INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CDS Group 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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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of ten records reviewed. Client #12 was admitted on July 14, 2025 and was a current client at the time of the licensing inspection. A release of information form for the client ' s sister and father was not documented in the client record until December 11, 2025; however, a family session progress note dated July 30, 2025, confirms disclosure was made prior to the release of information form being obtained. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #12 is no longer in services.
Executive Director review with staff on 12/11/25 the required elements of an release of information and to ensure that all family members in a family session have an ROI completed prior to the session. Staff was reminded of this again on 1/2/26.
Moving forward, the Director of Quality Assurance will work with the Executive Director to audit charts on a monthly basis to ensure compliance with ROI.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.Client #3 was admitted on August 13, 2025 and was involuntarily discharged on September 16, 2025. There was no documentation in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed the process for administrative discharges and written notification with the clinical team on 12/11/25. The Executive Director will work with the Office Manager to ensure that these notifcations are completed and sent to the client.
Moving forward, the Office Manager will audit discharges on a weekly basis to ensure all administrative discharge letters and completed and sent out.
A letter was sent to client #3 on 1/5/26
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709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on a review of partial hospitailization client records the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project to include case consultation notes in two of six applicable records reviewed. Client #1 was admitted on September 11, 2025, and discharged on October 17, 2025. The facility failed to follow their written procedure to complete case consultations within twenty days of admission. There was no documentation of a case consultation in client record.Client #2 was admitted on September 29, 2025 and discharged on October 24, 2025. The facility failed to follow their written procedure to complete case consultations within twenty days of admission. There were no documentation of a case consultation in client record.This is a repeat citation from the November 1, 2024 licensing inspection.These findings were reviewed with facility staff during licensing process.
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Plan of Correction
Executive Director reviewed the process and documentation expectations for case consults with the clinical team on 12/11/25. Staff were retrained on these expectations on 1/2/26.
Moving forward, the Director of Quality Assurance will work with the Executive Director to audit these on a monthly basis.
Both client #1 and #2 have been discharged. |
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 review of outpatient client records the facility failed to review and update treatment and rehabilitation plans at least every 60 days in two of six applicable records reviewed. Client #9 was admitted on October 27, 2025 and discharged on November 3, 2025. A treatment and rehabiliation plan was developed on October 1, 2025, while client was current in the partial hospitializtion program. Client #9 was stepped down from the partialization program on October 24, 2025, and the facility policy states the master treatment plan will be updated to reflect any level of care change. However, there was no documentation updating the treatment plan to reflect the level of care change from partial hospitialization to the outpatient program.Client #12 was admitted on July 14, 2025 and was a current client at the time of the licensing process. A treatment and rehabiliation plan was developed on July 30, 2025, and was due to be updated by September 30, 2025; however the treatment plan was not updated until November 12, 2025.These findings were reviewed with facility staff during licensing process.This is a repeat citation from the November 1, 2024 licensing inspection.
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Plan of Correction
Executive Director reviewed the process and documentation expectations for treatment plans and treatment plan updates with the clinical team on 12/11/25. Staff were retrained on these expectations on 1/2/26.
Moving forward, the Director of Quality Assurance will work with the Executive Director to audit these on a monthly basis.
Both client #1 and #2 have been discharged. |