INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on March 20, 2025 through March 21, 2025, 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of two applicable client records reviewed.
Client # 12 was admitted to the inpatient non-hospital rehabilitation activity on October 12, 2024 and was administratively discharged on December 3, 2024. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director trained all staff on 3/28/25 that all clients are to be given the administrative discharge form to review and sign and be uploaded into chart. Clinical Director will review charts on a monthly basis that this procedure is being completed. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's March 2024 through March 2025 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident which required the presence of police and/or ambulance personnel at the facility on May 2, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed on 3/25/25 with medical and clinical staff that all incidents, requiring emergency services be documented with DDAP within 3 days. Program Director and Administrative assistant will monitor, on a weekly basis, that all incidents requiring DDAP notification are completed within 3 business days |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on March 21, 2025 at approximately 11:45 AM, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
At the time of the inspection, there was what appeared to be mold/mildew on the ceiling in the shared bathroom in the men ' s rehab wing.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed with Facilities Manager that during a monthly walk-through he needs to document any abnormalities within the facility immediately and address how they are to be resolved within 5 business days. Bathroom noted in this inspection was repaired by April 11, 2025. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
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Observations
Based on a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client in three of seven client records reviewed.
Client # 9 was admitted to the inpatient non-hospital activity on February 20, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 23, 2025; however, there was no documentation indicating the plan was developed with the client.
Client # 12 was admitted to the inpatient non-hospital activity on October 12, 2024 and was discharged on December 3, 2025. The individual treatment and rehabilitation plan was completed on October 16, 2024; however, there was no documentation indicating the plan was developed with the client.
Client # 13 was admitted to the inpatient non-hospital activity on February 5, 2025 and was discharged on February 25, 2025. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director reviewed individually with each clinician how to complete and document an individual treatment plan with the client's input. These were done with individual supervision the week of 3/24 ? 3/28. It will be reviewed again at the group supervision scheduled for
4/21/25. Clinical Director will monitor with monthly chart audits.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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 client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in two of six applicable client records reviewed.
Client # 9 was admitted to the inpatient non-hospital activity on February 20, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 23, 2025; however, there was no documentation, on the plan, of the type and frequency of treatment and rehabilitation services to be provided to the client.
Client # 12 was admitted to the inpatient non-hospital activity on October 12, 2024 and was discharged on December 3, 2025. The individual treatment and rehabilitation plan was completed on October 16, 2024; however, there was no documentation, on the plan, of the type and frequency of treatment and rehabilitation services to be provided to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director reviewed individually with each clinician how to complete and document an individual treatment plan that documents frequency and type of treatment and services. These were done with individual supervision the week of 3/24 ? 3/28. It will be reviewed at the group supervision scheduled for
4/23/25. Clinical Director will monitor with monthly chart audits.
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709.52(a)(3) LICENSURE Support service type
709.52. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in two of six applicable client records reviewed.
Client # 9 was admitted to the inpatient non-hospital activity on February 20, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 23, 2025; however, there was no documentation, on the plan, of the proposed type of support services.
Client # 12 was admitted to the inpatient non-hospital activity on October 12, 2024 and was discharged on December 3, 2025. The individual treatment and rehabilitation plan was completed on October 16, 2024; however, there was no documentation, on the plan, of the proposed type of support services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director reviewed individually with each clinician how to complete and document on the individual treatment plan the proposed types of support services being offered. These were done with individual supervision the week of 3/24 ? 3/28. It will be reviewed at the group supervision scheduled for
4/23/25. Clinical Director will monitor with monthly chart audits.
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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 a review of client records, the facility failed to maintain a complete client record, which is to included documentation of follow-up information, in three of four applicable client records reviewed.
Client # 12 was admitted to the inpatient non-hospital activity on October 12, 2024 and was discharged on December 3, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client # 13 was admitted to the inpatient non-hospital activity on February 5, 2025 and was discharged on February 25, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client # 15 was admitted to the inpatient non-hospital activity on May 29, 2024 and was discharged on June 26, 2024. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed with Clinical Director, on 3/26/25 the procedure to document follow up information and upload to the electronic records that documentation. Program Director will monitor documentation in electronic records on a monthly basis. |