INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 13, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, White Deer Run of York 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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704.5(b) LICENSURE Clinical Supervisor
704.5. Qualifications for the positions of project director and facility director.
(b) If the facility does not have a clinical supervisor on staff, clinical responsibilities shall be addressed in one of the following ways:
(1) A facility director who has direct responsibility for clinical services shall meet the qualifications in at least one of the paragraphs of 704.7 (b) (relating to qualifications for the position of counselor).
(2) If the facility director does not meet counselor qualifications and the facility employs less than eight counselors, a lead counselor or part-time clinical supervisor shall be appointed.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that a lead counselor or part-time clinical supervisor is appointed. The facility director does not meet counselor qualifications.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor has been hired and will start 03/07/2025. In the absence of a clinical supervisor or in the event the clinical supervisor is out, a lead counselor will be assigned. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that at least one person trained in first aid is onsite during project's working hours.
The Staffing Requirements Facility Summary Report documents that only four out of twenty-two staff members who are employed onsite have first aid training.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the February 2, 2024 licensing inspection.
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Plan of Correction
1. All staff will be trained on first aid and CPR at orientation. Training will be a combination of Healthstream and in person learning. The HRD will be keeping a log of new hires, completion of trainings and the date of expiration. Staff who do not comply with timeframes will be removed form the schedule until they have received the trainings. HRD will review employee trainings weekly in supervision with the Regional Director.
2. Current staffing schedule has appropriate coverage during the treatment day. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirement Facility Staffing Form and the outpatient caseload report, the facility failed to comply with the client/counselor ratio of 35:1 in an outpatient facility. There was no counselor assigned to the clients receiving outpatient services.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will be starting 3/7/2025 and will be assigned clients who are in outpatient moving forward at a ratio of 35:1.
1. As clients enter the program, they will be assigned a counselor.
2. In the event that a counselor has a long term absence, the caseload will be reassigned in the system to another counselor.
3. The clinical supervisor will be responsible for assigning case loads daily and reviewing in clinical meeting weekly. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from February, 2024 - January, 2025 the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the months of February - December, 2024.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Facility filed exemption to fire pulls and awaiting response.
2. Verbal drills will be conducted monthly by either the BHA supervisor or facility director and be documented on the fire drill form.
3. Currently, drills have been completed for January, February and March 2025.
4. If the exemption is not approved the facility will need to have the landlord install fire pulls. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the February, 2024 - January, 2025 fire drill logs, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill on January 6, 2025.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the February 2, 2024 licensing inspection.
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Plan of Correction
1. Facility filed exemption to fire pulls and is awaiting response.
2. Verbal drills will be conducted monthly either by BHA supervisor or Facility Director and be documented on the fire drill form.
3. Currently drills have been completed for January, February and March of 2025.
4. Staff will ensure the box for verbal, fire alarm or smoke detector is checked.
5. If the exemption is not approved, the facility will ask the landlord to install fire pulls.
6. Facility Director will monitor compliance by reviewing the fire drill forms monthly. |
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 outpatient client records, the facility failed to obtain a consent to release information form prior to releasing information in two out of seven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #8 was admitted on November 13, 2024 and was still active at the time of the inspection.
Client #12 was admitted on September 20, 2024 and was discharged on November 12, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Facility Director has created a check list for releases to include all current client services and the clients funding source.
2. Consents will be completed at the time of admission.
3. During routine chart audits, consents will also be monitored by the facility director, clinical supervisor or during peer audits.
4. Each client will sign a release for their specific funding source. This will be monitored by the Facility Director, Clinical Supervisor and during peer audits monthly. If a clients funding source changes, the counselor assigned will create a new release for the client. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of outpatient client records, the facility failed to document written acknowledgement by the clients that they have been notified of their rights.
Client #8 was admitted on November 13, 2024 and was still active at the time of the inspection.
Client #10 was admitted on January 17, 2025 and was still active at the time of the inspection.
Client #12 was admitted on September 20, 2024 and was discharged on November 12, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Upon admission the client receives a notice of rights and acknowledgement collected by electronic signature by office manager.
2. This item has also been added to the routine chart audit checklist which is completed by facility director, clinical supervisor or clinical peer auditing when completing chart review.
3. Audits will be conducted weekly for compliance.
4. After review of current client charts, if a client does not have an acknowledgement of their rights they will be met with by clinical staff to receive these rights and sign the acknowledgement. This will then be audited by the facility director to ensure completion. |
709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document a preliminary treatment plan within the timeframe established by the policy and procedure manual in five out of seven records reviewed. The facility's policy and procedures manual states that the preliminary treatment plan must be completed at intake.
Client #1 was admitted on November 29, 2024 and was still active at the time of the inspection. The preliminary treatment plan was completed December 14, 2024.
Client #2 was admitted on October 29, 2024 and was still active at the time of the inspection. No preliminary treatment plan was documented.
Client #3 was admitted on November 8, 2024 and was still active at the time of the inspection. The preliminary treatment plan was completed November 13, 2024.
Client #4 was admitted on November 18, 2024 and was still active at the time of the inspection. The preliminary treatment plan was completed November 20, 2024.
Client #6 was admitted on September 6, 2024 and was discharged on December 12, 2024. The preliminary treatment plan was completed September 12, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. The preliminary treatment plans are being done at admission by the counselor assigned to admissions for the day.
2. Both client and staff sign electronically.
3. This item has been added to our chart audits which will be completed by the facility director, clinical supervisor or peer audit on a weekly basis. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document treatment plan updates within the timeframe established by the policy and procedure manual of every 14 days in seven out of seven records reviewed.
Client #1 was admitted on November 29, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on December 9, 2024 and an update was due no later than December 23, 2024; however, it was not completed until February 4, 2025.
Client #2 was admitted on October 29, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on October 30, 2024 and an update was due no later than November 13, 2024; however, it was not completed until November 26, 2024.
Client #3 was admitted on November 8, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on November 14, 2024 and an update was due no later than November 28, 2024; however, it was not completed until December 15, 2024.
Client #4 was admitted on November 18, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on November 20, 2024 and the next update was due no later than December 3, 2024; however, it was not completed until December 20, 2024.
Client #5 was admitted on November 26, 2024 and was discharged on January 3, 2025. A treatment plan update was completed on December 9, 2024 and an update was due no later than December 23, 2024; however, it was not completed until January 1, 2025.
Client #6 was admitted on September 6, 2024 and was discharged on December 12, 2024. A comprehensive treatment plan was completed on September 25, 2024, and an update was due no later than October 9, 2024; however, it was not completed until October 16, 2025.
Client #7 was admitted on October 30, 2024 and was discharged on January 30, 2025. A comprehensive treatment plan was completed on October 31, 2024 and an update was due no later than November 14, 2024; however, it was not completed until December 4, 2024.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the February 2, 2024 licensing inspection.
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Plan of Correction
1. Staff have been re-educated on the timeframe for treatment plan updates.
2. Facility Director/Clinical Supervisor will be reminding staff of due dates during weekly supervisions, treatment team meetings and clinical meetings.
3. Timeframe audit has been added to chart checks to be done by Facility Director, Clinical Supervisor and Peer Audit. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in three out of four applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 90 days following admission.
Client #2 was admitted on October 29, 2024 and was still active at the time of the inspection. A case consultation was due no later than January 29, 2025; however, it was not completed until February 6, 2025.
Client #3 was admitted on November 8, 2024 and was still active at the time of the inspection. No case consultation was documented.
Client #6 was admitted on September 6, 2024 and was discharged on December 12, 2024. No case consultation was documented.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the February 2, 2024 licensing inspection.
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Plan of Correction
Case consultations have been added during multidisciplinary meetings and are being documented in the chart by the facility director.
Case consultations will be added to the chart check sheet to ensure compliance. These will be done by Facility Director, Clinical Supervisor or during peer audit. |
709.83(a)(6) LICENSURE Client records
709.83. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of partial hospitalization client records, the facility failed to provide a complete client record, which is to include aftercare information in one out of three applicable discharged records reviewed.
Client #6 was admitted on September 6, 2024 and was discharged on December 12, 2024. No aftercare plan was documented.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the March 15, 2023 and February 6, 2024 licensing inspection.
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Plan of Correction
All staff have been re-educated on the aftercare record within the EMR. Staff will complete the aftercare information during final session with the client prior to discharge. This will include the discharge date, medical appointments, after care appointments, living arrangements, community/support systems, prognosis, recommendation and crisis plan in the event they need additional services.
The discharge record will be added to the chart checks that are being done by the facility director, clinical supervisor or peer audit team. |
709.83(a)(10) LICENSURE Client records
709.83. 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 partial hospitalization client records, the facility failed to provide a complete client record, which is to include a discharge summary in one out of three discharged records reviewed.
Client #6 was admitted on September 6, 2024 and was discharged on December 12, 2024. No discharge summary was documented.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff have been re-educated on the discharge summary in the EMR. Staff will complete the discharge summary on the day the client discharges from treatment. This document will include the discharge date, medical appointments, after care appointments, living arrangements, community/support systems, prognosis, recommendation and crisis plan in the event they need additional services.
The discharge record will be added to the chart checks that are being done by the facility director, clinical supervisor or peer audit team. |
709.83(a)(11) LICENSURE Client records
709.83. 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 partial hospitalization client records, the facility failed to document follow up 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 follow up must be completed within three days if they have an appointment or 30 days following discharge.
Client #5 was admitted on November 26, 2024 and was discharged on January 3, 2025. No follow up was documented.
Client #6 was admitted on September 6, 2024 and was discharged on December 12, 2024. No follow up was documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. A new follow up form has been created and provided to all counseling staff.
2. Counseling staff will schedule the after care follow up in their calendars to ensure timely follow up.
3. Staff will then upload the form to the chart once it is complete.
4. Audits of discharged clients will be done to ensure compliance that the form has been uploaded and it it was done timely. Audits will be done monthly by the Facility Director, Clinical Supervisor or by peer review on a weekly basis.
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709.91(a)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(1) Criteria for admission.
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Observations
Based on a review of outpatient client records, the facility failed to document disclosure to the client criteria for admission, treatment, completion and discharge in three out of seven records reviewed.
Client #8 was admitted on November 13, 2024 and was still active at the time of the inspection.
Client #10 was admitted on January 17, 2025 and was still active at the time of the inspection.
Client #12 was admitted on September 20, 2024 and discharged on November 12, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. During the admissions process the client will be fully oriented to the program and sign an acknowledgment.
2. This orientation includes client criteria for admission, treatment, and completion and discharge.
3. Review of the chart for orientation will be completed by the Facility Director, Clinical Supervisor or in peer audit.
4. Audits will be completed weekly. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of outpatient client records, the facility failed to document that client orientation had taken place in three out of seven records reviewed.
Client #8 was admitted on November 13, 2024 and was still active at the time of the inspection.
Client #10 was admitted on January 17, 2025 and was still active at the time of the inspection.
Client #12 was admitted on September 20, 2024 and discharged on November 12, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Client orientation is done during the clients initial admissions paperwork.
2. A folder was put together for the client to review during admission that includes the client handbook and other pertinent information.
3. An initialed checklist is provided to the facility director who reviews for completion.
4. Checklists are reviewed daily. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of outpatient client records, the facility failed to document medical histories in three out of seven records reviewed.
Client #8 was admitted on November 13, 2024 and was still active at the time of the inspection.
Client #11 was admitted on November 25, 2024 and was still active at the time of the inspection.
Client #13 was admitted on August 6, 2024 and discharged on November 28, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The medical history is located within the biopsychosocial assessment for outpatient clients.
2. A new clinical supervisor has been hired to run the outpatient program.
3. All clients entering outpatient services will receive a biopsychosocial that includes medical history, treatment history, current use history and other historical information within 24 hours.
4. This has been added to the chart checklist to be monitored by the facility director, clinical supervisor or peer audit.
5. Audits will be completed weekly. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of outpatient client records, the facility failed to document drug or alcohol histories in three out of seven records reviewed.
Client #8 was admitted on November 13, 2024 and was still active at the time of the inspection.
Client #11 was admitted on November 25, 2024 and was still active at the time of the inspection.
Client #13 was admitted on August 6, 2024 and discharged on November 28, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The drug and alcohol history is located within the biopsychosocial assessment for outpatient clients.
2. A new clinical supervisor has been hired to run the outpatient program.
3. All clients entering outpatient services will receive a biopsychosocial that includes medical history, treatment history, current use history and other historical information within 24 hours.
4. This has been added to the chart checklist to be monitored by the facility director, clinical supervisor or peer audit.
5. Audits will be done weekly. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of outpatient client records, the facility failed to document personal histories in three out of seven records reviewed.
Client #8 was admitted on November 13, 2024 and was still active at the time of the inspection.
Client #11 was admitted on November 25, 2024 and was still active at the time of the inspection.
Client #13 was admitted on August 6, 2024 and discharged on November 28, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The personal history is located within the biopsychosocial assessment for outpatient clients.
2. A new clinical supervisor has been hired to run the outpatient program.
3. All clients entering outpatient services will receive a biopsychosocial that includes medical history, treatment history, current use history and other historical information within 24 hours.
4. This has been added to the chart checklist to be monitored by the facility director, clinical supervisor or peer audit.
5. Audits will be done weekly. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of outpatient client records, the facility failed to document a psychosocial evaluation in five out of seven applicable records. There was no psychosocial evaluation in the record at the time of the inspection.
Client #8 was admitted on November 13, 2024 and was still active at the time of the inspection.
Client #10 was admitted on January 17, 2025 and was still active at the time of the inspection.
Client #11 was admitted on November 25, 2024 and was still active at the time of the inspection.
Client #12 was admitted on September 20, 2024 and discharged on November 12, 2024.
Client #13 was admitted on August 6, 2024 and discharged on November 28, 2024.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the February 6, 2024 licensing inspection.
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Plan of Correction
1. A new clinical supervisor has been hired to run the outpatient program.
2. All clients entering outpatient services will receive a biopsychosocial assessment that includes medical history, treatment history, current use history and other historical information within 24 hours.
3. This has been added to the chart checklist to be monitored by the facility director, clinical supervisor or peer audit.
4. This will be monitored weekly during chart audits. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of outpatient client records, the facility failed to document a preliminary treatment plan in four out of seven records reviewed. The facility's policy and procedures manual states that the preliminary treatment plan must be completed at the time of admission.
Client #8 was admitted on November 13, 2024 and was still active at the time of the inspection. None was documented.
Client #9 was admitted on August 29, 2024 and was still active at the time of the inspection. None was documented.
Client #12 was admitted on September 20, 2024 and discharged on November 12, 2024. None was documented.
Client #14 was admitted on September 17, 2024 and discharged on January 24, 2025. None was documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. The preliminary treatment plans are being done at admission by the counselor assigned to admissions for the day.
2. Both client and staff sign electronically.
3. This item has been added to our chart checks which will be completed by the facility director, clinical supervisor or peer audit.
4. Chart audits are completed weekly to ensure compliance. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 outpatient client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in five out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 21 days following admission.
Client #8 was admitted on November 13, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than December 4, 2024; however, none was completed.
Client #9 was admitted on August 29, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than September 19, 2024; however, it was not completed until September 27, 2024.
Client #11 was admitted on November 25, 2024 and was still active at the time of the inspection. No plan was completed.
Client #12 was admitted on September 20, 2024 and discharged on November 12, 2024. No plan was completed.
Client #13 was admitted on August 6, 2024 and discharged on November 28, 2024. No plan was completed.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the February 2, 2024 licensing inspection.
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Plan of Correction
1. A comprehensive master treatment plan will be developed by the assigned counselor and digitally signed by all parties.
2. Due dates will be tracked during treatment plan meetings, clinical meetings and individual supervisions. Dates will be assigned by the facility director or clinical supervisor.
3. Master Treatment Plans will be included in the chart audits completed by the facility director, clinical supervisor or peer audit. |
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 two out of two records reviewed.
Client #9 was admitted on August 29, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on September 27, 2024. An update was due no later than November 27, 2024; however, none was completed.
Client #14 was admitted on September 17, 2024 and discharged on January 24, 2025. A comprehensive treatment plan was completed on September 17, 2024. An update was due no later than November 17, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the February 6, 2024 licensing inspection.
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Plan of Correction
1. Staff have been re-educated on the timeframe for treatment plan updates.
2. Facility Director/Clinical Supervisor will be reminding staff of due dates during weekly supervisions, treatment team meetings and clinical meetings.
3. Timeframe audit has been added to chart checks to be done by Facility Director, Clinical Supervisor and Peer Audit. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in two out of three applicable records reviewed.
Client #9 was admitted on August 29, 2024 and was still active at the time of the inspection. The treatment plan dated September 29, 2024 indicated individual therapy 1-2x a week. No individual services were documented.
Client #10 was admitted on January 17, 2025 and was still active at the time of the inspection. The treatment plan dated January 17, 2025 indicated individual therapy one time per week. No individual services were documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. All staff have been re-educated on ensuring all counseling sessions are being offered and documented according to the treatment plan.
2. Counseling sessions will be monitored as part of the treatment team planning process, during clinical meetings and/or individual supervision.
3. Audits of counseling notes will be done weekly by the Facility Director, Clinical Supervisor and through peer audits.
4. Audits will be done weekly. |
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 outpatient client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in two out of two applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 90 days following admission.
Client #9 was admitted on August 29, 2024 and was still active at the time of the inspection. No case consultations were documented.
Client #14 was admitted on September 17, 2024 and discharged on January 24, 2025. No case consultations were documented.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the February 2, 2024 licensing inspection.
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Plan of Correction
Case consultations have been added during multidisciplinary meetings and are being documented in the chart by the facility director.
Case consultations will be added to the chart check sheet to ensure compliance. These will be done by Facility Director, Clinical Supervisor or during peer audit. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of outpatient client records, the facility failed to document an after care plan in three out of three applicable records reviewed.
Client #12 was admitted on September 20, 2024 and discharged on November 12, 2024. No plan was completed.
Client #13 was admitted on August 6, 2024 and discharged on November 28, 2024. No plan was completed.
Client #14 was admitted on September 17, 2024 and discharged on January 24, 2025. No plan was completed.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the February 2, 2024 licensing inspection.
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Plan of Correction
All staff have been re-educated on the aftercare record within the EMR. Staff will complete the aftercare information during final session with the client prior to discharge. This will include the discharge date, medical appointments, after care appointments, living arrangements, community/support systems, prognosis, recommendation and crisis plan in the event they need additional services.
The discharge record will be added to the chart checks that are being done by the facility director, clinical supervisor or peer audit team. |
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 outpatient client records, the facility failed to document a discharge summary in three out of three applicable records reviewed.
Client #12 was admitted on September 20, 2024 and discharged on November 12, 2024. No plan was completed.
Client #13 was admitted on August 6, 2024 and discharged on November 28, 2024. No plan was completed.
Client #14 was admitted on September 17, 2024 and discharged on January 24, 2025. No plan was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. All staff have been re-educated on the discharge within the EMR.
2. Staff will complete the discharge summary after a client has been discharged from the program. This will include a summary that includes the discharge date, medical appointments, after care appointments, living arrangements, community/support systems, prognosis, recommendation and crisis plan in the event they need additional services.
3. The discharge Summary will be added to the chart checks that are being done by the facility director, clinical supervisor or peer audit team.
4. Audits will be completed weekly.
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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 outpatient 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 3 days if an appointment or 30 days following discharge.
Client #12 was admitted on September 20, 2024 and discharged on November 12, 2024.
Client #13 was admitted on August 6, 2024 and discharged on November 28, 2024.
Client #14 was admitted on September 17, 2024 and discharged on January 24, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. A new follow up form has been created and provided to all counseling staff.
2. Counseling staff will schedule the after care follow up in their calendars to ensure timely follow up.
3. Staff will then upload the form to the chart once it is complete.
4. Audits of discharged clients will be done to ensure compliance that the form has been uploaded and it was done timely.
5. The audits will be completed weekly to ensure compliance. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of staff training records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for after care plans was submitted and approved by the Department for the March 15, 2023 and February 6, 2024 annual licensing inspections. After care plans was again found to be a deficiency in the February 13, 2025 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. All staff have been re-educated on the aftercare record within the EMR.
2. Staff will complete the aftercare information during final session with the client prior to discharge. This will include the discharge date, medical appointments, after care appointments, living arrangements, community/support systems, prognosis, recommendation and crisis plan in the event they need additional services.
3. Upcoming discharges will be discussed in daily clinical meetings to ensure compliance with completing the after care plan at the final session and on time.
4. If a client abruptly leaves the program due to medical or own will, staff will ensure proper documentation of such.
5. The discharge record will be added to the chart checks that are being done by the facility director, clinical supervisor or peer audit team.
6. Audits are completed weekly. |