INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 30, 2025 through October 1, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, St. Luke's Penn 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility's October 2024 through July 2025 fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every six months.
At the time of the inspection, the May 2025 fire drill was the only fire drill conducted during sleeping hours within the reviewed period.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facilities director will ensure that a fire drill is conducted during hours of sleep at least every six months. The facilities director will retrain the maintenance department staff specific to this regulatory requirement by 11/1/2025. The facilities director will review fire frill reports monthly to ensure this regulation is met. |
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 the management of treatment/rehabilitation services for clients in one of three applicable client records reviewed.
The facility policy and procedure manual stated the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Client # 7 was admitted to the inpatient non-hospital detoxification activity on August 15, 2025 and was discharged against medical advice on August 17, 2025. There was no documentation, in the record, indicating the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations provided a reminder via email to Nursing and Behavioral Health Technician staff on 10/2/2025 regarding the policy and procedure related to AMA discharges including the requirement for notifying the emergency contact within 12 hours of the AMA discharge. Additionally, the patient care manager will retain all behavioral health technician and nursing staff on this policy and procedure by 11/1/2025. The Patient Care Manager and Clinical Coordinators will conduct monthly chart audits to ensure compliance with this regulation. |
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 client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of seven applicable client records reviewed.
Client # 15 was admitted to the outpatient activity on January 21, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 4, 2025 and the first update was due no later than April 4, 2025; however, the update was not completed until April 15, 2025.
Client # 17 was admitted to the outpatient activity on April 14, 2025 and was still active at the time of the inspection. A treatment plan update was completed on June 11, 2025 and the next update was due no later than August 11, 2025; however, the update was not completed until September 15, 2025.
Client # 18 was admitted to the outpatient activity on January 29, 2025 and was discharged on September 10, 2025. A treatment plan update was completed on February 25, 2025 and the next update was due no later than April 25, 2025; however, the update was not completed until June 11, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Clinical Supervisor reviewed and updated the treatment plan and treatment plan update process policies. These policies will be presented and reviewed with the clinical team in group supervision meeting on 10/30/2025. Further review and follow up will be discussed in individual supervisions with clinicians as needed. Compliance will continue to be audited by the clinical supervisor as part of the monthly caseload review process. |