INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 22-24, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Summit BHC Westfield, LLC d/b/a Mountain Laurel Recovery Center 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document that a counselor meets the educational qualifications for the position in two out of ten records reviewed. Employee #7 was hired as a counselor on May 19, 2026, and was still active in that position at the time of inspection. The employee ' s bachelor's degree did not verify the major and no transcript was provided during the inspection process to verify a qualifying degree was obtained as required for the position. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The cited counselor was active in the counselor position at the time of inspection. The Director of Clinical Services and Human Resources will review the cited personnel file and confirm the employee's current status. For any employee serving in the counselor role, a transcript or other sufficient educational documentation will be obtained and maintained in the personnel file to verify compliance with the applicable qualification requirements.
By 11/30/26, Clinical Leadership will review the qualifications of the identified counselor and obtain additional educational documentation necessary to verify compliance with 704.7(b). Clinical Leadership will also review the qualifications of all currently employed counselors to confirm that each individual meets the applicable educational and experience requirements. When a diploma does not identify the degree or major, a transcript will be obtained. Going forward, Clinical Leadership will verify counselor qualifications are present in their HR file before placement into the counselor role, and Human Resources will ensure the personnel file contains the supporting documentation.
Human Resources will verify 100% of current counselor personnel files for supporting qualification documentation and will verify 100% of future counselor placements before the employee begins functioning in the counselor role. QRD will review completion of the initial file review and any identified gaps monthly through the Committee of the Whole and report results quarterly to the Governing Board.
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the facility's policy and procedures manual, the project director failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of an assessment of staff training needs, an overall plan for addressing these needs, a mechanism to collect feedback on completed training, and an annual evaluation of the overall training plan.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 11/30/26, the Project Director will correct the identified program-level deficiency by completing and formally implementing a comprehensive staff-development process that identifies responsible parties and established timeframes for the annual assessment of staff training needs, development of the overall training plan, collection of employee feedback following training, and annual evaluation of the overall training plan.
By 11/30/26, the Project Director will formalize the facility's annual staff-development process for the January-December calendar year. The process will define responsibility and timeframes for the annual training-needs assessment, development of the facility-wide training plan, collection of employee feedback following training, and annual evaluation of the prior year's training plan. Department Heads will identify the training needs of their staff and provide input into the facility-wide plan. Individual annual training plans will be completed with employees each January, with initial plans completed for new hires within the required timeframe.
By 11/30/26, the Project Director will complete and formally implement the updated staff-development process, including defined responsibility and timeframes for the annual training-needs assessment, facility-wide training plan, employee feedback, and annual evaluation of the training program. Human Resources will maintain the supporting training records and departmental submissions. Thereafter, the Project Director will verify completion of each required component annually, and QRD will review completion of the process monthly through the Committee of the Whole and report results quarterly to the Governing Board, with a goal of 100% completion of all required components.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document individual training plans within 30 days of hire and annually in January, per previously documented procedures from past inspections and review with facility staff, in ten out of twelve records reviewed. Employee #2 was hired as a clinical supervisor on March 24, 2026, and was still in that position at the time of inspection. The training plan was due April 23, 2026, but was not documented until August 27, 2026. Employee #3 was hired as a counselor on June 2, 2026, and was still in that position at the time of inspection. The training plan was due July 2, 2026, but was not documented until August 27, 2026. Employee #5 was hired as a counselor on March 11, 2025, and was still in that position at the time of inspection. The annual training plan was due in January 2026 but was not documented until August 27, 2026. Employee #6 was hired as a counselor on March 11, 2025, and was still in that position at the time of inspection. The annual training plan was due in January 2026 but was not documented until August 27, 2026.Employee #7 was hired as a counselor on May 19, 2026, and was still in that position at the time of inspection, The training plan was due June 18, 2026, but was not documented until August 27, 2026. Employee #8 was hired as a counselor on January 13, 2026, and was still in that position at the time of inspection. The training plan was due February 12, 2026, but was not documented until August 31, 2026. Employee #9 was hired as a counselor on March 10, 2026, and was still in that position at the time of inspection. The training plan was due by April 9, 2026, but was not documented until August 27, 2026. Employee #10 was hired as a counselor on September 26, 2023, and was still in that position at the time of inspection. The annual training plan was due in January 2026 but was not documented until August 27, 2026.Employee #11 was hired as a counselor on February 24, 2026, and was still in that position at the time of inspection. The training plan was due February 26, 2026, but was not documented until August 27, 2026. This is a repeat citation from the August 28, 2024, and September 10, 2025, annual licensing renewal inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The individual training plans identified during the inspection were completed after their required due dates. Human Resources and the applicable Department Heads will verify that each cited current employee has a completed individual training plan maintained in the personnel record. The facility will address the timeliness issue through Department Head accountability, completion of new-hire plans within 30 days of hire, completion of annual plans each January, and centralized Human Resources tracking.
By 12/15/26, each Department Head will review the individual training plans for employees under their supervision and complete any outstanding initial or annual plans with employee input. Each plan will be appropriate to the employee's position and skill level. Going forward, initial individual training plans will be completed within 30 days of hire, and annual individual training plans will be completed each January for the January-December calendar year. Department Heads will retain responsibility for timely completion, and Human Resources will provide centralized tracking and notice of upcoming or overdue plans.
Human Resources will monitor 100% of due individual training plans monthly with a goal of 100% timely completion. Due to the repeated nature of this finding, QRD will conduct secondary monthly review of the process. Results will be reported monthly to the Committee of the Whole and quarterly to the Governing Board. Enhanced monitoring will remain in place until sustained compliance is demonstrated and the Governing Board authorizes reduction of monitoring.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of administrative documents and personnel records, the facility failed to ensure that staff received a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD and other health related topics training using a department approved curriculum provided by qualified trainers in twelve out of twenty one records reviewed. The facility provides a self-guided PowerPoint rather than a qualified trainer to present the information. Employee #4 was hired at the facility on November 30, 2023, was promoted to the position of counselor on November 4, 2025, and was still in that position at the time of inspection. Employee #4 completed self-guided trainings rather than attending trainings provided by qualified trainers. Employee #5 was hired as a counselor on March 11, 2025, and was still in that position at the time of inspection. Employee #5 completed self-guided trainings rather than attending trainings provided by qualified trainers. Employee #6 was hired as a counselor on March 11, 2025, and was still in that position at the time of inspection. Employee #6 completed self-guided trainings rather than attending trainings provided by qualified trainers. Employee #10 was hired as a counselor on September 26, 2023, and was still in that position at the time of inspection. Employee #10 completed self-guided trainings rather than attending trainings provided by qualified trainers. Employee #14 was hired as a BHA on September 3, 2024, and was still in that position at the time of inspection. Employee #14 completed self-guided trainings rather than attending trainings provided by qualified trainers. Employee #15 was hired as a housekeeper on July 16, 2024, and was still in that position at the time of inspection. Employee #15 completed self-guided trainings rather than attending trainings provided by qualified trainers. Employee #16 was hired as a manager on April 30, 2024, and was still in that position at the time of inspection. Employee #16 completed self-guided trainings rather than attending trainings provided by qualified trainers. Employee #17 was hired as an intake coordinator on March 5, 2024, and was still in that position at the time of inspection. Employee #17 completed self-guided trainings rather than attending trainings provided by qualified trainers. Employee #18 was hired as an intake coordinator on October 26, 2023, and was still in that position at the time of inspection. Employee #18 completed self-guided trainings rather than attending trainings provided by qualified trainers. Employee #19 was hired as a maintenance technician on September 19, 2023. Employee #19 completed self-guided trainings rather than attending trainings provided by qualified trainers. Employee #20 was hired as a driver on August 28, 2023, and was still in that position at the time of inspection. Employee #20 completed self-guided trainings rather than attending trainings provided by qualified trainers. Employee #21 was hired as an intake coordinator on July 11, 2023. Employee #21 completed self-guided trainings rather than attending trainings provided by qualified trainers. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Human Resources will identify the current employment status of each employee cited in the finding. Each affected employee who remains employed will complete the applicable HIV/AIDS and TB/STD training using a Department-approved curriculum and qualified training process by 01/31/27. Completion documentation will be maintained in the applicable personnel file.
By 01/31/27, all applicable staff requiring HIV/AIDS and TB/STD training will complete the required training either through Department-approved training or through internal training provided by the facility's Infection Control Nurse or an RN designee. Human Resources will identify employees requiring HIV/AIDS and TB/STD training, maintain a centralized roster of all applicable employees, and notify Department Heads of outstanding requirements and approaching deadlines. The Infection Control Nurse or RN designee will coordinate and facilitate training through the approved training methods. Department Heads will ensure assigned staff complete the required training within the applicable timeframe. Completion certificates or other acceptable documentation will be submitted to Human Resources for the personnel file.
Human Resources will monitor training status monthly until 100% of identified employees are compliant. Thereafter, Human Resources will track new hires and employees approaching regulatory deadlines to support timely completion. Outstanding requirements will be communicated to the applicable Department Heads for follow-up. Results will be reported monthly to the Committee of the Whole and quarterly to the Governing Board until the identified corrective work is complete. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirement Facility Summary Report (SRFSR) form and personnel records, the facility failed to document that each counselor completed at least 25 clock hours of training in the January - December 2025 training year. Employee #10 was hired as a counselor on September 26, 2023, and was still in the position at the time of the inspection. The employee record documented only 14 clock hours of training in the reviewed training year. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
DDAP identified that the cited counselor completed 14 of the required 25 training hours during the January-December 2025 training year and was active in the counselor position at the time of inspection. The Director of Clinical Services will review the counselor's current-year training record, assign additional qualifying training as necessary, and ensure completion of the required minimum of 25 qualifying clock hours for the current training year by 12/31/26.
By 11/9/26, Human Resources will compile and review documented current-year training hours for all currently employed counselors and provide the Director of Clinical Services with each counselor's completed hours and any remaining deficit toward the required minimum of 25 qualifying clock hours. The Director of Clinical Services will review the training for applicability to the counselor's role, assign additional qualifying training as needed, and ensure counselors complete the required annual hours by 12/31/26.
Human Resources will maintain the centralized counselor training-hour tracker, verify that supporting documentation is maintained in the personnel record, and provide updated training-hour and compliance reports to the Director of Clinical Services monthly. Counselors and Clinical Leadership will submit completed training documentation to Human Resources so the tracker remains current.
The Director of Clinical Services will use the monthly reports to address outstanding requirements during supervision, assign additional qualifying training, and follow up with counselors to ensure timely completion. The compliance goal is 100% of counselors completing at least 25 qualifying clock hours during the applicable training year. Compliance status will be reported monthly to the Committee of the Whole and quarterly to the Governing Board.
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to maintain hot water not exceeding 120 degrees. The residential hall bathroom A for rooms 416 and 418 had a water temperature of 133.5 F, bathroom B for rooms 417 and 419 had a water temperature of 131.0 F, and Bathroom D without a sign with bedroom designations had a water temperature of 128.5 F on September 23, 2026. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Facilities has ordered the required mixing valve to correct the hot-water condition identified during the inspection. Following installation, Facilities will verify water temperatures at the three bathroom locations identified during the licensing inspection and at additional bathrooms throughout each client building to confirm that hot-water temperatures do not exceed 120°F. Corrective work and verification readings will be documented.
By 10/30/26, the Director of Facilities will complete corrective work to the hot-water system serving the residential area so that water temperatures do not exceed 120°F. The required mixing valve has been fixed as of 10/16/2026. Following installation, Facilities will verify water temperatures in the three bathrooms identified during the licensing inspection and in additional bathrooms throughout each client building to confirm that appropriate temperature control has been restored. Corrective work and verification readings will be documented.
Following completion of the mixing-valve installation, Facilities will implement a routine water-temperature monitoring process for bathrooms in each client building. Water temperatures will be checked and documented weekly for 60 days and monthly thereafter. The compliance goal is 100% of tested fixtures at or below 120°F. Any reading above 120°F will require immediate corrective action and a documented follow-up temperature check to verify resolution. Monitoring records will be maintained by Facilities, reviewed monthly through the facility's quality oversight process and Committee of the Whole, and reported quarterly to the Governing Board.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative documents, the facility failed to ensure the project director prepared, annually updated, and signed the written manual delineating project policies and procedures.The written manual was previously signed on March 6, 2025. The document presented during the licensing process did not include a date, nor was it signed by an individual who was documented by the Department as the project director during March 2026, which is when the annual preparation, update and signature were due to be completed by.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 11/30/26, the Project Director will review the current facility policy and procedure manual, make any necessary revisions, and sign and date the manual to correct the identified deficiency. Thereafter, the Project Director will complete the required annual review, update, signature, and dating of the policy and procedure manual each January.
By 11/30/26, the Project Director will complete a full review of the facility policy and procedure manual, revise the manual as needed, and sign and date the manual to document completion of the review. Beginning in January 2027, the Project Director will complete this review annually each January, including any necessary updates, and will sign and date the manual to document completion. Documentation of the annual review will be maintained with the policy and procedure manual.
QRD will verify completion of the annual policy and procedure manual review, including the required Project Director signature and date, with a goal of 100% annual compliance. Completion and any identified deficiencies will be monitored monthly through the Committee of the Whole and reported quarterly to the Governing Board until resolved.
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709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency, or organization to whom the disclosure is made in one out of fourteen client records reviewed. Client #6 was admitted to the Detox level of care on May 13, 2026, and was discharged on May 19, 2026. There was a release of information signed by the client on May 14, 2026, that did not identify the name of the person, agency, or organization to whom the disclosure is made.This is a repeat citation from the September 10, 2026, annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The cited client was discharged on 05/19/26. QRD will review the cited Release of Information and use the finding as part of staff education and process clarification regarding the appropriate use of TPO consent versus a separate Release of Information and the required elements for each.
By 10/26/2026, QRD will review the requirements of 709.28(c)(1), applicable DDAP guidance, and the facility's TPO/ROI process with Admissions, Nursing, and Clinical leadership. The facility's workflow will be reviewed and adjusted as needed to clearly distinguish TPO disclosures from disclosures requiring a separate ROI and to ensure the correct authorization process is consistently used. By 11/30/2026, 100% of applicable Admissions, Nursing, and Clinical staff will receive education on the distinction between disclosures made under a Treatment, Payment, and Health Care Operations (TPO) consent and disclosures requiring a separate, specific Release of Information. Education will include the required elements for each type of authorization and the appropriate identification of recipients or permitted classes of recipients. Completion of the education will be documented and maintained by the facility.
QRD will audit a random sample of 30 applicable TPO/ROI disclosures per month, or 100% of applicable disclosures if fewer than 30 occur, to verify that the appropriate authorization was used based on the purpose of the disclosure and that all required elements for the applicable consent were completed.
The compliance goal will be 100%. Monitoring will continue on an ongoing monthly basis to support sustained compliance. Results will be reported monthly through the Committee of the Whole and quarterly to the Governing Board. If compliance falls below 100%, identified deficiencies will be addressed through documented corrective follow-up and continued monitoring until compliance is re-established.
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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 a decision to involuntarily terminate the client ' s treatment at the project in two out of two applicable records reviewed. Client #6 was admitted to the Detox level of care on May 13, 2026, and was involuntarily terminated on May 19, 2026. The record did not contain documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.Client #13 was admitted to the Residential level of care on May 14, 2026, and was involuntarily terminated on June 12, 2026. The record did not contain documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.This is a repeat citation from the September 10, 2026, annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The two clients identified in the finding were involuntarily terminated on 05/19/26 and 06/12/26. The Director of Clinical Services will review the cited records and incorporate the findings into staff education and the revised administrative-discharge process. The ATD tracker will include verification that written notification of involuntary termination, including the reason for termination, is completed and maintained in each applicable client record.
By 11/30/26, the Director of Clinical Services and the MLRC Leadership team will be retrained on 709.33(a) and the facility's administrative discharge procedure. The ATD/administrative discharge tracker will be updated to include confirmation that written notification of involuntary termination, including the reason for termination, was completed and placed in the client record. The staff member who facilitated the administrative discharge or the assigned designee will be responsible for ensuring the written notification is completed for each applicable involuntary termination and that the documentation is available in the medical record.
The QRD will audit 30 administrative/involuntary discharge records each month, or all applicable records if fewer than 30 are available,
with a compliance goal of 100%. Monitoring will continue on an ongoing monthly basis to support sustained compliance. QRD will review the audit results monthly. Results will be reported monthly through the Committee of the Whole and quarterly to the Governing Board, which maintains oversight of corrective-action implementation. If compliance falls below 100%, identified deficiencies will be addressed through documented corrective follow-up and continued monitoring until compliance is re-established.
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709.63(a)(6) LICENSURE Aftercare plan
709.63. 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 client records, the facility failed to maintain a complete client record on an individual, which is to include an aftercare plan completed prior to discharge as part of the discharge summary, per facility policy, in one out of one applicable record reviewed. Client #6 was admitted to the Detox level of care on May 13, 2026, and was discharged on May 19, 2026. There was no aftercare plan in the client record at the time of inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The cited detox client was discharged on 05/19/26. The Director of Clinical Services and Director of Nursing will review the cited record and incorporate the finding into the revised detox discharge workflow. The process will require completion and documentation of the applicable aftercare plan as part of the discharge process before the record is closed.
By 12/15/26, the Director of Clinical Services and Director of Nursing will review the requirement for aftercare planning in detox client records and reinforce the discharge workflow with applicable staff. Aftercare-plan completion will be added to the daily leadership Flash for applicable detox discharges so outstanding items can be identified and addressed before the record is closed. Clinical and Nursing leadership will ensure that the required aftercare plan is completed and maintained in the client record for each applicable discharge.
Clinical/Nursing leadership will audit 30 closed detox-only records each month, or all applicable records if fewer than 30 are available, with a compliance goal of 100% aftercare-plan completion. Monitoring will continue on an ongoing monthly basis to support sustained compliance. Results will be reported monthly through the Committee of the Whole and quarterly to the Governing Board. If compliance falls below 100%, identified deficiencies will be addressed through documented corrective follow-up and continued monitoring until compliance is re-established.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include follow-up information completed within 7 days of discharge, per facility policy, in one out of two applicable client records reviewed. Client #6 was admitted to the Detox level of care on May 13, 2026, and was discharged on May 19, 2026. There was no documentation of a follow-up being completed in the client record at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The cited detox client was discharged on 05/19/26. The Director of Business Development will review the cited record and incorporate the finding into the revised post-discharge follow-up process. The updated process will include defined call assignments, backup coverage, and documentation expectations to support completion of follow-up within the timeframe established by facility policy.
By 11/30/26, the Director of Business Development will implement a standardized post-discharge follow-up protocol for detox clients. The process will identify primary and backup call assignments so follow-up responsibilities remain covered during absences, scheduled time off, and other staffing changes. Applicable staff will be educated on the expectation that follow-up is completed and documented in the client record within the timeframe established by facility policy.
The Director of Business Development will audit 30 closed detox records each month, or all applicable records if fewer than 30 are available, for 60 consecutive days with a goal of 100% timely follow-up documentation.
Results will be reported monthly to the Committee of the Whole and quarterly to the Governing Board until the compliance goal is met.
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709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include progress notes completed within 24 hours, per facility policy, in three out of seven records reviewed. Client #9 was admitted to the residential level of care on August 10, 2026, and was still active at the time of inspection. The record contained progress notes for group sessions occurring on August 13, 2026, August 20, 2026, August 30, 2026, September 11, 2026, September 14, 2026, and September 20, 2026, that were not documented until September 7, 2026, September 14, 2026, September 17, 2026, September 19, 2026, and September 23, 2026, respectively.Client #10 was admitted to the residential level of care on August 27, 2026, and was still active at the time of inspection. The record contained progress notes for group sessions occurring on September 11, 2026, and September 15, 2026, that were not documented until September 19, 2026, and September 20, 2026, respectively.Client #14 was admitted to the residential level of care on August 23, 2026, and was discharged on September 22, 2026. The record contained progress notes for group sessions occurring on August 30, 2026, September 11, 2026, and September 14, 2026, that were not documented until September 7, 2026, September 17, 2026, September 19, 2026, and September 23, 2026, respectively.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
DDAP identified untimely progress-note documentation in three residential records. Clients #9 and #10 were active at the time of inspection, and Client #14 was discharged on 09/22/26. The Director of Clinical Services will review the cited records to confirm required documentation is present and will use the findings to reinforce the 24-hour documentation requirement through daily Clinical Flash review, supervisory follow-up, and ongoing auditing.
By 12/15/26, the Director of Clinical Services will review the facility requirement for completion of residential progress notes within 24 hours with all applicable clinical staff. Required progress-note completion will be reviewed during the daily Clinical Flash so overdue documentation can be identified and addressed promptly. Clinical leadership will provide focused follow-up with staff when late or missing notes are identified and will reinforce both timeliness and documentation expectations.
The Director of Clinical Services will audit 30 residential client records each month, or all applicable records if fewer than 30 are available, with a compliance goal of 100% completion of required progress notes within the facility's 24-hour timeframe. Monitoring will continue on an ongoing monthly basis to support sustained compliance. Results will be reviewed monthly through the Committee of the Whole and reported quarterly to the Governing Board. If compliance falls below 100%, Clinical Leadership will initiate documented corrective follow-up with responsible staff and continue monitoring until compliance is re-established.
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709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include an aftercare plan completed at discharge, per facility policy, in three out of four applicable records reviewed. Client #11 was admitted to the residential level of care on June 10, 2026, and was discharged from the facility on June 13, 2026. There was no aftercare plan documented in the client record. Client #12 was admitted to the residential level of care on May 31, 2026, and was discharged from the facility on June 4, 2026. There was no aftercare plan documented in the client record. Client #13 was admitted to the residential level of care on May 14, 2026, and was discharged from the facility on June 12, 2026. There was no aftercare plan documented in the client record.This is a repeat citation from the September 25, 2025, on-site complaint investigation. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #11, #12, and #13 identified in the finding were discharged prior to the inspection. The Director of Clinical Services and Director of Nursing will review the cited records and incorporate the findings into the revised residential discharge workflow. The process will require completion and documentation of applicable aftercare plans at discharge before the record is closed.
By 12/15/26, the Director of Clinical Services and Director of Nursing will reinforce the residential discharge workflow to ensure required aftercare plans are completed and maintained in the client record for each applicable discharge. Aftercare-plan completion will be added to the daily leadership Flash for residential discharges so missing or incomplete plans can be identified and resolved before the record is closed. Applicable staff will be re-educated on the requirement and their role in the process.
Clinical/Nursing leadership will audit 30 closed residential records each month, or all applicable records if fewer than 30 are available, with a compliance goal of 100% aftercare-plan completion. Monitoring will continue on an ongoing monthly basis to support sustained compliance. Results will be reported monthly through the Committee of the Whole and quarterly to the Governing Board. If compliance falls below 100%, identified deficiencies will be addressed through documented corrective follow-up and monitoring will continue until compliance is re-established.
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709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include a discharge summary completed within 24 hours of discharge, per facility policy, in three out of four applicable records reviewed. Client #11 was admitted to the residential level of care on June 10, 2026, and was discharged from the facility on June 13, 2026. There was no discharge summary documented in the client record. Client #12 was admitted to the residential level of care on May 31, 2026, and was discharged from the facility on June 4, 2026. There was no discharge summary documented in the client record.Client #13 was admitted to the residential level of care on May 14, 2026, and was discharged from the facility on June 12, 2026. There was no discharge summary documented in the client record.This is a repeat citation from the September 10, 2025, annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #11, #12, and #13 identified in the finding were discharged prior to the inspection. The Director of Clinical Services and Director of Nursing will review the cited records and incorporate the findings into the revised residential discharge workflow. The process will require discharge summaries to be completed within 24 hours of discharge and maintained in the client record.
By 12/15/26, the Director of Clinical Services and Director of Nursing will review the residential discharge process and reinforce the facility requirement that discharge summaries be completed within 24 hours of discharge. Residential discharges will be reviewed during the daily leadership Flash until required discharge documentation is confirmed complete. Leadership will identify responsibility for completion at the time of discharge and address missed or overdue summaries with the responsible staff.
Clinical/Nursing leadership will audit 30 closed residential records each month, or all applicable records if fewer than 30 are available, with a compliance goal of 100% completion of discharge summaries within 24 hours. Monitoring will continue on an ongoing monthly basis to support sustained compliance. Results will be reported monthly through the Committee of the Whole and quarterly to the Governing Board. If compliance falls below 100%, identified deficiencies will be addressed through documented corrective follow-up and monitoring will continue until compliance is re-established.
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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 on an individual, which is to include a follow-up documented within one week of discharge, per facility policy, in two out of three applicable records reviewed. Client #12 was admitted to the residential level of care on May 31, 2026, and was discharged from the facility on June 4, 2026. There was no follow-up documented in the client record.Client #13 was admitted to the residential level of care on May 14, 2026, and was discharged from the facility on June 12, 2026. There was no follow-up documented in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #12 and #13 identified in the finding were discharged prior to the inspection. The Director of Business Development will review the cited records and incorporate the findings into the revised post-discharge follow-up process. The updated process will include defined call assignments, backup coverage, and documentation expectations to support completion of follow-up within one week of discharge.
By 11/30/26, the Director of Business Development will implement a standardized post-discharge follow-up protocol for residential clients. The protocol will identify primary and backup call assignments to maintain coverage during absences and staffing changes and will establish a clear process for documenting the follow-up attempt and outcome in the client record within one week of discharge, consistent with facility policy.
The Director of Business Development will audit 30 closed residential records each month, or all applicable records if fewer than 30 are available, for 60 consecutive days with a goal of 100% timely follow-up documentation.
. Results will be reported monthly to the Committee of the Whole and quarterly to the Governing Board until the compliance goal is met.
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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 facility records, the facility failed to comply with a plan of correction that was approved by the Department. A plan of correction for documenting a written individual training plan for each employee was submitted and approved by the Department for the August 28, 2024, and September 10, 2025, annual licensing inspections. Documenting a written individual training plan for each employee was again found to be a deficiency in the September 24, 2026, licensing inspection. These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The individual training plans identified under L0063 were completed after their required due dates. The Project Director and Human Resources will review the cited personnel files to verify that the required plans are present and complete. The facility will address the repeated deficiency through Department Head accountability, centralized Human Resources tracking, and shared Project Director, Human Resources, and Quality oversight of the 2026 Plan of Correction.
By 12/15/26, the Project Director will oversee a comprehensive review of the facility's processes related to previously approved Plans of Correction, with specific attention to the repeated deficiency involving individual training plans. The Project Director and facility leadership team will review current policies, procedures, and operational practices to identify gaps that contributed to recurrence of the finding and will reinforce accountability for completion of required corrective actions. This review will include clarification of Department Head responsibilities, strengthening Human Resources tracking and notification processes, reinforcement of documentation requirements, and implementation of ongoing Quality oversight to ensure corrective actions are completed and sustained. Facility leadership will continue to monitor compliance through routine internal review, Committee of the Whole reporting, and Governing Board oversight to support sustained regulatory compliance and prevent recurrence of previously cited deficiencies. DDAP Licensing POC 2025 DDAP Licensing POC 2025
The Project Director, Human Resources, and QRD will provide shared oversight of implementation and ongoing compliance with the 2026 Plan of Correction. Responsible Department Heads will remain accountable for completing corrective actions within their respective areas and providing supporting documentation. Human Resources will oversee workforce-related requirements and documentation, QRD will provide regulatory and quality oversight, and the Project Director will maintain overall operational accountability for completion of the Plan of Correction. Corrective-action status and compliance concerns will be reviewed monthly through the Committee of the Whole, with overall progress reported quarterly to the Governing Board. Enhanced oversight will remain in place until sustained compliance is demonstrated and the Governing Board determines that additional monitoring may be reduced or discontinued.
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