INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 1 & 2, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Care LLC dba Miners Medical 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 a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of eleven records reviewed.
Client #9 was admitted on March 26, 2025 and was discharged on July 7, 2025. There was documentation in the client record that a treatment facility was contacted on March 26, 2025; however, there was not an informed and voluntary consent signed by the client for the treatment facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Training on confidentiality was conducted on 10/6/25 and 10/20/25 instructing staff that prior to releasing any information regarding a patient, voluntary written informed consent must be obtained from the patient prior to the disclosure of information containing exactly what information is to be disclosed. Confidentiality training is also required for all staff to complete via Pinnacle Treatment electronic training system upon hire and annually that includes and reinforces confidentiality requirements.
Counselors will complete the voluntary written consent form in its entirety, checking that all information that the patient wants released is contained in the consent form prior to the disclosure of any information.
Clinical Supervisor and Lead Counselor will conduct 2 chart audits during supervision which include checking the consent forms to ensure that they are accurately completed, and regularly report findings to the Executive Director and Regional Clinical Director.
Annual consent review with the patient. |
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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the specific information to be disclosed in three out of eleven records reviewed.
Client #2 was admitted on June 16, 2025 and was still active at the time of the inspection. The record contained informed and voluntary consents to release information to a medical provider and a funding source signed by the client on June 16, 2025, that did not identify what specific information could be released. The record also contained one informed and voluntary consent to release information to a substance use treatment facility signed by the client on June 16, 2025 that identified the purpose for disclosure as " other " , however no information was listed for what the specific information could be released.
Client #7 was admitted on July 20, 2022 was still active at the time of the inspection. The record contained an informed and voluntary consent to release information to a medical facility signed by the client on May 5, 2025, that did not document specific information to be released.
Client #11 was admitted on November 21, 2024 and discharged on May 23, 2025. The record contained informed and voluntary consents to release information to medical providers, substance use treatment facility, mental health treatment provider, social service provider and a funding source signed by the client on November 21, 2024, that did not document the specific information to be disclosed.
This is a repeat citation from October 1, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training on confidentiality was conducted on 10/6/25 and 10/20/25 instructing staff that prior to releasing any information regarding a patient, voluntary written informed consent must be obtained from the patient prior to the disclosure of information containing exactly what information is to be disclosed. Confidentiality training is also required for all staff to complete via Pinnacle Treatment electronic training system upon hire and annually that includes and reinforces confidentiality requirements.
Counselors will complete the voluntary written consent form in its entirety, checking that all information that the patient wants released is contained in the consent form prior to the disclosure of any information.
Annual review of consent forms with patients.
Clinical Supervisor and Lead Counselor will conduct regular chart audits which include checking the consent forms to ensure that they are accurately completed, and regularly report findings to the Executive Director and Regional Clinical Director.
Executive Director and Regional Clinical Director will randomly check 10 charts quarterly to ensure quality and that consents forms are accurately completed.
#2 has been discharged so correction cannot be made.
#7 ROI was corrected on 10/22/25 - a new completed ROI was signed.
#11 has been AWOL, contact continues to be attempted, ROI will be completed upon their return or patient will be discharged if no contact. |
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 the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of eleven client records reviewed.
Client #3 was admitted on March 5, 2025 and was still 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 government agency dated March 5, 2025, was offered to the client.
This is a repeat citation from October 1, 2024 licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Training on confidentiality was conducted on 10/6/25 and 10/20/25 instructing staff that prior to releasing any information regarding a patient, voluntary written informed consent must be obtained and a copy offered is documented by checking the box on the form. Confidentiality training is also required for all staff to complete via Pinnacle Treatment electronic training system upon hire and annually that includes and reinforces confidentiality requirements.
When consent forms are being completed, Counselors will ensure that a copy of the form is offered to the patient and that it must be documented on the form whether the patient received or refused a copy.
ROI was updated and offered on 10/22/25; patient declined copy which is reflected on ROI. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients.
During the week of June 8-14, 2025, the patient census was 551. The facility was required to provide at least 55.1 physician hours. There were 49.35 physician hours documented.
During the week of June 15-21, 2025, the patient census was 598. The facility was required to provide at least 59.8 physician hours. There were 57.24 physician hours documented.
During the week of July 13-19, 2025, the patient census was 553. The facility was required to provide at least 55.3 physician hours. There were 53.33 physician hours documented.
During the week of July 20-26, 2025, the patient census was 546. The facility was required to provide at least 54.6 physician hours. There were 52.66 physician hours documented.
During the week of July 27-August 2, 2025, the patient census was 538. The facility was required to provide at least 53.8 physician hours. There were 42.44 physician hours documented.
During the week of August 17-23, 2025, the patient census was 528. The facility was required to provide at least 52.8 physician hours. There were 40.21 physician hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executives will review the regulation and assist in acquiring physician coverage to meet the regulatory requirement.
Arrangements will be made for a physician to provide coverage onsite during 1week or more scheduled Clinic physician PTO.
Executive Director will review any physician coverage needed with Regional Director to ensure regulatory compliance. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census.
During the week of May 25-31, 2025, the patient census was 547. The physician was required to provide two-thirds of the 54.7 hours, which equals 18.05 hours. The physician only provided 16.59 hours.
During the week of June 8-14, 2025, the patient census was 551. The physician was required to provide two-thirds of the 55.1 hours, which equals 18.18 hours. The physician only provided 17.07 hours.
During the week of June 22-28, 2025, the patient census was 556. The physician was required to provide two-thirds of the 55.6 hours, which equals 18.34 hours. The physician only provided 16.5 hours.
During the week of July 13-19, 2025, the patient census was 553. The physician was required to provide two-thirds of the 55.3 hours, which equals 18.24 hours. The physician only provided 16.75 hours.
During the week of August 17-23, 2025, the patient census was 528. The physician was required to provide two-thirds of the 52.8 hours, which equals 17.42 hours. The physician only provided 17.01 hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executives will review the regulation and assist in acquiring physician coverage to meet the regulatory requirement.
Arrangements will be made for a physician to provide coverage onsite during 1week or more scheduled Clinic physician PTO.
Executive Director will review any physician coverage needed with Regional Director. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document the notification of the previous narcotic treatment program of the admission and initial dose of the patient in one out of three applicable records reviewed.
Patient #9 was transferred in on March 26, 2025 and was discharged on July 7, 2025. There was no documentation that the facility sent the transferring narcotic treatment program verification of the patient' s admission date or the initial dose given to the patient.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Procedure of documenting the notification to the transferring program of patient's initial dose and date was reviewed in the staff meeting on 10/6/25 and 10/20/25.
-LPN's will notify the transferring program of patient's initial dose and date and document the
notification in the EHR.
- Lead LPN will check to ensure that the notification process to transferring program is documented in the EHR.
- This step will be included in the admission chart audit form that Clinical Supervisor and Lead
Counselor use to audit new admission/ transfer charts in IAuditor |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document an annual evaluation of the patient's status by the patient's counselor and reviewed, dated and signed by the medical director by the regulatory time frame in one out of four applicable records reviewed.
Patient #7 was admitted on July 20, 2022 and was still active at the time of the inspection. An annual clinical evaluation was due no later than July 2025; however, there is no documentation that one was completed.
This is a repeat citation from October 20, 2023, and October 1, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors will:
- receive training on use of the spreadsheet tracking tool that clearly outlines tasks and deadlines in order to prioritize and schedule annual clinical evaluations ahead of time.
- Clinical Supervisor and Lead Counselor:
- Received training on use of the spreadsheet tracking tool and EHR reports provided by Regional Clinical Director and QI Director on 10/30/25.
- Provide training to Counselors on use of the spreadsheet tracking tool.
- Retrain on spreadsheet tracking tool when needed,
- Follow up with Counselors during individual and group supervision to ensure use of scheduler and timeliness of the annual clinical evaluations, and appropriate chart documentation. Acknowledge progress in this area and resolve any identified barriers to timely completion of treatment plan updates and annual clinical evaluations.
All counselors will:
Use the spreadsheet tracking tool to organize their schedule.
- Schedule the next appointment with patients at the end of sessions.
- Use the EHR scheduler to schedule appointments and clearly state what the appointment is for.
- Remind patients of appointments to ensure that appointments are kept- call to confirm before appointments.
- Document all sessions and efforts when appointments are not kept.
Clinical Supervisor and Lead Counselor:
Monitor at least weekly that spreadsheet tracking tool is being used properly by their supervisees. Check the EHR reports to ensure that annual clinical evaluations appointments are scheduled and documented, timely completion of annual clinical evaluations, and prompt follow up when deadlines are not met.
- Notify ED, QI Director, and Regional Clinical Director of progress in this area.
- Retrain on spreadsheet tracking tool when needed,
- Conduct 2 chart audits during supervision using IAuditor to ensure appropriate documentation and timeliness of annual clinical evaluations.
- Follow up with Counselors during individual and group supervision to ensure use of scheduler and timeliness of treatment plan updates and annual clinical evaluations, and appropriate chart documentation. Acknowledge progress in this area and resolve any identified barriers to timely completion of annual clinical evaluations.
ED, QI Director, and Regional Clinical Director:
- Monitor that the tracking system is in place and that the CS and LC are following up.
- Conduct 10 chart audits quarterly using IAuditor to ensure appropriate documentation and timeliness of annual clinical evaluations.
- Take progressive discipline steps when necessary to ensure timely completion of treatment plan updates and annual clinical evaluations. |
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 the facility ' s policy and procedure manual and client records the facility failed to follow their policy that treatment plans were to be completed within thirty days of arrival up until February 1, 2025 when they changed the policy time frame to require the comprehensive treatment plan be documented within fourteen days of arrival in three out of seven records reviewed.
Client # 8 was admitted on November 4, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 4, 2024; however, it was completed on January 11, 2025.
Client #9 was admitted on March 26, 2025 and was discharged on July 7, 2025. A comprehensive treatment plan was due no later than April 9, 2025; however, it was completed on July 2, 2025.
Client #11 was admitted on November 21, 2024 and discharged on May 23, 2025. A comprehensive treatment plan was due no later than December 21, 2024; however, it was completed on December 26, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training was held on 10/6/25 and 10/20/25 to reinforce the completion of the initial treatment plan within 14 days of admission to the program.
A training is planned for the counseling staff for 10/30/25 to educate Counselors on how to complete and maintain the work tracking spreadsheet which summarizes when the treatment plans are due and other EHR reports to use to track deadlines and due dates.
Cases will be assigned to counselors upon admission and an appointment will be made for the initial treatment plan to be developed within 14 days of admission.
The EHR report for treatment plan due dates will be used to monitor compliance.
The scheduler will be used and patient will be reminded to keep appointment.
The Clinical Supervisor and Lead Counselor will follow up with the Counselors to ensure that the treatment plan is completed within 14 days.
Counselors will document all efforts to complete the treatment plan within 14 days of admission. |
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 eight out of eleven records reviewed.
Client #1 was admitted on May 22, 2025 and was still active at the time of the inspection. A treatment plan was completed on June 10, 2025, and the next update was due no later than August 9, 2025; however, it was completed on August 12, 2025.
Client #4 was admitted on September 29, 2022 and discharged on September 19, 2025. A treatment plan was completed on May 28, 2025, and the next update was due no later than July 27, 2025; however, it was completed on August 1, 2025.
Client #5 was admitted on November 12, 2024 and discharged on July 1, 2025. A treatment plan was completed on February 11, 2025, and the next update was due no later than April 12, 2025; however, it was completed on April 24, 2025.
Client #6 was admitted on November 13, 2018 and discharged on July 24, 2025. A treatment plan was completed on April 23, 2025, and the next update was due no later than June 22, 2025; however, it was completed on June 26, 2025.
Client #7 was admitted on July 20, 2022 and was still active at the time of the inspection. A treatment plan was completed on January 8, 2025, and the next update was due no later than March 9, 2025; however, it was completed on March 14, 2025. A treatment plan update was completed on July 2, 2025, and the next update was due no later than August 31, 2025; however, it was completed on September 8, 2025.
Client #8 was admitted on November 4, 2024 and was still active at the time of the inspection. A treatment plan was completed on February 12, 2025, and the next update was due no later than April 13, 2025; however, it was completed on April 24, 2025.
Client #10 was admitted on November 3, 2022 and discharged on September 15, 2025. A treatment plan was completed on April 24, 2025, and the next update was due no later than June 23, 2025; however, it was completed on July 24, 2025.
Client #11 was admitted on November 21, 2024 and discharged on May 23, 2025. A treatment plan was completed on December 26, 2024, and the next update was due no later than February 24, 2025; however, it was completed on March 11, 2025.
This is a repeat citation from October 20, 2023, and October 1, 2024 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors will:
- receive training on use of the spreadsheet tracking tool that clearly outlines tasks and deadlines in order to prioritize and schedule treatment plan updates ahead of time on 10/20/25.
- Clinical Supervisor and Lead Counselor:
- Received training on use of the spreadsheet tracking tool provided by Regional Clinical Director on 10/15/25.
- Provide training to Counselors on use of the spreadsheet tracking tool.
- Retrain on spreadsheet tracking tool when needed,
- Follow up with Counselors during individual and group supervision to ensure use of scheduler and timeliness of treatment plan updates and annual clinical evaluations, and appropriate chart documentation. Acknowledge progress in this area and resolve any identified barriers to timely completion of treatment plan updates.
All counselors will:
Use the spreadsheet tracking tool to organize their schedule.
- Schedule the next appointment with patients at the end of sessions.
- Use the EHR scheduler to schedule appointments and clearly state what the appointment is for.
- Remind patients of appointments to ensure that appointments are kept- call to confirm before appointments.
- Document all sessions and efforts when appointments are not kept.
Clinical Supervisor and Lead Counselor:
Monitor at least weekly that spreadsheet tracking tool is being used properly by their supervisees. Check the EHR reports to ensure that treatment plan updates and annual clinical evaluations appointments are scheduled and documented, timely completion of treatment plan updates and annual clinical evaluations, and prompt follow up when deadlines are not met.
- Notify ED and Regional Clinical Director of progress in this area.
- Retrain on spreadsheet tracking tool when needed,
- Conduct 2 chart audits during supervision to ensure appropriate documentation and timeliness of treatment plan updates and annual clinical evaluations.
- Follow up with Counselors during individual and group supervision to ensure use of scheduler and timeliness of treatment plan updates and annual clinical evaluations, and appropriate chart documentation. Acknowledge progress in this area and resolve any identified barriers to timely completion of treatment plan reviews and updates.
ED, QI Director, and Regional Clinical Director:
- Monitor that the tracking system is in place and that the CS and LC are following up.
- Conduct 2 chart audits during supervision to ensure appropriate documentation and timeliness of treatment plan reviews and updates.
- Take progressive discipline steps when necessary to ensure timely completion of treatment plan reviews and updates. |
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, the facility failed to document case consultations every ninety days for the first year and annually thereafter, per facility policy, in seven out of eleven records reviewed.
Client #1 was admitted on May 22, 2025 and was still active at the time of the inspection. A case consultation was due no later than August 20, 2025; however, it was completed on August 27, 2025.
Client #3 was admitted on March 5, 2025 and was still active at the time of the inspection. A case consultation was due no later than June 5, 2025; however, there is no documentation that one was completed.
Client #5 was admitted on November 12, 2024 and was discharged on July 1, 2025. A case consultation occurred on February 10, 2025, and the next one was due no later than May 10, 2025; however, there is no documentation that one was completed.
Client #6 was admitted on admitted on November 13, 2018 and discharged on July 24, 2025. A case consultation was due no later than November 13, 2024; however, there is no documentation that one was completed.
Client #8 was admitted on November 4, 2024 and was still active at the time of the inspection. A case consultation was completed on December 23, 2024, and the next one was due no later than March 23, 2025; however, there is no documentation that one was completed.
Client #9 was admitted on March 26, 2025 and was discharged on July 7, 2025. A case consultation was due no later than June 24, 2025; however, there is no documentation that one was completed.
Client #11 was admitted on November 21, 2024 and discharged on May 23, 2025. A case consultation was due no later than February 21, 2025; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors will:
- receive training on use of the spreadsheet tracking tool that clearly outlines tasks and deadlines in order to prioritize and schedule case consultations ahead of time. (10/30/25)
- Clinical Supervisor and Lead Counselor:
- Received training on use of the spreadsheet tracking tool provided by Regional Clinical Director on 10/15/25.
- Provide training to Counselors on use of the spreadsheet tracking tool and EHR scheduled events (10/30/25)
- Retrain on spreadsheet tracking tool when needed,
- Follow up with Counselors during individual and group supervision to ensure use of scheduler and timeliness of case consultations, and appropriate chart documentation. Acknowledge progress in this area and resolve any identified barriers to timely completion of case consultations.
All counselors will:
Use the spreadsheet tracking tool to organize their schedule.
- Schedule the next appointment with patients at the end of sessions.
- Use the EHR scheduler to schedule appointments and clearly state what the appointment is for.
- Remind patients of appointments to ensure that appointments are kept- call to confirm before appointments.
- Document all sessions and efforts when appointments are not kept.
Clinical Supervisor and Lead Counselor:
Monitor at least weekly that spreadsheet tracking tool is being used properly by their supervisees. Check the EHR reports to ensure that treatment plan updates and annual clinical evaluations appointments are scheduled and documented, timely completion of case consultations, and prompt follow up when deadlines are not met.
- Notify ED, QI Director, and Regional Clinical Director of progress in this area.
- Retrain on spreadsheet tracking tool when needed,
- Conduct 2 chart audits during supervision using IAuditor to ensure appropriate documentation and timeliness of case consultations.
- Follow up with Counselors during individual and group supervision to ensure use of scheduler and timeliness of treatment plan updates and annual clinical evaluations, and appropriate chart documentation. Acknowledge progress in this area and resolve any identified barriers to timely completion of treatment plan updates and annual clinical evaluations.
ED, QI Director, and Regional Clinical Director:
- Monitor that the tracking system is in place and that the CS and LC are following up.
- Conduct 10 chart audits quarterly using IAuditor to ensure appropriate documentation and timeliness of case consultations.
- Take progressive discipline steps when necessary to ensure timely completion of case consultations. |
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, the facility failed to provide a complete client record, which is to include follow-up information for clients terminated within three days of discharge and for all other discharges follow-up contacts occur at seven, thirty and sixty days after discharge, per facility policy, in six out of six applicable records reviewed.
Client #4 was admitted on September 29, 2022 and discharged on September 19, 2025. A follow up was due no later than September 26, 2025; however, there was no documentation that one was completed.
Client #5 was admitted on November 12, 2024 and discharged on July 1, 2025. A follow up was due no later than July 4, 2025; however, there is no documentation that one was completed.
Client # 6 was admitted on November 13, 2018 and discharged on July 24, 2025. A follow up was due no later than July 31, 2025; however, there was no documentation that one was completed.
Client #9 was admitted on March 26, 2025 and was discharged on July 7, 2025. Follow ups were due no later than July 14, 2025, August 7, 2025 and September 7, 2025: however, there is no documentation that they were completed.
Client #10 was admitted on November 3, 2022 and discharged on September 15, 2025. A follow up was due no later than September 22, 2025; however, there was no documentation that one was completed.
Client #11 was admitted on November 21, 2024 and discharged on May 23, 2025. Follow ups were due no later than May 30, June 23 and July 23, 2025; however, there is no documentation that they were completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/30/25, Counselors will be re-trained on use of the scheduler in the EHR which automatically schedules follow-up contacts at 3 days of discharge (for administrative discharges), 7 days, 30 days and 60 days post discharge
- Counselors will document all attempts to contact clients at 3/7/30/and 60 days post discharge.
- Supervisor and Lead Counselor will ensure that outreach contact is conducted and documented on a timely basis during supervision and check discharged patient charts ( 3 per quarter) and will coach and counsel when needed. |
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 completing and documenting treatment plan updates for the outpatient records was submitted and approved by the Department for October 20, 2023, and October 1, 2024, annual licensing inspections. Completing and documenting treatment plan updates was again found to be a deficiency on October 1 & 2, 2025 licensing inspection.
A plan of correction for completing and documenting annual clinical evaluations for the narcotic treatment patient records was submitted and approved by the Department for the October 20, 2023, and October 1, 2024, annual licensing inspection. Completing and documenting annual clinical evaluation was again found to be a deficiency in the October 1 & 2, 2025 licensing inspection.
This is a repeat citation from the October 1, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors will:
- receive training on use of the spreadsheet tracking tool that clearly outlines tasks and deadlines in order to prioritize and schedule treatment plan updates and annual clinical evaluations ahead of time; training scheduled for 10/30/25
- QI Director will provide training on the EHR reports that can be used to identify documentation deadlines and due dates; training scheduled for 10/30/25
- Clinical Supervisor and Lead Counselor:
- Received training on use of the spreadsheet tracking tool provided by Regional Clinical Director on 10/30/25.
- Provide training to Counselors on use of the spreadsheet tracking tool (10/30/25).
- Retrain on spreadsheet tracking tool when needed,
- Follow up with Counselors during individual and group supervision to ensure use of scheduler and timeliness of treatment plan updates and annual clinical evaluations, and appropriate chart documentation. Acknowledge progress in this area and resolve any identified barriers to timely completion of treatment plan updates and annual clinical evaluations.
All counselors will:
Use the spreadsheet tracking tool to organize their schedule.
- Schedule the next appointment with patients at the end of sessions.
- Use the EHR scheduler to schedule appointments and clearly state what the appointment is for.
- Remind patients of appointments to ensure that appointments are kept- call to confirm before appointments.
- Document all sessions and efforts when appointments are not kept.
Clinical Supervisor and Lead Counselor:
Monitor at least weekly that spreadsheet tracking tool is being used properly by their supervisees. Check the EHR reports to ensure that treatment plan updates and annual clinical evaluations appointments are scheduled and documented, timely completion of treatment plan updates and annual clinical evaluations, and prompt follow up when deadlines are not met.
- Notify ED and Regional Clinical Director of progress in this area.
- Retrain on spreadsheet tracking tool when needed,
- Conduct 2 chart audits during supervision using IAuditor to ensure appropriate documentation and timeliness of treatment plan updates and annual clinical evaluations.
- Follow up with Counselors during individual and group supervision to ensure use of scheduler and timeliness of treatment plan updates and annual clinical evaluations, and appropriate chart documentation. Acknowledge progress in this area and resolve any identified barriers to timely completion of treatment plan updates and annual clinical evaluations.
ED and Regional Clinical Director:
- Monitor that the tracking system is in place and that the CS and LC are following up.
- Conduct quarterly chart audits on at least 10 charts using I Auditor to ensure appropriate documentation and timeliness of treatment plan updates and annual clinical evaluations.
- Take progressive discipline steps when necessary to ensure timely completion of treatment plan updates and annual clinical evaluations.
- The ED will ensure that the plan of correction is implemented and remains in compliance by monitoring all related reports (Spreadsheet, EHR Reports for t/p updates, individual counselor plan of correction, Supervisor plan of correction, and report on results monthly to Regional Director that program is in compliance and that effective training, disciplinary action and corrective action is taken to achieve compliance.
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