INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 17, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Children's Service Center of Wyoming Valley 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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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on review of client records, the facility failed to obtain a completed informed and voluntary consent which included the specific information to be disclosed in one out seven records reviewed.
Client #7 was admitted on July 7, 2025, and discharged November 10, 2025. A release of information form for a primary care physician, was signed and dated July 7, 2025; however, it did not include the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility is working with the IT and QA departments to implement form validations to ensure the specific information to be disclosed is completed prior to signature, with the goal of this being completed as of March 25, 2026. Additionally as of February 25, 2026 Clinical staff have been re-educated on confidentiality requirements and proper completion of consent forms.
Effective immediately, staff obtaining Releases of Information are responsible for ensuring all required fields, including the specific information to be disclosed, are completed at the time of signing. Compliance with informed consent documentation requirements will be monitored through ongoing monthly chart audits conducted by Clinical Supervisors. Any incomplete forms identified during audit will be corrected promptly, and staff will receive additional coaching as needed.
The Program Director and Clinical Supervisors are responsible for oversight of implementation and monitoring to ensure sustained compliance with §709.28(c)(2).
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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 the regulatory timeframe in four out of four applicable records reviewed.
Client #1 was admitted on May 07, 2025 and was discharged on October 13, 2025. The comprehensive treatment and rehabilitation plan was completed on May 20, 2025, and the treatment plan update was due no later than July 20, 2025; however, the client record did not contain any documentation of treatment plan updates completed prior to the client 's discharge.
Client #3 was admitted on May 12, 2025 and was discharged on October 07, 2025. The comprehensive treatment and rehabilitation plan was completed on May 29, 2025, and the treatment plan update was due no later than July 29, 2025; however, the client record did not contain any documentation of treatment plan updates completed prior to the client's discharge.
Client #6 was admitted on March 14, 2025 and was discharged on November 12, 2025. The comprehensive treatment and rehabilitation plan was completed on March 28, 2025, and the treatment plan update was due no later than May 28, 2025; however, the client record did not contain any documentation of treatment plan updates completed prior to client's discharge.
Client #7 was admitted on July 07, 2025 and was discharged on November 10, 2025. The comprehensive treatment and rehabilitation plan was completed on August 04, 2025, and the treatment plan update was due no later than October 04, 2025; however, the client record did not contain any documentation of treatment plan updates completed prior to client's discharge.
This is a repeat citation from the March 11, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 25, 2026 Clinical staff and Clinical Supervisors have been re-educated on regulatory requirements for timely treatment plan reviews and documentation. The facility is also working with the IT department to implement electronic health record alerts and tracking mechanisms to notify assigned staff of upcoming and overdue treatment plan update due dates.
Effective immediately, assigned clinicians are responsible for completing and documenting treatment plan reviews at least every 60 days. Clinical Supervisors will monitor compliance through ongoing monthly chart audits to ensure treatment plans are updated within required timeframes. Any missed or overdue updates identified will be addressed promptly, with corrective action and additional staff coaching as needed.
The Program Director and Clinical Supervisors are responsible for oversight of implementation and ongoing monitoring to ensure sustained compliance.
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709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes completed with treatment plan updates, per the facility's policy, in four out of four applicable records reviewed.
Client #1 was admitted on May 07, 2025 and was discharged on October 13, 2025. The client record did not contain documentation of case consultation notes.
Client #3 was admitted on May 12, 2025 and was discharged on October 07, 2025. The client record did not contain documentation of case consultation notes.
Client #6 was admitted on March 14, 2025 and was discharged on November 12, 2025. The client record did not contain documentation of case consultation notes.
Client #7 was admitted on July 07, 2025 and was discharged on November 10, 2025. The client record did not contain documentation of case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 25, 2026 Clinical staff and Clinical Supervisors have been re-educated on documentation requirements for case consultations and the requirement to complete and file case consultation notes in conjunction with treatment plan updates. The facility is also working with the IT department to implement electronic health record prompts to ensure case consultation documentation is completed and linked to treatment plan reviews.
Effective immediately, assigned clinicians are responsible for completing and documenting case consultation notes as required. Clinical Supervisors will monitor compliance through ongoing monthly chart audits to ensure case consultation documentation is present and timely. Any missing documentation identified will be addressed promptly, with corrective action and additional staff coaching as needed.
The Program Director and Clinical Supervisors are responsible for oversight of implementation and ongoing monitoring to ensure sustained compliance
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