INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 22, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Sarah Jane Bentley Foundation 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 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguisher in the basement storage area was last inspected in November, 2020.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. On Tuesday, July 28, 2026, the fire extinguisher in the basement storage area was replaced with a new fire extinguisher which was inspected and approved by Kint Inc.
2.The Director will conduct and document a monthly check on all fire extinguishers for servicing, if needed.
2.The Director will and ensure that all fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative documents and an interview with the facility director, the project failed to document an annual report.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Project Director will meet with Administrative Staff to ensure that the Sarah Jane Bentley Foundation's Annual Report is completed and posted on the Sarah Jane Bentley Foundation's Website.
2. The 2005 Sarah Jane Bentley Foundation's Annual Report will be posted on the Sarah Jane Bentley Foundation Website by August 31, 2026. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents and an interview with the facility director, the project failed to document an annual financial audit for the fiscal year ending December 31, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Project Director submitted an Exception Request Waiver on July 22, 2026, because the Sarah Jane Bentley Foundation does not meet the requirement to submit an annual financial audit
2. The Project Director will meet with Administrative Staff to ensure that the Annual Financial Audit will be completed annually.
3. The Project Director will submit an Exception Request, if needed, prior to DDAP annual inspection date. |
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 a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of seven records reviewed.
Client #1 was admitted on March 27, 2026 and was still active at the time of the inspection. There was no consent to release information form for the funding source. Facility staff confirmed billing had occurred.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Client 1#'s release of information for funding source cannot be completed due to Client #1 being discharge on 7/24/26 by referral source.
2. Clinical Supervisor will facilitate a "Clinical Documentation Training" with all Counselors on obtaining and documenting consent to release information within guidelines established by the Sarah Jane Bentley Foundation's policy and procedures manual by August 31, 2026.
3. Clinical Supervisor will conduct a biweekly audit on all client charts.
4. Clinical Supervisor and meet with primary counselors to discuss any documentation issues.
5. Program Director will meet with Clinical Supervisor weekly to discuss all chart audits.
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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 a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in five out of six applicable records reviewed.
Client #1 was admitted on March 27, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 1, 2026 and an update was due no later than June 1, 2026; however, none was completed.
Client #2 was admitted on September 17, 2025 and was still active at the time of the inspection. A treatment plan update was completed on November 21, 2025, and an update was due no later than January 21, 2026; however, it was not completed until February 3, 2026.
Client #3 was admitted on March 10, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 12, 2026 and an update was due no later than May 12, 2026; however, it was not completed until May 21, 2026.
Client #4 was admitted on March 31, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 7, 2026 and an update was due no later than June 7, 2026; however, none was completed.
Client #7 was admitted on June 17, 2025 and was discharged on February 13, 2026. A treatment plan update was completed on August 29, 2025 and an update was due no later than October 29, 2025; however, it was not completed until June 30, 2026.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 17, 2025 licensing inspection.
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Plan of Correction
1. Clinical Supervisor will facilitate "Clinical Documentation Training" with all Counselors on implementation and completion of the comprehensive and updated treatment plans within guidelines established by the Sarah Jane Bentley Foundation's policy and procedures manual by August 31, 2026.
2. Clinical Supervisor will conduct a biweekly audit on all client charts.
3. Clinical Supervisor and meet with primary counselors to discuss any documentation issues.
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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 a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of seven records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 60 days following admission.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Clinical Supervisor will facilitate a "Clinical Documentation Training" with all Counselors on discussion, implementation of Case Consultations within guidelines established by the Sarah Jane Bentley Foundation's policy and procedures manual by August 31, 2026.
2. Clinical Supervisor will conduct a biweekly audit on all client charts and meet with primary counselor to discuss any documentation issues.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge information within guidelines established by the facility's policy and procedures manual in two out of three applicable records reviewed. The facility's policy and procedures manual states that the discharge summary must be completed seven days following discharge.
Client #6 was admitted on October 16, 2024 and was discharged on February 23, 2026. A discharge summary was due no later than March 2, 2026; however, it was not completed until July 21, 2026.
Client #7 was admitted on June 17, 2025 and was discharged on February 13, 2026. A discharge summary was due no later than February 20, 2026; however, it was not completed until June 30, 2026.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Clinical Supervisor will facilitate "Clinical Documentation Training" with all Counselors on the completion of discharge summaries within guidelines established by the Sarah Jane Bentley Foundation's policy and procedures manual by August 31, 2026.
2. Clinical Supervisor will conduct a biweekly audit on all client charts.
3. Clinical Supervisor and meet with primary counselors to discuss any documentation issues.
4. Program Director will meet with Clinical Supervisor weekly to discuss all chart audits.
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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 a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in three out of three applicable records reviewed. The facility's policy and procedures manual states that the follow-up must be completed 60 days following discharge.
Client #5 was admitted on January 20, 2026 and was discharged on March 11, 2026. No follow-up was completed.
Client #6 was admitted on October 16, 2024 and was discharged on February 23, 2026. No follow-up was completed.
Client #7 was admitted on June 17, 2025 and was discharged on February 13, 2026. No follow-up was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Clinical Supervisor will facilitate "Clinical Documentation Training" with all Counselors on the completion of " Client Follow-Up " document within guidelines established by the Sarah Jane Bentley Foundation's policy and procedures manual by August 31, 2026.
2. Clinical Supervisor will conduct a biweekly audit on all client charts.
3. Clinical Supervisor and meet with primary counselors to discuss any documentation issues.
4. Program Director will meet with Clinical Supervisor weekly to discuss all chart audits.
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