INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 13, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Keystone Drug and Alcohol 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 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one of seven client records reviewed.
Client #2 was admitted on August 13, 2024, and was discharged on November 15, 2024. There was no documented informed and voluntary consent from the client for the funder. The facility confirmed billing had occurred.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the August 29, 2024 licensing inspection.
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Plan of Correction
The Program Director held an all-staff meeting on June 26, 2025 to review the facility's 709.28(c) Confidentiality Policy and Procedure to educate staff on how to properly complete an informed voluntary consent from the client for the funder form. Program director is currently conducting an internal audit to ensure that all active clients have completed the informed voluntary consent from the client for the funder forms audit to be completed by Thursday July 10, 2025. The program director created a pre-billing compliance checklist for an administrative assistant to complete and for the program director to review, ensuring that all clients to be billed have voluntary consent from the client for the funder before billing may be submitted. This process will take effect on Monday, June 30, 2025. The program director updated the facility's 709.28(c) Confidentiality Policy and Procedure on June 26, 2025, to include "no billing will occur until informed voluntary consent from the client for the funder is in client chart. If a client does not have informed and voluntary consent, an immediate hold is placed on all client billing until the client has signed the consent" starting on June 26, 2025. The program director updated all chart audit forms to include an audit portion that ensures informed, voluntary consent from the client for the funder source is completed at the time of intake as of June 26, 2025. The Lead Counselor will perform weekly chart audits on all intake clients, ensuring that informed, voluntary consent from the client for the funder is documented in each chart, starting on June 30, 2025. The program director will review chart audits for compliance starting on July 1, 2025. The program director will ensure policy and audit procedures are in full compliance by Thursday, July 10, 2025. |
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, which included the specific information to be disclosed in four out of seven records reviewed.
Client #1 was admitted on January 15, 2025, and was still active at the time of the inspection. A release of information form to the funder was signed and dated by the client on January 15, 2025, that did not include the specific information to be disclosed.
Client #4 was admitted on September 09, 2024, and was discharged on May 28, 2025. A release of information form to the funder was signed and dated by the client on September 09, 2024, that did not include the specific information to be disclosed.
Client #6 was admitted on January 7, 2025, and was still active at the time of the inspection. A release of information form to the funder was signed and dated by the client on January 24, 2025, that did not include the specific information to be disclosed.
Client #7 was admitted on October 29, 2024 and was still active at the time of the inspection. A release of information form to the funder and a support service was signed and dated by the client on October 29, 2024, and May 21, 2025, respectively; that did not include the specific information to be disclosed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On June 26, 2025, the program director held an all-staff meeting to educate staff on how to complete an informed and voluntary consent properly
forms. The program director is currently conducting an internal audit to ensure that all active clients have correctly completed informed consent forms in their charts, specifically detailing the information that the facility will disclose starting June 26, 2025, and to be completed by July 10, 2025. For Clients #1 and #6, the program director completed new informed and voluntary consent forms on June 26, 2025. Client #1 signed this new and updated informed and voluntary consent form on June 27, 2025. Client #6 is at risk of being discharged on July 1, 2025, if the lead counselor cannot reach Client #6 for re-engagement by July 1, 2025. The program director has placed an alert in the facility's Electronic Medical Record system to notify the clinical staff that Client #6 needs to complete an updated informed and voluntary consent on June 27, 2025. The program director is conducting an internal audit to ensure that all active clients have completed informed and voluntary consent forms with the specific information to be disclosed, starting on June 27, 2025, and to be completed by July 10, 2025. The program director is updating any informed and voluntary consent forms that may not include the specific information to be disclosed starting on June 27, 2025, and to be completed by July 10, 2025. The program director updated the facility's 709.28 Confidentiality Policy and Procedure on June 27, 2025. Updates include Lead Counselor conducting internal audits on all new client charts to ensure each client has a correct and completed voluntary consent, and they include the specific information to be disclosed with a minimum of 10% of active client charts to be audited for same, starting on June 30, 2025. The program director will review all audits for any discrepancies beginning on July 3, 2025. The program director will ensure that policies, audits, and procedures are followed. The facility will be in full compliance by July 10, 2025
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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 two out of seven client records reviewed.
Client #5 was admitted on August 27, 2024 and discharged on June 12, 2025. A release of information form for county probation did not have documentation that the client was offered a copy of the consent form.
Client #7 was admitted on October 29, 2024 and was still active at the inspection. A release of information form for a funding source did not have documentation that the client was offered a copy of the consent form.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On June 26, 2025, the program director held an all-staff meeting to educate staff on 709.28(d) Confidentiality Policy and Procedure 709.28(d) and how to properly complete the client consent forms, which included offering copies of all voluntary consent signed by clients and how to identify/document the client's acceptance or refusal of a copy in facility's Electronic Medical Record system. The program director is currently conducting an internal audit of all active clients to ensure active clients have been offered copies of their voluntary consent and that such an offer is documented within the form on starting on June 30, 2025, and to be completed by July 10, 2025. Client #7 has a new ROI form awaiting the client's signature. The program director placed an alert in the facility's Electronic Medical Record system, which has been sent to all staff, alerting them to the client's need to sign and the staff's need to document the client's acceptance or refusal of the release. Lead Counselor conducting internal audits on all new client charts to ensure each client has complete client consent forms which included offering copies of all voluntary consent signed by clients and the consent identity/document of the client's acceptance or refusal of a copy with a minimum of 10% of active client charts to be audited for same, starting on June 30, 2025. The program director will review all audits for any discrepancies beginning on July 3, 2025. Lead Counselor conducting monthly intern chart audits to ensure compliance. The program director will provide training to new staff and ensure documentation compliance. The program director will ensure that policy and audit procedures are followed, starting on July 10, 2025. |
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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in five of seven applicable records reviewed.
Client # 1 was admitted on January 15, 2025 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on January 15, 2025, and the treatment plan update was due no later than March 15, 2025; however, the update was not completed until May 23, 2025.
Client #3 was admitted on January 13, 2025 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on January 16, 2025, and the treatment plan update was due no later than March 16, 2025; however, the update was not completed until March 26, 2025.
Client #5 was admitted on August 27, 2024 and discharged on June 12, 2025. A comprehensive treatment and rehabilitation plan was completed on August 28, 2024, and the treatment plan update was due no later than October 28, 2024; however, the update was not completed prior to the client ' s discharge.
Client #6 was admitted on January 07, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was completed on January 21, 2025, and the treatment plan update was due no later than March 21, 2025; however, the update was not completed until May 21, 2025.
Client #7 was admitted October 29, 2024 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was completed on October 29, 2024, and the treatment plan update was due no later than December 29, 2024; however, the update was not completed until March 06, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 29, 2024 licensing inspection.
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Plan of Correction
The program director held all-staff meetings reviewing policy and procedure TREATMENT /REHABILITATION MANAGEMENT services 28 Pa. Code 709.92 (b) on June 26, 2025, and our policy timeline of updating treatment plans every sixty (60) days. The facility is in the process of being onboarded with state-of-the-art Electronic Medical Record to assist in streamlining tracking and eliminate our failure to document treatment plan updates within the regulatory timeframe, treatment plans no later than September 1, 2025. In the interim, starting on June 28, 2024, the program director with assistance of the lead counselor are creating a spreadsheet/calendar and tracking log which will identify treatment plan due dates. The program director will meet with clinical staff weekly to review spreadsheets and identify treatment plans due for updates and complete updates with clients during sessions starting on July 3, 2025. The program director will audit charts weekly to ensure compliance starting on 7/3/2025. The program director is conducting a full audit of all current client charts to identify any additional missing or overdue treatment plan updates to be completed by 7/15/2025. |
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 a case consultation within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 90 days following admission.
Client #1 was admitted on January 15, 2025 and was still active at the time of the inspection. A case consultation was due no later than April 15, 2025; however, it was not completed until June 04, 2025.
Client #4 was admitted on September 9, 2024 and was discharged on May 28, 2025. A case consultation was due no later than December 9, 2024, and March 9, 2025, however, there is no documentation that one was completed.
Client #5 was admitted on August 27, 2024 and was discharged on June 12, 2025. A case consultation was due no later than November 27, 2024, however, there is no documentation that one was completed.
Client #7 was admitted on October 29, 2024 and was still active at the time of the inspection. A case consultation was due no later than January 29, 2025, and April 29, 2025, however, one was not completed until June 06, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 29, 2024 licensing inspection.
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Plan of Correction
The program director held all-staff meetings reviewing policy and procedures of TREATMENT /REHABILITATION MANAGEMENT 28 Pa. Code 709.93 (a) on June 26, 2025, and our policy timeline of case consults quarterly/every ninety (90) days. The facility is in the process of being on boarded with a different Electronic Medical Record (EMR) company to assist in streamlining tracking and eliminate our failure to document case consultants as established by our facility's policy and procedures manual no later than September 1, 2025. In the interim starting on June 28, 2024, the program director and lead counselor are creating a spreadsheet/calendar and tracking log that will identify each client's case consult due date. The program director will meet Clinical staff weekly to review spreadsheets and identify clients who are due for case consultants. The program director will audit charts weekly to ensure compliance starting on July 3, 2025. The program director is conducting a full audit of all current client charts to identify any additional missing or overdue case consultations and updating as needed to be completed by July 15,2025. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, in two of three applicable records reviewed.
Client #2 was admitted on August 13, 2024 and was discharged on November 15, 2024. The client record did not contain documentation of an aftercare plan.
Client #4 was admitted on September 09, 2024 and was discharged on May 28, 2025. The client record did not contain documentation of an aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director held an all-staff meeting reviewing policy and procedure 28 Pa. Code 709.93 (a) on July 2, 2025, to discuss after-care planning which will occur during the intake process. The program director updated policy and procedure Re:709.29 (a) to reflect that aftercare planning will start at time of intake. Aftercare planning will then occur every ninety (90) days or upon client discharge for the first year of treatment. Aftercare planning will then be updated annually or as the client indicates. The facility is in the process of being onboarded with a different Electronic Medical Record system/company to assist in streamlining tracking and eliminate our failure to document case consultation within guidelines established by the facility's policy and procedures manual, no later than September 1, 2025. In the interim, the program director, with assistance from the lead counselor, are creating a spreadsheet/calendar and tracking log that will identify each client's aftercare plan due date. The program director will meet with the clinical staff weekly to review spreadsheets and clients who will be due for aftercare plan. The program director will audit charts weekly to ensure compliance starting on July 8, 2025. The program director is conducting a full audit of all current client charts to identify any additional missing or overdue aftercare planning and will update as needed to be completed by July 22, 2025 |
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 document follow up information within guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed 30 days following discharge.
Client #2 was admitted on August 13, 2024 and discharged on November 15, 2024. A follow up was due no later than December 15, 2024; however, it was not completed until May 27, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program director held an all-staff meeting reviewing policy and procedure 28 Pa. Code 709.93 (a) on July 2, 2025, to review follow-up information which will occur one month or 30 days after discharge from the facility. The facility is in the process of being onboarded with a different Electronic Medical Record system/company to assist in streamlining tracking and eliminate our failure to document Follow-up information within guidelines established by the facility's policy and procedures manual, no later than September 1, 2025. In the interim, the program director, with assistance from the lead counselor, are creating a spreadsheet/calendar and tracking log that will identify each client's need for follow-up due date and documentation. The program director will meet with clinical staff weekly to review spreadsheets and clients who will be due for follow-up information and documentation. The program director will audit charts weekly to ensure compliance, starting on July 8, 2025. The program director is conducting a full audit of all current client charts to identify any additional missing or overdue follow-up information and updating as needed to be completed by July 22, 2025. |