INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18, 2026 through March 19, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lehigh County Center for Recovery 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the project failed to ensure that one of five employees received a minimum of six hours of HIV/AIDS and four hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee # 5 was hired as a driver on October 10, 2023 and was currently in that position at the time of the inspection. Employee #5 was due to have the communicable disease training no later than October 10, 2025. There was no documentation indicating that this employee received the six hours of HIV/AID training and four hours of TB/STD training at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Employee #5 completed the required Communicable disease trainings on 2/23/24. These certificates were not in her employee file. When employee was asked she produced the certificates on 3/19/26 and they were uploaded into the shared folder late in the afternoon of 3/19/26. Moving forward the Program Director will track and ensure completion of all DDAP-approved communicable disease training for new hires. Program Director will review completion on a quarterly basis. Compliance findings will be reviewed biweekly by the Plan of Correction (POC) Committee, and corrective actions will be implemented as indicated to sustain compliance. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on March 19, 2026, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit.
When tested, the hot water in a staff bathroom was 129.3 degrees Fahrenheit.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Facility Manager replaced the faucet in the staff bathroom with a metering, single cast faucet that automatically shuts off after 30 seconds to prevent excessive water flow. On April 13, 2026, the Facility Manager tested the hot water temperature, which did not exceed 120 degrees Fahrenheit, ensuring compliance with safety standards.
To prevent recurrence, the Facility Manager will monitor hot water temperature monthly during routine walk through inspections and document findings. The Program Director will review the monthly inspection reports to verify completion and ensure continued compliance. Any variance identified will be addressed immediately and documented.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for notifying emergency contacts within twelve hours if a client leaves against staff advice in two of two applicable records reviewed.
Client #6 was admitted to the inpatient non-hospital residential level of care on October 16, 2025 and was discharged Against Staff Advice (ASA) on October 20, 2025. The facility failed to follow their policy related to ASA discharges of calling the emergency contact within twelve hours.
Client #10 was admitted to the inpatient non-hospital detox level of care on July 7, 2025 and was discharged Against Staff Advice (ASA) on July 18, 2025. The facility failed to follow their policy related to ASA discharges of calling the emergency contact within twelve hours.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Nursing Manager and/or Clinical Director will review all unplanned discharges within 24 hours of occurrence and document notification of the emergency contact. If no emergency contact is listed, this will be documented accordingly. The Program Director will conduct a daily review of unplanned discharges. Compliance findings will be reviewed biweekly by the Plan of Correction (POC) Committee, and corrective actions will be implemented as indicated to sustain compliance.
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709.28 (c) 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.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of fourteen records reviewed.
Client #4 was admitted on November 28, 2025 and discharged on December 3, 2025. There was documentation that facility staff contacted a pharmacy on December 1, 2025; however, there was not an informed and voluntary consent form obtained prior to the disclosure.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
All nursing staff will be re-educated on the requirement to obtain a valid consent to disclose information to a pharmacy prior to verifying a client's medications. Documentation of the signed consent will be maintained in the client's medical record. The Nurse Manager will conduct weekly audits of medical records to monitor and ensure ongoing compliance with this requirement. Compliance findings will be reviewed biweekly by the Plan of Correction (POC) Committee, and corrective actions will be implemented as indicated to sustain compliance |
709.63(a)(2) LICENSURE D & A support plan
709.63. 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:
(2) Drug and alcohol support plan.
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Observations
Based on the review of client records, the project failed to document a complete client record on an individual that included a drug and alcohol support plan in three of seven records reviewed.
Client #3 was admitted on February 24, 2026 and discharged on March 1, 2026. There was no drug and alcohol support plan documented in the client record.
Client #4 was admitted on November 28, 2025 and discharged on December 3, 2025. There was no drug and alcohol support plan documented in the client record.
Client #6 was admitted on October 16, 2025 and was discharged on October 20, 2025. There was no drug and alcohol support plan documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On April 13, 2026, Medical Providers received education on completing a D&A support plan to be included in the client's H&P. The Nurse Manager will conduct weekly chart reviews to monitor compliance.
Additionally, compliance findings will be reviewed biweekly by the Plan of Correction (POC) Committee, and corrective actions will be implemented as indicated to sustain compliance.
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709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on the review of client records, the project failed to document a complete client record on an individual that included a discharge summary in three of five applicable client records reviewed.
Client #4 was admitted on November 28, 2025 and discharged on December 3, 2025. There was no discharge summary documented in the client record.
Client #6 was admitted on October 16, 2025 and was discharged on October 20, 2025. There was no discharge summary documented in the client record.
Client #7 was admitted on February 23, 2026 and was discharged on February 26, 2026. There was no discharge summary documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinical Director will conduct weekly chart audits of all discharged clients to ensure that discharge summaries are completed and properly documented in the medical record. The Program Director will review the audit results on a monthly basis to ensure ongoing compliance. Compliance findings will be reviewed biweekly by the Plan of Correction (POC) Committee, and corrective actions will be implemented as indicated to sustain compliance. |
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 the review of client records and the project ' s policies and procedures manual, the project failed to document a complete client record on an individual that included a follow-up contact note within seven days of discharge, per facility policy, in two of four applicable client records reviewed.
Client #9 was admitted on May 27, 2025 and was discharged on June 28, 2025. There was no follow-up contact documented in the client record.
Client #12 was admitted on February 2, 2026 and was discharged on February 14, 2026. There was no follow-up contact documented in the client record.
This is a repeat citation from the March 21, 2025 annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinical Director has designated a staff member to complete follow-up forms on a daily basis. Once completed, the forms are scanned into the medical record. The Clinical Director conducts weekly audits to ensure compliance. Compliance findings will be reviewed biweekly by the Plan of Correction (POC) Committee, and corrective actions will be implemented as indicated to sustain compliance |