INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 23, 2026 through September 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, Promont Recovery LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ensure bathrooms were ventilated by an exhaust fan or a window.
At the time of the inspection, conducted on September 24, 2026, the exhaust fan in the bathroom near the yoga room was not operable and there was no window in the bathroom.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
**Plan of Correction ? 705.24(5): Bathroom Ventilation**
The Director of Operations will coordinate the repair or replacement of the nonoperational exhaust fan in the bathroom near the yoga room to ensure proper ventilation. Upon completion, the Operations Manager will verify that the exhaust fan is functioning properly.
To maintain compliance, the Director of Compliance will incorporate verification of bathroom exhaust fan functionality into routine facility environmental inspections. Any identified deficiencies will be reported and addressed promptly. The Clinical Director will provide oversight to ensure continued compliance.
**Date of Full Compliance:** November 28, 2026. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's October 2025 through July 2026 fire drill logs, the facility failed to ensure the preparation of alternate exit routes to be used during fire drills.
At the time of the inspection, every monthly fire drill conducted during the reviewed period indicated the front door was used as the exit route. There was no other documentation indicating an alternate exit route was prepared to be used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
**Plan of Correction ? Fire Drills: Alternate Exit Routes**
The Director of Compliance will review and update the facility's fire drill procedures to ensure alternate exit routes are identified and incorporated into monthly fire drills. Staff will be educated on the designated primary and alternate evacuation routes and the requirement to vary exit routes during fire drills.
To maintain compliance, the Clinical Director will ensure alternate exit routes are utilized during fire drills and documented on the monthly fire drill logs. The Clinical Director will review fire drill documentation monthly to verify compliance and address any identified deficiencies.
**Date of Full Compliance:** November 28, 2026. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's October 2025 through July 2026 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day, and on different staffing shifts.
At the time of the inspection, every fire drill log completed during the reviewed period indicated each fire drill was conducted on a Monday at 10:00 a.m.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will implement a fire drill schedule that ensures monthly fire drills are conducted on varying days of the week, at different times of the day, and across applicable staffing shifts. Staff will be educated on the updated fire drill procedures and documentation requirements.
To maintain compliance, the Clinical Director will ensure each fire drill is documented accurately, including the date, time, and participating staff. The Director of Compliance will review fire drill logs monthly to verify appropriate variation in scheduling and address any identified deficiencies.
Date of Full Compliance: November 28, 2026. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in two of fourteen client records reviewed.
Client # 1 was admitted to the partial hospitalization activity December 29, 2025 and was discharged on February 23, 2026. There was documentation of laboratory results dated February 11, 2026; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure of information.
Client #2 was admitted to the partial hospitalization activity February 2, 2026 and was discharged on February 13, 2026. There was evidence of disclosures to the funding source during the client ' s treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures of information.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will review the facility's release of information procedures and provide staff training on obtaining and documenting informed, voluntary, and properly executed consent prior to disclosing client information, including disclosures to laboratories and funding sources, unless otherwise permitted by applicable law.
To maintain compliance, the Clinical Director will conduct monthly chart audits to verify that required consents are completed and documented prior to disclosures. Any identified deficiencies will be addressed through immediate corrective action and staff reeducation as necessary. The Director of Compliance will provide oversight through monthly reviews of audit findings to ensure ongoing compliance.
Date of Full Compliance: November 28, 2026. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event or condition upon which the consent will expire on consent to release information forms in five of fourteen client records reviewed.
Client # 3 was admitted to the partial hospitalization activity on February 10, 2026 and was discharged on February 20, 2026. There was a release of information form to a referral source signed by the client on February 10, 2026, but the release form did not include documentation of the date, event or condition upon which the consent would expire.
Client # 4 was admitted to the partial hospitalization activity on February 25, 2026 and was discharged on April 30, 2026. There was a release of information form to an emergency contact signed by the client on February 25, 2026, but the release form did not include documentation of the date, event or condition upon which the consent would expire.
Client # 5 was admitted to the partial hospitalization activity on February 26, 2026 and was discharged on March 20, 2026. There were release of information forms to a referral source, emergency contact, and partner signed by the client on February 26, 2026, but the release forms did not include documentation of the date, event or condition upon which the consents would expire.
Client # 6 was admitted to the partial hospitalization activity on March 17, 2026 and was discharged on April 18, 2026. There was a release of information form to a recovery house signed by the client on March 17, 2026, but the release form did not include documentation of the date, event or condition upon which the consent would expire.
Client # 12 was admitted to the outpatient activity on April 18, 2026 and was discharged on May 29, 2026. There was a release of information form to a recovery house signed by the client on March 17, 2026, but the release form did not include documentation of the date, event or condition upon which the consent would expire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will review and update the facility's consent to release information forms to ensure a date, event, or condition upon which the consent will expire is required. Staff will be trained on the updated forms and the requirement to complete all applicable fields prior to obtaining client signatures and disclosing information.
To maintain compliance, the Clinical Director will conduct monthly chart audits to verify that release of information forms are completed accurately, including the required expiration date, event, or condition. Any identified deficiencies will be addressed through corrective action and staff reeducation as necessary. The Director of Compliance will provide oversight through monthly reviews of audit findings to ensure ongoing compliance.
Date of Full Compliance: November 28, 2026. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent to release information form was offered to the client in thirteen of thirteen applicable client records reviewed.
In each applicable record reviewed, there was a release of information form to the funding source; however, there was no documentation in the record indicating if a copy of the release forms were offered to the client.
This is a repeat citation from the September 12, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will update the facility's consent to release information forms to include a required acknowledgment documenting that the client was offered a copy of the signed consent. Staff will be trained on the updated forms and the requirement to offer clients a copy of each completed consent, including releases to funding sources, and document the offer regardless of whether the client accepts or declines.
To maintain compliance, the Clinical Director will conduct monthly chart audits to verify that the offer of a copy is documented on all applicable consent forms. Any identified deficiencies will be addressed immediately through corrective action and staff reeducation. Due to this being a repeat citation, the Director of Compliance will review audit findings monthly to verify sustained compliance.
Date of Full Compliance: November 28, 2026. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgment by clients that they have been notified of their rights in fourteen of fourteen client records reviewed.
In every client record reviewed, there was a client rights acknowledgement form, signed by each client; however, all the regulatory-required client rights were not included on the acknowledgement form and there was no other documentation in the record indicating the client rights were presented to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance will review and update the facility's Client Rights Acknowledgment form to ensure all rights required by applicable DDAP regulations are included. The Clinical Director will train staff on the updated form and the requirement to review all client rights with each client and obtain a signed acknowledgment documenting receipt and notification of those rights.
To maintain compliance, the Clinical Director will conduct monthly chart audits to verify that the updated Client Rights Acknowledgment form is completed and signed by each client. Any identified deficiencies will be addressed through immediate corrective action and staff reeducation as necessary. The Director of Compliance will provide oversight through monthly reviews of audit findings to ensure ongoing compliance.
Date of Full Compliance: November 28, 2026. |
709.81(b)(1) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, the disclosure to the client of the criteria for admission, treatment, completion and discharge, in seven of seven applicable client records reviewed.
In each partial hospitalization client record reviewed, there was no documentation of the disclosure to the client of criteria for admission, treatment, completion and discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance will develop an acknowledgment form outlining the facility's criteria for admission, treatment, completion, and discharge for the partial hospitalization program. The Clinical Director will train staff on the requirement to review these criteria with each client during the intake and admission process and obtain a signed acknowledgment documenting the disclosure.
To maintain compliance, the Clinical Director will conduct monthly chart audits to verify that the acknowledgment is completed and documented in each applicable client record. Any identified deficiencies will be addressed through immediate corrective action and staff reeducation as necessary. The Director of Compliance will provide oversight through monthly reviews of audit findings to ensure ongoing compliance.
Date of Full Compliance: November 28, 2026. |
709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to document, as part of their intake and admission process, a preliminary treatment and rehabilitation plan in four of seven applicable client records reviewed.
The facility policy and procedure manual stated that the preliminary treatment plan will be completed within 3 days of admission.
Client # 1 was admitted to the partial hospitalization activity on December 29, 2025 and was discharged on February 23, 2026. The preliminary treatment plan was due to be completed by January 1, 2026; however, the plan was completed on January 5, 2026.
Client # 2 was admitted to the partial hospitalization activity on February 2, 2026 and was discharged on February 13, 2026. The preliminary treatment plan was due to be completed by February 5, 2026; however, the plan was not completed prior to discharge.
Client # 3 was admitted to the partial hospitalization activity on February 10, 2026 and was discharged on February 20, 2026. The preliminary treatment plan was due to be completed by February 13, 2026; however, the plan was completed on February 18, 2026.
Client # 4 was admitted to the partial hospitalization activity on February 25, 2026 and was discharged on April 30, 2026. The preliminary treatment plan was due to be completed by February 28, 2026; however, the plan was completed on March 3, 2026.
This is a repeat citation from the September 12, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance will update the facility's policy and procedures to require completion of the preliminary treatment and rehabilitation plan within five business days of admission, consistent with applicable regulatory requirements. The Clinical Director will train clinical staff on the updated timeframe and documentation requirements and implement a process to monitor treatment plan completion deadlines.
To maintain compliance, the Clinical Director will monitor treatment plan completion through supervisory follow-up and conduct monthly chart audits to verify that plans are completed within the required timeframe. Any identified deficiencies will be addressed through immediate corrective action and staff reeducation as necessary. Due to this being a repeat citation, the Director of Compliance will review audit findings monthly to ensure sustained compliance.
Date of Full Compliance: November 28, 2026. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every thirty days in one of three applicable client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on December 29, 2025 and was discharged on February 23, 2026. The individual treatment and rehabilitation plan was completed on January 6, 2026 and an update was due no later than February 6, 2026; however, the update was completed on February 13, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will provide training to clinical staff on the requirement to review and update treatment and rehabilitation plans at least every 30 days. The Clinical Director will implement a tracking process to monitor upcoming treatment plan review deadlines and ensure updates are completed within the required timeframe.
To maintain compliance, the Clinical Director will monitor treatment plan review deadlines through supervisory follow-up and conduct monthly chart audits to verify timely completion. Any identified deficiencies will be addressed through immediate corrective action and staff reeducation as necessary. The Director of Compliance will provide oversight through monthly reviews of audit findings to ensure ongoing compliance.
Date of Full Compliance: November 28, 2026. |
709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in three of seven applicable client records reviewed.
The facility policy and procedure manual stated that follow-up information is to be documented 7 days, 1 month, 2 months, 6 months, 1 year and 2 years after discharge.
Client # 2 was admitted to the partial hospitalization activity on February 2, 2026 and was discharged on February 13, 2026. At the time of the inspection, there was no follow-up information documented for one and two months after discharge.
Client # 3 was admitted to the partial hospitalization activity on February 10, 2026 and was discharged on February 20, 2026. At the time of the inspection, there was no follow-up information documented for one and two months after discharge.
Client # 4 was admitted to the partial hospitalization activity on February 25, 2026 and was discharged on April 30, 2026. There was no follow-up information documented in the client record at the time of the inspection.
This is a repeat citation from the September 11, 2024 and September 12, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance will revise the facility's discharge follow-up policy to establish a more manageable follow-up schedule, with outreach occurring at defined intervals closer to the client's discharge date. The Clinical Director will train applicable staff on the revised follow-up requirements, including documenting completed outreach attempts, client responses, and outcomes in the client record.
To maintain compliance, the Clinical Director will implement a tracking process to monitor required follow-up activities and conduct monthly chart audits to verify that follow-up documentation is completed in accordance with the revised policy. Any identified deficiencies will be addressed through corrective action and staff reeducation as necessary. Due to this being a repeat citation, the Director of Compliance will review audit findings monthly to ensure sustained compliance.
Date of Full Compliance: November 28, 2026. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, the disclosure to the client of the criteria for admission, treatment, completion and discharge, in seven of seven applicable client records reviewed.
In each outpatient client record reviewed, there was no documentation of the disclosure to the client of criteria for admission, treatment, completion and discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance will develop an acknowledgment form outlining the facility's criteria for admission, treatment, completion, and discharge for the outpatient program. The Clinical Director will train staff on the requirement to review these criteria with each client during the intake and admission process and obtain a signed acknowledgment documenting the disclosure.
To maintain compliance, the Clinical Director will conduct monthly chart audits to verify that the acknowledgment is completed and documented in each applicable client record. Any identified deficiencies will be addressed through immediate corrective action and staff reeducation as necessary. The Director of Compliance will provide oversight through monthly reviews of audit findings to ensure ongoing compliance.
Date of Full Compliance: November 28, 2026. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to document, as part of their intake and admission process, a preliminary treatment and rehabilitation plan in six of seven applicable client records reviewed.
The facility policy and procedure manual stated that the preliminary treatment plan will be completed within 3 days of admission.
Client # 8 was admitted to the outpatient activity on July 30, 2026 and was still active at the time of the inspection. The preliminary treatment plan was due to be completed by August 2, 2026; however, the plan was not completed as of the date of the inspection.
Client # 9 was admitted to the outpatient activity on August 3, 2026 and was still active at the time of the inspection. The preliminary treatment plan was due to be completed by August 6, 2026; however, the plan was not completed as of the date of the inspection.
Client # 10 was admitted to the outpatient on March 17, 2026 and was discharged on August 14, 2026. The preliminary treatment plan was due to be completed by March 20, 2026; however, the plan was completed on April 1, 2026.
Client # 11 was admitted to the outpatient activity on February 23, 2026 and was discharged on April 1, 2026. The preliminary treatment plan was due to be completed by February 26, 2026; however, the plan was not completed as of the date of the inspection.
Client # 12 was admitted to the outpatient activity on April 18, 2026 and was discharged on May 29, 2026. The preliminary treatment plan was due to be completed by April 21, 2026; however, the plan was not completed as of the date of the inspection.
Client # 13 was admitted to the outpatient activity on May 1, 2026 and was discharged on May 15, 2026. The preliminary treatment plan was due to be completed by May 4, 2026; however, the plan was not completed as of the date of the inspection.
This is a repeat citation from the September 12, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance will update the facility's policies and procedures to require completion of the preliminary treatment and rehabilitation plan within five business days of admission, consistent with applicable regulatory requirements. The Clinical Director will train clinical staff on the updated timeframe and documentation requirements and implement a process to monitor treatment plan completion deadlines.
To maintain compliance, the Clinical Director will monitor treatment plan completion through supervisory follow-up and conduct monthly chart audits to verify that plans are completed within the required timeframe. Any identified deficiencies will be addressed through immediate corrective action and staff reeducation as necessary. Due to this being a repeat citation, the Director of Compliance will review audit findings monthly to ensure sustained compliance.
Date of Full Compliance: November 28, 2026. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to ensure individual treatment and rehabilitation plans were developed with the client, per facility policy, in six of seven applicable client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within two weeks of admission.
Client # 8 was admitted to the outpatient activity on July 30, 2026 and was still active at the time of the inspection The individual treatment and rehabilitation plan was due to be completed no later than August 3, 2026; however, the treatment plan was completed on August 21, 2026.
Client # 9 was admitted to the outpatient activity on August 3, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than August 17, 2026; however, the treatment plan was completed on August 28, 2026.
Client # 10 was admitted to the outpatient on March 17, 2026 and was discharged on August 14, 2026. The individual treatment and rehabilitation plan was due to be completed no later than March 31, 2026; however, the treatment plan was completed on April 1, 2026.
Client # 11 was admitted to the outpatient activity on February 23, 2026 and was discharged on April 1, 2026. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client # 12 was admitted to the outpatient activity on April 18, 2026 and was discharged on May 29, 2026. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client # 14 was admitted to the outpatient activity on May 1, 2026 and was discharged on May 15, 2026. The individual treatment and rehabilitation plan was due to be completed no later than April 14, 2026; however, the treatment plan was completed on April 20, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will provide training to clinical staff on the requirement to develop individualized treatment and rehabilitation plans collaboratively with clients within two weeks of admission, in accordance with facility policy. The Clinical Director will implement a tracking process to monitor treatment plan deadlines and ensure timely completion and documentation.
To maintain compliance, the Clinical Director will monitor treatment plan completion through supervisory follow-up and conduct monthly chart audits to verify that plans are developed with client participation and completed within the required timeframe. Any identified deficiencies will be addressed through immediate corrective action and staff reeducation as necessary. The Director of Compliance will provide oversight through monthly reviews of audit findings to ensure ongoing compliance.
Date of Full Compliance: November 28, 2026. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in one of two applicable client records reviewed.
Client # 10 was admitted to the outpatient on March 17, 2026 and was discharged on August 14, 2026. A treatment plan update was completed on May 13, 2026 and the next update was due no later than July 13, 2026; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will provide training to clinical staff on the requirement to review and update treatment and rehabilitation plans at least every 60 days. The Clinical Director will implement a tracking process to monitor upcoming treatment plan review deadlines and ensure updates are completed within the required timeframe.
To maintain compliance, the Clinical Director will monitor treatment plan review deadlines through supervisory follow-up and conduct monthly chart audits to verify timely completion. Any identified deficiencies will be addressed through immediate corrective action and staff reeducation as necessary. The Director of Compliance will provide oversight through monthly reviews of audit findings to ensure ongoing compliance.
Date of Full Compliance: November 28, 2026. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in four of five applicable client records reviewed.
The facility policy and procedure manual stated that follow-up information is to be documented 7 days, 1 month, 2 months, 6 months, 1 year and two years after discharge.
Client # 10 was admitted to the outpatient on March 17, 2026 and was discharged on August 14, 2026. There was no follow-up information documented in the client record at the time of the inspection.
Client # 12 was admitted to the outpatient activity on April 18, 2026 and was discharged on May 29, 2026. There was no follow-up information documented in the client record at the time of the inspection.
Client # 13 was admitted to the outpatient activity on May 1, 2026 and was discharged on May 15, 2026. There was no follow-up information documented in the client record at the time of the inspection.
Client # 14 was admitted to the outpatient activity on May 1, 2026 and was discharged on May 15, 2026. There was no follow-up information documented in the client record at the time of the inspection.
This is a repeat citation from the September 11, 2024 and September 12, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance will revise the facility's discharge follow-up policy to establish a more manageable follow-up schedule, with outreach occurring at defined intervals closer to the client's discharge date. The Clinical Director will train applicable staff on the revised follow-up requirements, including documenting completed outreach attempts, client responses, and outcomes in the client record.
To maintain compliance, the Clinical Director will implement a tracking process to monitor required follow-up activities and conduct monthly chart audits to verify that follow-up documentation is completed in accordance with the revised policy. Any identified deficiencies will be addressed through corrective action and staff reeducation as necessary. Due to this being a repeat citation, the Director of Compliance will review audit findings monthly to ensure sustained compliance.
Date of Full Compliance: November 28, 2026. |
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 an administrative review, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for failing to maintain a complete client record, which is to include the documentation of follow-up information for both the partial hospitalization and outpatient activities, were submitted and approved by the Department for the September 11, 2024 and September 12, 2025 annual licensing renewal inspections. Failing to maintain a complete client record, which is to include the documentation of follow-up information for both the partial hospitalization and outpatient activities, was again found to be a deficiency in the September 23, 2026 through September 24, 2026 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance will review the previously approved plans of correction and revise the facility's discharge follow-up policy to establish clearly defined, manageable follow-up intervals for both partial hospitalization and outpatient services. The Clinical Director will train applicable staff on the revised requirements and implement a tracking process to ensure all required follow-up activities are completed and documented.
To maintain compliance, the Clinical Director will conduct monthly chart audits to verify completion of required post-discharge follow-up documentation. The Director of Compliance will review audit findings monthly, monitor implementation of the corrective actions, and ensure identified deficiencies are addressed promptly through staff reeducation and corrective action as necessary. Compliance monitoring will continue to verify that corrective actions are sustained and previously identified deficiencies do not recur.
Date of Full Compliance: November 28, 2026. |