INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pathway to Recovery Counseling and Educational Services 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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709.91(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 the review of client records, the project failed to ensure that the intake procedures included documentation of a preliminary treatment and rehabilitation plan in three of seven client records reviewed.
Client #1 was admitted on February 11, 2025 and was discharged on May 13, 2025. A preliminary treatment and rehabilitation plan was not documented in the client record at intake.
Client #2 was admitted on September 18, 2025 and was discharged on November 11, 2025. A preliminary treatment and rehabilitation plan was not documented in the client record at intake.
Client #7 was admitted on July 2, 2025 and was active at the time of the inspection. A preliminary treatment and rehabilitation plan was not documented in the client record at intake.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
This citation was discussed at our Quality Assurance meeting on December 22, 2025 to decide our plan of action. At our next Treatment Team Meeting on January 8, 2026 the Clinical Director will retrain all counselors on completing the initial treatment plan at the end of our bio-psychosocial assessment. Counselors will then be responsible for completing the initial treatment plan during each assessment they conduct. For all assessments done in CPR/WITS, the counselors will be shown how to complete an initial treatment plan document in the BestNotes chart. They will then be expected to do this moving forward for all county funded clients. During monthly chart auditing by the Clinical Director, the initial treatment plan will be reviewed to ensure compliance with this documentation requirement |
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 the review of outpatient client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in three of six applicable records reviewed.
Client #1 was admitted on February 11, 2025 and was discharged on May 13, 2025. A comprehensive treatment and rehabilitation plan was documented in the record on February 21, 2025, with the next update due no later than April 21, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client #3 was admitted on March 26, 2025 and was discharged on November 3, 2025. A comprehensive treatment and rehabilitation plan was documented in the record on April 4, 2025, with the next update due no later than June 4, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until July 21, 2025.
Client #7 was admitted on July 2, 2025 and was active at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on October 8, 2025, with the next update due no later than December 8, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until December 16, 2025.
This is a repeat citation from the December 11, 2024 annual licensing renewal inspection.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
During our Quality Assurance meeting on December 22, 2025 this citation was reviewed and our corrective plan was discussed. At our next Treatment Team Meeting on January 8, 2026 the Clinical Director will go over the requirement of Treatment Plan Reviews being completed every 60 days. We will discuss having the counselors complete a Treatment Plan Review by the 60 day mark even if it needs to be completed without the client being present. Each counselor will be required to implement a system for tracking the due dates of Treatment Plan Reviews for their clients (ex: excel spreadsheet or BestNotes task bar). Tracking options will be introduced and implemented during Treatment Team on January 8, 2026. During monthly chart auditing by the Clinical Director, timeliness of Treatment Plan Reviews will be monitored to ensure compliance with this documentation requirement |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in three of five applicable records reviewed.
Client #1 was admitted on February 11, 2025 and was discharged on May 13, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on February 21, 2025, indicated that the client was to receive one individual counseling session per month; however, there were no individual counseling sessions documented in the record for the months of March 2025 and April 2025.
Client #3 was admitted on March 26, 2025 and was discharged on November 3, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on April 4, 2025, indicated that the client was to receive one individual counseling session biweekly or two times per month; however, there were no individual counseling sessions documented in the record for the months of May 2025, August 2025, September 2025 and October 2025. Additionally, there was only one individual counseling session documented in the record for the months of June 2025 and July 2025.
Client #7 was admitted on July 2, 2025 and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on February 21, 2025, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the record for the weeks of August 10, 2025 through August 16, 2025, August 17, 2025 through August 23, 2025, August 24, 2025 through August 30, 2025 and there were no individual counseling sessions documented in the record for the month of September 2025.
This is a repeat citation from the December 11, 2024 annual licensing renewal inspection.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
This citation was discussed at our Quality Assurance meeting on December 22, 2025 to decide our plan of action. The Clinical Director will review 709.92 (c) with all counselors during Treatment Team on January 8, 2026 to increase their understanding of the need to follow all interventions documented on Treatment Plans which includes the frequency of sessions. Counselors will be asked to be more mindful of the frequency they are documenting in Treatment Plans to ensure the sessions are able to be scheduled in the identified time frame. If a client is unable to schedule a session in accordance with the documented frequency, the reason for the change will be documented in the plan section of their progress note or in a collaboration/missed service note if it is discussed outside of a session. The Clinical Director will monitor the following of treatment plans during monthly chart audits. |
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'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 follow-up information entered within one week of the client's discharge, per the facility's policy, in three out of four applicable records reviewed.
Client #1 was admitted on February 11, 2025 and was discharged on May 13, 2025. Follow-information was not documented in the client record until June 3, 2025
Client #2 was admitted on September 18, 2025 and was discharged on November 11, 2025. There was no follow-up information documented in the client record at the time of the inspection.
Client #3 was admitted on March 26, 2025 and was discharged on November 3, 2025. Follow-information was not documented in the client record until December 4, 2025
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
During our Quality Assurance meeting on December 22, 2025 this citation was reviewed and the decision was made to update our client follow-up policy/procedure to more accurately reflect what is being done by the agency. It was discovered that this policy/procedure has not been changed over time to accurately reflect the changes made to the client follow-up process. The Clinical Director completed the policy update on December 29, 2025 and provided a copy to all staff involved in the follow-up process. The timeliness of discharge letters and follow-up letters will be monitored during our monthly Quality Assurance meetings. |