attends a scheduled group, rather than the date of admission.
Staff will be educated regarding the revised policy and the updated definition of the client's start date. The Executive Director is responsible for implementing the updated policy, and compliance with this requirement will be monitored monthly through Performance Improvement Committee meetings by our Compliance team. Any identified deficiencies will be addressed promptly through additional staff education and corrective action, as appropriate.
These corrective actions are being implemented to ensure staff have a clear understanding of the revised requirements, promote timely completion of comprehensive treatment plans, maintain compliance with the facility's treatment planning procedures, and prevent recurrence of this finding.
|