INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 10, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cleanslate Medical Group of Pennsylvania 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 on June 10, 2026, the facility failed to ensure each bathroom was ventilated by operable windows or have mechanical ventilation.
The exhaust fan in client bathroom #2 was inoperable and there was no window available.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate's Center Manager completed a maintenance request on 6/11/2026 to fix the exhaust fan. The maintenance request was completed and the exhaust fan located in the bathroom has been fixed and working properly as of 6/12/2026.
As of 7/1/2026 the Center Manager at the facility will be responsible for completing a facility inspection checklist on a monthly basis. This checklist will include all DDAP required items and specifically checking the exhaust fan in each bathroom. |
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 offer a copy of informed and voluntary consent to release information form in five of seven records reviewed.
Client #1 was admitted to the outpatient program on September 30, 2025 and was discharged March 30, 2026. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source signed by the client on March 3, 2026 was offered to the client.
Client #2 was admitted to the outpatient program on November 11, 2025, and discharged March 3, 2026. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source signed by the client on May 28, 2025, in the medication assisted treatment program, was offered to the client while the client was in the outpatient level of care.
Client #3 was admitted to the outpatient program on November 18, 2025, and was active at the time of the licensing inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source signed by the client on March 3, 2026, was offered to the client.
Client #6 was admitted to the outpatient program on February 9, 2026, and was active at the time of the licensing inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source signed by the client March 2, 2026, was offered to the client.
Client #7 was admitted to the outpatient program on February 16, 2026, and was active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source signed by the client on March 23, 2026, was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSLate's Release of Information (ROI) form has been updated to include a section allowing patients to indicate whether they accept or decline a copy of the completed ROI. All Pennsylvania location staff will be trained on the revised ROI form on June 17, 2026, and implementation will begin on June 18, 2026, for all new admissions.
During the admission process, Medical Receptionist staff will review ROI forms for completeness and provide a copy to the patient if requested. ROI forms will be reviewed monthly by Medical Receptionist staff to ensure they remain valid and have not expired. In addition, the Center Manager will conduct monthly chart audits to verify ROI completion and compliance.
All currently enrolled patients will be given the opportunity to review their existing ROI forms and complete a new ROI that includes the option to accept or decline a copy. The review and update of all active patient ROI forms will be completed by September 1, 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 review of client records, the facility failed to include documentation of a preliminary treatment and rehabilitation plan within thirty days of admission, per facility policy, in five out of seven records reviewed.
Client #1 was admitted to the outpatient level of care on September 30, 2025, and was discharged March 30, 2026. The preliminary treatment plan was due October 30, 2025; however, it was not documented until February 30, 2026.
Client #2 was admitted to the outpatient level of care on November 5, 2025 and discharged March 3, 2026. The preliminary treatment plan was due December 11, 2025; however, it was not documented until January 14, 2026.
Client #3 was admitted to the outpatient level of care on November 18, 2025, and was currently active at the time of the licensing inspection. The preliminary treatment plan was due December 18, 2025; however, it was not documented until January 12, 2026.
Client #4 was admitted to the outpatient level of care on December 31, 2025, and was active at the time of the licensing inspection. The preliminary treatment plan was due January 31, 2026; however, it was not documented until April 27, 2026.
Client #7 was admitted to the outpatient level of care on February 16, 2026, and was currently active at the time of the licensing inspection. The preliminary treatment plan was due March 16, 2026; however, it was not documented until April 3, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate's Behavioral Health Director will provide training to all current and newly hired counseling staff on the requirement to complete an initial treatment plan within 30 days of the biopsychosocial assessment. To support compliance with this requirement, patients will be scheduled more frequently during the early phases of treatment to ensure sufficient opportunities for treatment plan development and completion.
The Center Manager will monitor patient scheduling on a weekly basis using the Patient Compliance Report to identify and address any potential barriers to timely treatment plan completion. In addition, the Senior Director of Behavioral Health will conduct bi-weekly group supervision sessions during which up to 35% of each counselor's caseload will be reviewed to verify compliance with initial treatment plan requirements.
The Compliance Department will perform monthly audits of at least 10% of each counselor's caseload to monitor adherence to treatment plan timelines. Any deficiencies identified through the audit process will be communicated to the counselor, Vice President of Operations, and Senior Director of Behavioral Health. Corrective actions, including target completion dates, will be established and monitored to ensure timely resolution and ongoing compliance with regulatory requirements. |
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 document treatment plan updates within 60 days in four out of four applicable records reviewed.
Client #3 was admitted to the outpatient level of care on November 18, 2025, and was active at the time of the licensing inspection. A comprehensive treatment plan was completed on January 12, 2026, and an update was due no later than March 12, 2026; however, there was no treatment plan update documented until April 1, 2026.
Client #5 was admitted to the outpatient level of care on January 20, 2026, and was active at the time of the licensing inspection. A comprehensive treatment plan was completed on January 29, 2026, and an update was due no later than March 29, 2026; however, there was no treatment plan update documented until April 16, 2026.
Client #6 was admitted to the outpatient level of care on February 9, 2026, and was active at the time of the licensing inspection. A comprehensive treatment plan was completed on February 23, 2026, and an update was due no later than April 23, 2026; however, there was no treatment plan update documented until May 22, 2026.
Client #7 was admitted to the outpatient level of care on February 16, 2026, and was active at the time of the licensing inspection. A comprehensive treatment plan was completed on April 3, 2026, and an update was due no later than June 3, 2026; however, there was no treatment plan update documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSLate's Behavioral Health Director will provide training to all current and newly hired counseling staff on the requirement to complete treatment plan updates every 60 days. Patient scheduling will be maintained in accordance with each patient's level of care to ensure sufficient clinical contact and timely completion of treatment plan updates as required by regulation.
All current active patients will have an updated treatment plan documented in their chart by 7/28/2026 by the facility director assigned at the location. Senior Director of Behavioral Health will ensure facility director prioritizes scheduling and completing active patient treatment plans reviews by the required deadline. Senior Director of Behavioral Health will review with the facility director weekly to ensure completion.
Going forward, the Center Manager will monitor patient scheduling on a weekly basis using the Patient Compliance Report to identify and address any potential barriers to compliance. Additionally, the Senior Director of Behavioral Health will conduct bi-weekly group supervision sessions during which up to 60% of each counselor's caseload will be reviewed to verify timely completion of treatment plan updates. Review will include a caseload tracker kept by the counselor.
The Compliance Department will perform monthly audits of at least 10% of each counselor's caseload to monitor adherence to treatment plan update requirements. Any deficiencies identified through the audit process will be communicated to the counselor, Vice President of Operations, and Senior Director of Behavioral Health. Corrective action plans, including expected completion dates, will be developed and monitored to ensure timely resolution and ongoing compliance with regulatory standards. |