INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 12, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia DRC Inc. 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(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to document that upon employment the facility director had at least two years of experience in a human service agency, preferably in a drug and alcohol setting and includes supervision of others, direct service and program planning in one of one applicable personnel record reviewed.
Employee #2 was hired as facility director on April 1, 2025. At the time of the inspection, there was no resume documented in the personnel record; therefore, the Licensing Representative was unable to review and verify if the facility director had the required supervision of others, direct service, and program planning experience prior to hiring.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective action taken:
The Facility Director's resume that was current during the inspection already documented four to five years of approved supervision of staff, direct service, and program planning experience in a drug and alcohol setting. This resume has been updated to clearly state the Facility Director's hire date as Facility Director (4/1/2025) and has been placed in the personnel file to verify compliance with the experience requirement. The resume was completed on 12/11/2025.
Systemic change to prevent recurrence:
Going forward, Facility Director will ensure that, prior to the end of each employee's introductory period/change of position period, the personnel file contains a current resume that documents required experience for their position, including hire date into that role and new role title and responsibilities.
In addition, the facility will prevent recurrence by HR Generalist requiring a completed personnel-file checklist (including current resume and verification of two years of relevant experience) for all required leadership positions at hire and also an updated resume within 7 days of any staff being promoted into a new position. The updated resume will be uploaded by HR Generalist into employees personal file The Facility Director and HR designee will review all personnel files quarterly for compliance, document the review in a personnel file audit log, and report any deficiencies and corrective actions in monthly HR Leadership meeting minutes which will be expected to be corrected by employee responsible within 30 days of notification by next HR Leadership meeting.
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure clinical supervisors who have not functioned for two years as a supervisor in the provision of clinical services, completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel record reviewed.
Employee # 3 was hired as clinical supervisor on April 28, 2025 and did not have two years of clinical supervision experience prior to being hired. At the time of the inspection, there was no documentation in the personnel record indicating a clinical supervision core curriculum training was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective action taken:
Employee #3, Clinical Supervisor has been enrolled in a DDAP approved Clinical Supervisor training. Due to high cost of training, training will be paid for through Gaudenzia DRC credit card. Employee #3 will complete the Clinical Supervisor training on 1/8/2025 through Relias Academy and the training certificate will be placed in the personnel file to verify compliance with the requirement. This will be completed by 1/8/26.
Systemic change to prevent recurrence:
Going forward, the Facility Director will ensure that any staff hired or promoted into a Clinical Supervisor role either have at least two years of documented supervisory experience in the behavioral health field or are enrolled in a DDAP approved core clinical supervisor curriculum with a documented completion date. Documentation of required experience or enrollment and completion date will be maintained in the personnel file and verified during the introductory/change of position period.
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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 ensure a written individual training plan, with input from both the employee and the supervisor, was completed annually in one of five personnel records reviewed.
Employee #2 was hired as the facility director on April 1, 2025. There was no individual training plan for the current training year documented in the record at the time of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective action taken:
By 12/30/2025, the Regional Director and Facility Director will have signed an individual training plan for Employee #2 (Facility Director) for the current training year. The completed plan will be placed in Employee #2's personnel file.
Systemic change to prevent recurrence:
Beginning 12/30/2025, the Regional Director will ensure that an individual training plan is completed, signed, and filed annually for the Facility Director at the start of each training year, in alignment with the July 1?June 30 training cycle. The Regional Director will also verify during quarterly personnel file reviews that the Facility Director's current training plan is present and up to date.
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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 personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in seven of seven applicable personnel records reviewed.
Employee # 4 was hired as a counselor on July 29, 2024 and was due to have the HIV/AIDS training and the TB/STD training completed no later than July 29, 2025. Both the HIV/AIDS training and the TB/STD training were not completed as of the date of the inspection.
Employee # 5 was hired as a counselor on September 23, 2024 and was due to have the HIV/AIDS training and the TB/STD training completed no later than September 23, 2025. The HIV/AIDS training was not completed until November 5, 2025 and the TB/STD training was not completed as of the date of the inspection.
Employee # 6 was hired as a residential aide on October 10, 2022 and was due to have the HIV/AIDS training and the TB/STD training completed no later than October 10, 2024. Both the HIV/AIDS training and the TB/STD training were not completed as of the date of the inspection.
Employee # 7 was hired as a residential aide on May 9, 2022 and was due to have the HIV/AIDS training and the TB/STD training completed no later than May 9, 2024. Both the HIV/AIDS training and the TB/STD training were not completed as of the date of the inspection.
Employee # 8 was hired as a residential aide on February 27, 2023 and was due to have the HIV/AIDS training and TB/STD training completed no later than February 27, 2025. Both the HIV/AIDS training and the TB/STD training were not completed as of the date of the inspection.
Employee # 9 was hired as a residential aide on February 28, 2022 and was due to have the HIV/AIDS training and the TB/STD training completed no later than February 28, 2024. Both the HIV/AIDS training and the TB/STD training were not completed as of the date of the inspection.
Employee # 10 was hired as a residential aide on November 6, 2023 and was due to have the HIV/AIDS training and the TB/STD training completed no later than November 6, 2025. Both the HIV/AIDS training and the TB/STD training were not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
Beginning 12/15/2025, the Operations Director and the Facility Director will collaborate with Gaudenzia's Training department to ensure Employees #4?#10 complete the required HIV/AIDS and TB/STD trainings in Relias by 1/14/2026. The Operations Director will be the primary staff responsible for tracking completion and filing training documentation into each Residential Aid's personnel file.
Systemic change moving forward:
The Operations Director who oversees Residential Aids will verify training completion and file documentation by 1/14/2026 for Employees #4?#10. Quarterly personnel file audits of residential aids personnel files will confirm ongoing compliance and timely tracking of mandatory trainings. The Operations Director will email Gaudenzia's Training Department when needed for scheduling of facility wide trainings in which she will preschedule and notify all employees needed of training dates and times. Facility Director will complete quarterly audit of all Residential Aid files who report to inpatient Facility.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguishers upon staff employment in one of one applicable personnel record reviewed.
Employee # 3 was hired as clinical supervisor on April 28, 2025. At the time of the inspection, there was no fire extinguisher training documentation in the personnel record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3 (Clinical Supervisor), hired 4/28/2025, will complete the use of fire extinguishers training by 12/30/25 in relias and will be off schedule until this training is completed with verified documented training certificate which will be immediately placed in Employee #3's personnel record.
Clinical Supervisor will also continue to search for signed safety day training from her 40 hours of orientation training from orientation week as safety training including fire safety was completed in first week of hire as a part of 40 hour orientation. HR Administrative Coordinator will also search for signed orientation fire safety training from orientation. Upon finding this form it will be filed in personnel file.
Beginning 12/15/2025, the Facility Director will ensure that all staff receive instruction in the use of fire extinguishers and that documentation of this training is maintained in each personnel record. All new hires will complete fire extinguisher training within orientation week upon hire and signed orientation hours signifying the completion of all aspects of the 40 hours training week will be uploaded to personnel file at the end of orientation week by HR administrative coordinator. Facility Director will conduct quarterly personnel file audits to verify that required safety trainings are completed and documented and will verify with HR administrative coordinator that all signed and completed orientation hours are uploaded into new employees personnel file by the Monday after orientation week.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's October 2024 through October 2025 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
The facility did not provide documentation indicating that fire drills were conducted during the months of October 2024, November 2024, December 2024, July 2025, and October 2025.
This finding was reviewed with the facility during the licensing process.
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Plan of Correction
Corrective Action:
Beginning 12/12/2025, the Operations Director will ensure that unannounced fire drills are conducted and documented at least once per month for the facility and facility director will scan in each completed fire drill sheet and save to shared file which compliance, operations director, and facility director will have easy access to. The Operations Director and The Facility Director will review the fire drill log by the 21st of each month to verify completion and to make sure there are no missed months. Also Clinical Director will have compliance team check all folders before submitting to DDAP for review moving forward because the missing fire logs were completed but the missing months in folder submitted were only missing from the scanned and submitted folder accidentally but not from the physical logs.
Systemic change moving forward to ensure no reoccurrence.
On 12/12/2025, the Facility Director developed a standardized fire drill log shared drive so that completion dates and completed drill documentation can be easily seen in shared drive by Facility Director and Operations Director. for the period November 2025 through November 2026. Fire drills for November 2025 and December 2025 will be completed and documented by 12/31/2025 to re-establish compliance. The Operations Director and The Facility Director will review the fire drill log on by the 21st of each month to verify completion and to make sure there are no missed months uploaded in shared folder or a fire drill not completed for the month. Facility Director will use shared drive to abstract files for inspection and will have the files double checked by compliance officer before submitting.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel, on all shifts, were trained to perform assigned tasks during emergencies in one of one applicable personnel record reviewed.
Employee # 3 was hired as a clinical supervisor on April 28, 2025. At the time of the inspection, there was no emergency preparedness training documented in the personnel record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3 (Clinical Supervisor), hired 4/28/2025, will complete emergency preparedness training by 12/30/25 in relias and will be off schedule until this training is completed with verified documented training certificate which will be immediately placed in Employee #3's personnel record.
Clinical Supervisor will also continue to search for signed safety day training from her 40 hours of orientation training from orientation week as safety training including emergency preparedness was completed in first week of hire as a part of 40 hour orientation. HR Administrative Coordinator will also search for signed orientation fire safety training from orientation. Upon finding this form it will be filed in personnel file.
Beginning 12/15/2025, the Facility Director will follow at the end of orientation week to ensure that all staff oriented have completed and signed all orientation training requirements. HR administrative coordinator will upload all new staffs 40 hour orientation week completion confirmations in their personnel files at end of orientation week. Facility director will check to see make sure that all orientation hour signed confirmations of completion have been uploaded by HR administrative assistant by the Monday after orientation for all new employees.
Facility Director will conduct quarterly personnel file audits to verify that required safety trainings are completed and documented and will verify with HR administrative coordinator that all signed and confirmation of completed hours are uploaded into new employee's personnel files
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable record reviewed.
The facility policy stated emergency contacts would be called within twelve hours of a client leaving treatment against staff advice.
Client # 6 was admitted on February 25, 2025 and was discharged against staff advice on March 8, 2025. There was no documentation in the record indicating the client's emergency contact was contacted within twelve hours of the client leaving treatment against staff advice.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
Beginning 12/15/2025, the Intake Specialist will maintain an Excel spreadsheet logging all attempts to notify emergency contacts within 12 hours for any client who leaves AMA. The Clinical Supervisor and the Facility Director will have shared access to this spreadsheet for oversight and verification.
Systemic Change moving forward:
On 12/15/2025, intake specialist will be training on how to utilize emergency contact follow up spreadsheet and also on will be retrained on the emergency contact notification policy and will sign inhouse training log for record or inhouse training.
The Intake Specialist will continue as the staff responsible for calling and logging notifications and outcomes in the shared Excel spreadsheet. The Clinical Supervisor will review the log daily and the Facility Director will review it weekly; monthly client file audits will verify timely outreach and documentation. |
709.26 (b) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(1) Application or resume for employment.
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Observations
Based on a review of personnel records, the facility failed to ensure an application or resume for employment was included in personnel records in one of two applicable personnel records reviewed.
Employee #2 was hired as facility director on April 1, 2025. As of the date of the inspection, there was no resume documented in the record reflecting the employee's promotion from clinical supervisor to facility director.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
As of 12/12/25, The Facility Director has updated and submitted an up-to-date resume documenting required experience, the promotion from Clinical Supervisor to Facility Director, and the Facility Director hire date of 4/1/2025. This resume was placed in Employee #2's personnel record.
Beginning 12/15/2025, the Facility Director will ensure that each personnel file contains a current resume or application documenting required qualifications, hire date, position, and any subsequent promotions or changes in role. For any promotion or position change, an updated resume or application will be obtained and filed before the end of the employee's introductory period in the new role. Quarterly personnel file audits will be conducted by the Facility Director to verify that resumes/applications are present and current for all employees, and any missing or outdated documents will be corrected immediately.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure the completion of annual written individual staff performance evaluations, which shall be reviewed and signed by the employee, in two of two applicable personnel records reviewed.
Employee # 4 was hired as a counselor on July 29, 2024. There was no individual performance evaluation, for the previous year, documented in the record as of the date of the inspection.
Employee # 5 was hired as a counselor on September 23, 2024. There was no individual performance evaluation, for the previous year, documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
Facility Director completed annual individual staff performance evaluations for employee#4 and employee#5 for the July 1, 2024 ? June 30, 2025 performance year. Employee #4 (hired 7/29/2024) and Employee #5 (hired 9/23/2024) had missing evaluations; those evaluations were completed. Employees #4 and #5 are being given time to review, comment, and sign by 12/16/2025. These evaluation will be finalized and saved in APD.
Systemic Change moving forward:
The Facility Director will maintain the an annual evaluation spreadsheet to document completion dates, evaluator names, and file locations. New hires will receive their first performance evaluation within their introductory period, and all evaluations will be verified during quarterly personnel file audits. Any missing evaluations identified during audits will be completed within 30 days of discovery.
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, the facility failed to secure hard copy client records within locked storage containers.
At the time of the inspection, there were several piles of client-identifying documents stacked on a windowsill in the director's office, which was located on the second floor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
On 11/20/2025, The Regional Director removed all client records from the windowsill in the second-floor Regional Director's office and secured them in locked filing cabinets in the designated records areas. All Staff were reminded that hard copy client records and any client-identifying documents must be stored in secured, designated record areas when not in active use.
Systematic Change moving forward:
Beginning 12/12/2025, the Regional Director, the Compliance Officer, and the Facility Director will ensure that all hard copy client records are maintained in locked cabinets or secure record storage areas when not being reviewed. Client-identifying documents will not be stored on windowsills, desks, or other unsecured surfaces. A daily end-of-shift walk-through will be completed by management staff to verify that no client records are left unsecured in offices or common areas, and any variances will be corrected immediately.
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709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a record keeping system that allowed for the identification of clients' admissions and discharges within a specific time period.
The list of active and discharged clients for the facility from the previous annual licensing inspection to present was requested by the Licensing Representative at 9:15 a.m. The facility was unable to provide the full client list in a timely fashion as the list was not completed and provided until 10:55 a.m.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
On 11/11/2025, Facility Director expressed the need for IT representative to be available at all times during inspections incase of any technical issues to ensure that inspection staff does not have any delays due to technical issues. Compliance Officer reviewed DDAP inspection preparation requirements with Facility Director for files needed to be ready before before the date of inspection and files and also re-reviewed various places to find all of the documentation to prevent late submission or not having documents prepared before the day of inspection.
Beginning 12/12/2025 the Facility Director will coordinate with the agency's IT staff to ensure an IT representative is available during licensing inspections to address any technical issues that may impact access to electronic records or printing. Backup computers and laptops will be available, and staff will be paired so that a second designated staff member can generate and print requested reports if one workstation experiences technical problems. This process will ensure that technical errors do not delay the timely provision of client admission and discharge lists or other documentation requested by licensing staff. And also to prevent any documents from needing to be printed on the day of that have already been requesting Facility Directory will have all requested documents ready and in folders before the day of inspection.
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709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of case consultation notes, in three of three applicable records reviewed.
The facility ' s policy and procedure manual stated that case consultation notes are to occur every 30 days.
Client # 3 was admitted on October 8, 2025 and was active at the time of inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 5 was admitted on December 19, 2025 and was discharged on January 21, 2025. There were no case consultation notes documented in the record at the time of the inspection.
Client # 7 was admitted on February 26, 2025 and was discharged on April 4, 2025. There were no case consultation notes documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
On 12/16/2025, the Facility Director & Clinical Supervisor will do inhouse review with clinical staff on the agency's & DDAPs case consultation policy to clarify the requirement that case consultation notes be completed and documented at least every 30 days for all active clients. The Facility Director and Clinical Supervisor also review deficiencies of documented case consultation from inspection with staff on 12/16/2025 to discuss expectations and notify of documented supervision and accountability that will occur if staff do not follow required timeline for case consultations to be completed.
Systemic Change:
Beginning 12/16/2025, the Facility Director and Clinical Supervisor will ensure that case consultation notes are completed and documented at least every 30 days for all active clients in accordance with agency policy. A case consultation log will be maintained that lists each active client and the date of the most recent case consultation. The Clinical Supervisor will review this log weekly to verify timely completion and documentation of case consultations. The Facility Director will review the log and a sample of client records monthly during routine audits to verify that case consultation notes are being completed going forward. Any missing or overdue consultations identified moving forward will be completed within 7 days of audit.
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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, which is to include the documentation of an aftercare plan when applicable in one of three applicable records reviewed.
Client # 5 was admitted on December 19, 2024 and was discharged on January 21, 2025. There was no aftercare plan documented in the 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
Corrective Action:
On 12/16/2025, the Facility Director and Clinical Supervisor will review the agency's discharge and aftercare planning policy with clinical staff, emphasizing that an aftercare plan must be initiated and documented in the client record at least 72 hours prior to a planned discharge and finalized on the day of discharge to prevent last minute discharge plan completion and to prevent missing completion of a discharge plan. The role of the primary counselor is completing and finalizing the aftercare plan, and the role of the Clinical Supervisor is reviewing the record to confirm that the aftercare plan is present and complete prior to discharge.
Systematic Change moving forward:
Beginning 12/17/2025, the primary counselor for each client will be responsible to initiate the aftercare plan and document it in the client record at least 72 hours before the planned discharge date, and to finalize and upload the completed aftercare plan on the day of discharge. The Clinical Supervisor will review discharge lists and associated client records to verify that an aftercare plan is present, completed, and filed in the record prior to discharge. The Facility Director will review a sample of discharged client records monthly during routine audits to confirm that aftercare plans are consistently initiated in advance and completed on the day of discharge. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in two of four applicable records reviewed.
Client # 5 was admitted on December 19, 2024 and was discharged on January 21, 2025. There was no follow-up information documented in the record as of the date of the inspection.
Client # 6 was admitted on February 25, 2025 and was discharged on March 8, 2025. There was no follow-up information documented in the client record as of the date of the inspection.
This is a repeat citation from the October 22, 2024, September 18, 2023, December 9, 2022, and December 14, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
On 12/16/2025, the Facility Director and clinical supervisor will review the facility's follow up documentation policy with the Intake Specialist to ensure intake specialist signs a written understand that the follow up notes for discharged clients must be completed and filed in the client record within seven (7) days of discharge. The Intake Specialist will reach out to follow up to complete outstanding follow up notes for Client #5 (admitted 12/19/2024, discharged 1/21/2025) and Client #6 (admitted 2/25/2025, discharged 3/8/2025) all by 12/19/2025.
Systematic Change moving forward:
Beginning 12/16/2025, the Intake Specialist will continue to be responsible to complete and document a follow up note in the client record within seven (7) days following any client discharge. The Clinical Supervisor will review the discharge list and associated client records weekly to verify follow up notes are completed within seven days. The Facility Director will audit a sample of discharged client records monthly to confirm ongoing compliance. Any missing follow up notes identified moving forward will be completed and documented within 7 days of discovery.
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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 client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for not documenting follow-up information in the client record was submitted and approved by the Department for the December 14, 2021, December 9, 2022, September 18, 2023, and October 22, 2024 annual licensing inspections. Not documenting follow-up information in the client record was again found to be a deficiency in the November 12, 2025 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To prevent recurrence of deficiencies through following all plans of correction, the facility is standardizing communication and task tracking across all disciplines. Rather than relying on old complex or scattered communications which can become overwhelming or get lost in a vacuum of communications, the Regional Director and management team, including the Facility Director, are finalizing role discipline specific flow sheets for each discipline for implementation in 2026. Each staff member will be responsible for maintaining the responsibilities of their own standardized flow sheet so that duties, timelines, and follow up steps are clearly outlined, easily tracked, and not lost in scattered or informal communication or only in supervisions. Simplified, discipline specific flow sheets and tracking have already demonstrated improved consistency when used, and this standardized approach is intended to support clear communication, reinforce expectations, and prevent future deficiencies and reoccurrences through following plans of corrections accurately.
Management has been meeting with regional director for the past few weeks to make sure flowsheets are simplified, accurate, practical, comprehensible, and that the goals are obtainable within reason. Any necessary adjustments reported and made expediently to make sure all operations flow within compliance and that duties are carried out.
Role specific duties are being taught to other employees within union boundaries and within reason of responsibility load with union employees and within reason of responsibility load of non union employees so that if a person responsible for a certain task including Program Director is out on vacation there will be consistent coverage by a staff who can complete the tasks in a compliant and will informed manor.
Regional Director and Facility Director will review flow sheets with staff from all disciplines to ensure that they understand the flow, responsibilities, and timeliness by 1/6/26.
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