INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 10, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, UHS Recovery Foundation, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection conducted on March 10, 2026, the facility failed to limit smoking to designated smoking areas.
Cigarette smoke could be smelled inside the bathroom on the first floor across from room # 126 and in the bathroom on the second floor across from room # 226.
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Plan of Correction
Director of Plant Operations has reeducated all housekeeping and maintenance staff of 705.9 (3) regulations. Director of Plant Operations increased and implemented a new cleaning checklist for staff to complete daily. This new form was implemented on 3/30/2026.
Non-Compliance of the smoking policy will be immediately reported to the Clinical Supervisor, Manager or Director for patient's to be immediately addressed clinically. |
709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
Based on a review of client records, the facility failed to have client records readily accessible for a minimum of 4 years following the discharge of a client.
Client # 5 was admitted on October 4, 2025, and discharged on October 21, 2025. This client chart was not available for review during a complaint investigation conducted on March 10, 2026.
Client # 6 was admitted on November 29, 2025, and discharged on December 9, 2025. This client chart was not available for review during a complaint investigation conducted on March 10, 2026.
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Plan of Correction
Keystone Center immediately requested the records that were not housed onsite. Despite all efforts to obtain the medical records from the off-site vendor, the vendor did not provide accurate information for retrieval. The letter provided by the external entity was supplied to the site inspector for ownership of the failure.
Ongoing, Keystone Center will continue work collaboratively with the off-site vendor in order to ensure that records are readily available same day whenever required. Keystone Center will also go-live with an Electronic Medical Record in May 2026. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of client records and the Medication Administration policy, the facility failed to follow their written policy and procedures regarding the documentation of the administration of medication.
The Medication Administration policy states the nurse will administer the prescribed medication in the prescribed dose, at the prescribed time, by the prescribed route to the identified patient per valid physician order.
Client # 1 was admitted on November 17, 2025, and discharged on December 17, 2025. There was a physician's order dated 11/18/25 for a medication to be taken three times per day for pain. This medication was not documented as being administered on 11/20 at 8 am, 11/25, 11/28, 11/29, and 11/30 at 2 pm, 12/2 and 12/3 at 2 pm and 9 pm, 12/5 at 9 pm, 12/8 at 2 pm and 9 pm, 12/9 at 9 pm, 12/10 at 2 pm and 9 pm, 12/12 at 2 pm and 9 pm, 12/13, and 12/14 at 2 pm and 9 pm. There was a physician's order dated 11/18/25 for a medication to be taken once daily at bedtime. This medication was not documented as being administered from 12/12-12/17. There was no explanation as to why the medication was not administered.
Client # 2 was admitted on December 11, 2025, and discharged on December 30, 2025. There was a physician's order dated 12/12/25 for a medication to be taken once daily at bedtime. This medication was not documented as being administered on 12/15 or 12/16. There was a physician's order dated 12/12/25 for a medication to be administered one time on 12/29/25. This medication was not documented as being administered on 12/29/25. There was no explanation as to why the medication was not administered.
Client # 4 was admitted on December 23, 2025, and discharged on January 14, 2026. There was a physician's order dated 12/23/25 for a medication to be taken once daily. This medication was not documented as being administered on 12/25, 1/2, 1/6, and 1/7. There was a physician's order dated 12/23/25 for a medication to be taken once daily for 7 days. This medication was not documented as being administered on 12/25. There was no explanation as to why the medication was not administered.
Client # 5 was admitted on October 4, 2025, and discharged on October 21, 2025. There was a physician's order dated 10/5/25 for a medication to be taken three times per day. This medication was not documented as being administered on 10/6 at 9 pm and on 10/10 at 2 pm. There was no explanation as to why the medication was not administered.
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Plan of Correction
Director of Nursing reeducated all nursing staff on the 709.32(c)(1)(i)(ii) regulation.
Ongoing, 3rd shift nursing staff completes an audit of all open chart MARs to follow-up with patients who did not receive any of their medications that day. Physicians are notified of any refusals of the medications for reassessment.
Monthly, open and closed charts are audited by Director of Nursing and Nurse Manager. The compliance of the MARs completion is reported to the Performance Improvement Committee. |