INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 31, 2025 through August 1, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure that counselor assistants were given semiannual performance evaluations in one of two applicable personnel records reviewed. The facility documentation titled Semi-Annual Review for Counselor Assistants - 180 days is automatically scheduled following the date of hire in the position.
Employee # 14 was promoted to the position of counselor assistant on July 1, 2024. The personnel record had a document dated February 28, 2025, titled Semi-Annual Review for Counselor Assistants - 180 days that was blank at the time of the inspection, and no other documentation of a semi-annual review was in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure completion of semiannual performance evaluations for counselor assistants within the required timeframe, the clinical director will utilize a monthly tracking system and the training champion (office manager and administrative assistant) will run a quarterly compliance report via our internal workforce management system. Based on these monitoring efforts, the ED will review needed performance evaluations with the appropriate managers monthly so they can complete with each counselor assistant within the required timeframes. This system will be rolled out on September 14, 2025, for the 2025 Performance Evaluations. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee # 14 was promoted to the position of counselor assistant on July 1, 2024. Employee # 14 had a GED at the time of promotion, and may counsel clients only under the direct supervision of a trained counselor or clinical supervisor for the first 3 months of employment and under close supervision for the next 9 months. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision in each week reviewed.
Close supervision is defined by regulation as follows: "Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week."
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical director will utilize the Hillside Supervision Tracker to document and monitor direct supervision for all counselor assistants during their initial three months of employment. The supervision requirements will vary based on the counselor assistant's education level, in accordance with state regulations. Compliance with state regulations will be verified through weekly reviews every Monday. The ED will review the tracker biweekly to provide additional accountability. This process will be rolled out on 9/14/2025. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that counselor assistants documented to the facility director, upon the completion of each calendar year, that they are continuing to work towards counselor status in two of two applicable personnel records reviewed.
Employee # 12 has been in the position of counselor assistant since April 15, 2024. There was no documentation to the facility director that they were working toward counselor status by the end of the 2024 calendar year as of the date of the inspection.
Employee # 14 has been in the position of counselor assistant since July 1, 2024. There was no documentation to the facility director that they were working toward counselor status by the end of the 2024 calendar year as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and Clinical Leads will utilize the Hillside Training Tracker electronic tracking system to ensure consistent documentation and recording of positive assessments and intents to counsel. The Training Champion (Office Manager and Administrative Assistant) will monitor this process biweekly to ensure compliance and accuracy. Documentation of positive assessments and intents to counsel will be implemented by September 14, 2025. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level per the facility ' s policy and procedures manual in five out of fourteen employee records reviewed. The facility ' s policy and procedures manual states that the annual individual training plan is due by December 31.
Employee # 3 has been in the position of clinical supervisor since November 27, 2022. The plan is dated June 27, 2025.
Employee # 4 has been in the position of counselor since October 27, 2024. The plan is dated May 15, 2025.
Employee # 6 has been in the position of counselor since February 24, 2025. Employee # 6 should have had an initial individual training plan developed within 30 days of the date of hire; however, a written individual training plan was not developed until May 12, 2025.
Employee # 9 has been in the position of counselor since February 24, 2025. Employee # 9 should have had an initial individual training plan developed within 30 days of the date of hire; however, a written individual training plan was not developed until May 15, 2025.
Employee # 12 has been in the position of counselor assistant since April 15, 2024. The plan is dated June 30, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Hillside will utilize the Hillside Training Schedule electronic tracker to ensure that Training Plans i.e., Individual Development Plans (IDPs) are completed promptly, with all plans finalized by December 31, 2025. The Training Champion (Office Manager and Administrative Assistant) will maintain biweekly oversight to ensure compliance and accuracy ensuring all new hires have the IDP completed within the first 30 days of employment. Documentation of IDPs will be fully integrated into the electronic tracking system by September 14, 2025. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that two applicable employees received a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee # 12 has been in the position of counselor assistant since April 15, 2024. Employee # 12 was due to have the communicable disease trainings no later than April 15, 2025; however, the TB/STD training was not completed as of the date of the inspection.
Employee # 16 has been in the position of Maintenance since October 18, 2021. Employee # 16 was due to have the communicable disease trainings no later than November 30, 2024, per the Department approved plan of correction for the July 11, 2024 annual licensing renewal inspection. However, the HIV/AIDS training was not completed until June 11, 2025 and the TB/STD training was not completed until July 9, 2025.
This is a repeat citation from the July 11, 2024, August 3, 2023, and September 6, 2022 annual licensing renewal inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Hillside Leadership will utilize the training tracker in a electronic tracking system to ensure that TB/STD trainings are completed within the regulatory timeframe. The Training Champion (Office Manager and Administrative Assistant) will maintain biweekly oversight to ensure compliance and accuracy. The ED will perform biweekly auditing of the electric tracking system as added accountability. TB/STD training will be fully integrated into the Smartsheet system by September 14, 2025. Employee #12 completed her training on 9/14/2025. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on August 1, 2025, the facility failed to provide operable soap dispensers in each bathroom as bathrooms in bedrooms 102, 108, 202, and D-5 did not have operable soap dispensers.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Maintenance Manager has implemented detailed checklists for Housekeeping staff to ensure thorough cleaning and maintenance of designated areas. These checklists specify areas requiring attention, include sections for comments to enhance communication with maintenance management, and address the specific needs of each bathroom. The maintenance manager reviews and signs off on these checklists daily and uploads to an electronic tracking system.To ensure compliance with state regulations, these checklists will be reviewed biweekly and will be officially rolled out on 9/14/2025.It should be noted those soap dispensers have since be corrected. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection on August 1, 2025, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. Shower curtains in bathrooms of bedrooms 105, 109, 203, 205, 212, and D-4 appeared to have a mold or mildew substance.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The maintenance manager has implemented detailed checklists for Housekeeping staff to ensure thorough cleaning and maintenance of designated areas. These checklists specify areas requiring attention, include sections for comments to enhance communication with maintenance management, and address the specific needs of each bathroom. The maintenance manager reviews and signs off on these checklists daily and uploads to an electronic tracking system. To ensure compliance with state regulations, these checklists will be reviewed biweekly and will be officially rolled out on 9/14/2025. It should be noted these shower curtains were replaced on the same day as the audit. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection on August 1, 2025, the facility failed to ensure that exits from the residential facility were unobstructed. A second floor emergency exit door from the Annex and two exits from the Withdrawal Management unit were obstructed, as they were locked.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Hillside has submitted a Facility Exception Request for DDAP Regulation 705.10(a)(1)(i), ensuring that stairways, hallways, and exits from rooms and the residential facility remain unobstructed, in compliance with regulatory standards. In the event the exception request get's denied, the facility would have to increase zone placement of BHTs around the facility (implemented by BHT Manager) as well as upgrade the camera system (Maintenance Manager). This would be a large overhaul, the completion of which would be approximately 90 days out - 11/29/2025 |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from August 2024 through June 2025, the facility failed to conduct an unannounced fire drill at least once a month. The facility failed to conduct an unannounced fire drill during March 2025. Additionally, the fire drill logs for the 2025 months of January, February, April, and May indicated that the drills were announced.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Hillside has appointed a Safety Champion (Maintenance Manager) tasked with auditing Frill Drill and Safety Drill electronic tracking system and conducting documented walk-throughs to ensure comprehensive client safety. The Safety Champion will be re-educated on the regulatory expectation on September 1, 2025. This initiative will officially commence on September 14, 2025. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that personnel records contained an annual written performance evaluation that was reviewed and signed by the employee in two of four applicable personnel records reviewed.
Employee # 2 has been in the position of Facility Director since January 21, 2024 and is current in that position. The annual written staff performance evaluation documented in the record was not signed by the employee as of the date of the inspection.
Employee # 12 has been in the position of counselor assistant since April 15, 2024 and is current in that position. The annual written staff performance evaluation that was documented in the record was not completed as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Hillside has implemented an electronic tracker system to monitor the status of each Performance Evaluation. Supervised by the Training Champion (office manager and administrative assistant), the tracker will be reviewed biweekly until completion. The official rollout is scheduled for September 1, 2025 |
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 the review of client records, the project failed to offer a copy of release of information forms for the funding source in eleven of eleven applicable client records reviewed.
Client # 1 was admitted to the inpatient non-hospital detoxification level of care on January 11, 2025 and transferred to the inpatient non-hospital rehabilitation level of care on January 14, 2025, and was subsequently discharged on February 11, 2025. There was no documentation the client was offered a copy of the release of information form.
Client # 2 was admitted to the inpatient non-hospital detoxification level of care on January 25, 2025 and was discharged on January 30, 2025. There was no documentation the client was offered a copy of the release of information form.
Client # 3 was admitted to the inpatient non-hospital detoxification level of care on April 2, 2025 and was discharged on April 6, 2025. There was no documentation the client was offered a copy of the release of information form.
Client # 4 was admitted to the inpatient non-hospital detoxification level of care on June 12, 2025 and was discharged on June 17, 2025. There was no documentation the client was offered a copy of the release of information form.
Client # 5 was admitted to the inpatient non-hospital detoxification level of care on January 21, 2025 and was discharged on January 26, 2025. There was no documentation the client was offered a copy of the release of information form.
Client # 6 was admitted to the inpatient non-hospital detoxification level of care on June 17, 2025 and transferred to the inpatient non-hospital rehabilitation level of care on June 22, 2025, and was active at the time of the inspection. There was no documentation the client was offered a copy of the release of information form.
Client # 7 was admitted to the inpatient non-hospital detoxification level of care on June 17, 2025 and transferred to the inpatient non-hospital rehabilitation level of care on June 22, 2025, and was active at the time of the inspection. There was no documentation the client was offered a copy of the release of information form.
Client # 8 was admitted to the inpatient non-hospital rehabilitation level of care on February 16, 2025 and was discharged on March 1, 2025. There was no documentation the client was offered a copy of the release of information form.
Client # 9 was admitted to the inpatient non-hospital rehabilitation level of care on April 24, 2025 and was discharged on May 27, 2025. There was no documentation the client was offered a copy of the release of information form.
Client # 11 was admitted to the inpatient non-hospital rehabilitation level of care on May 7, 2025 and was discharged on May 21, 2025. There was no documentation the client was offered a copy of the release of information form.
Client # 12 was admitted to the inpatient non-hospital rehabilitation level of care on April 13, 2025 and was discharged on April 26, 2025. There was no documentation the client was offered a copy of the release of information form.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Pyramid Healthcare has submitted a ticket into its health records system to add an enhancement. This enhancement will denote that a copy of the Consent for Treatment, Payment and Healthcare Operations consent is offered to the client and will be memorialized and maintained in the client record. This denote will be a required field at the bottom of the document. As a result, staff will be unable to move forward to complete the document without the review and acknowledgement of whether a copy was offered to the client or not. Compliance monitors on a monthly basis the completion of the Consent for Treatment, Payment and Healthcare Operations consent for all clients active in treatment. The monitoring information is shared with the facilities operations and clinical leadership team through a scorecard to review and identify if any client receiving care may be missing one. If clients are determined to be missing a document, facility leadership and/or designee will be responsible for ensuring completion of the Consent for Treatment, Payment and Healthcare Operations consent with those clients and offering a copy.
Intake Supervisor will re-educate staff on the expectation to offer a copy of the Treatment, Payment and Healthcare Operations consent to each client and document that offering on the updated consent form in a staff meeting by 10/1/2025. This re-education will be recorded in the meeting minutes/notes.
In order to monitor compliance with our plan of correction, the Clinical Supervisor will be responsible for weekly supervision with direct care staff to ensure compliance. Executive Director will supervise the Clinical Supervisor weekly to monitor the plan of correction. Executive Director will provide updates to the Regional Director bi-weekly to ensure compliance with plan of correction
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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 a review of client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project, in one of the applicable records reviewed.
Client # 10 was transferred to the inpatient non-hospital rehabilitation level of care on January 14, 2025 and was involuntarily discharged on February 11, 2025. The record did not contain documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Case Coordination Manager will implement a Daily Clinical Discharges tracker to monitor and track all Discharge Management Plans (DMPs). This digital tool must be completed by all case coordinators prior to a client's discharge and ensures compliance with regulations by verifying the following the proper completion of DMPs (which includes written notification of all discharges). Case Coordination Manager will educate all case coordinators on the system by 9/4/2025. The Executive Director will perform biweekly audits of the tracker. The system will go live on September 14, 2025. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include a discharge summary, in two of four applicable records reviewed.
Client # 3 was admitted to the inpatient non-hospital detoxification level of care on April 2, 2025 and was discharged on April 6, 2025. The record did not contain a discharge summary.
Client # 5 was admitted to the inpatient non-hospital detoxification level of care on January 21, 2025 and was discharged on January 26, 2025. The record did not contain a discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Case Coordination Manager will implement a Clinical Discharges tracker to monitor and track all Discharge Management Plans (DMPs). This digital tool must be completed by case coordinators prior to a client's discharge and ensures compliance with regulations by verifying the following: proper completion of DMPs (which includes the discharge summary). Case Coordination Manager will educate all case coordinators on the system by 9/4/2025The system will go live on September 14, 2025. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of seven client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within 24 hours of admission or transfer from a higher level of care, per facility policy, in five of six applicable records reviewed.
Client # 8 was admitted to the inpatient non-hospital rehabilitation level of care on February 16, 2025 and was discharged on March 1, 2025. The psychosocial evaluation was not completed until February 24, 2025.
Client # 9 was admitted to the inpatient non-hospital rehabilitation level of care on April 24, 2025 and was discharged on May 27, 2025. The psychosocial evaluation was not completed until May 6, 2025.
Client # 11 was admitted to the inpatient non-hospital rehabilitation level of care on May 7, 2025 and was discharged on May 21, 2025. The record did not contain a psychosocial evaluation.
Client # 12 was admitted to the inpatient non-hospital rehabilitation level of care on April 13, 2025 and was discharged on April 26, 2025. The psychosocial evaluation was not completed until April 21, 2025.
Client # 14 was transferred to the inpatient non-hospital rehabilitation level of care on June 22, 2025 and was active at the time of the inspection. The psychosocial evaluation was not completed until July 1, 2025.
This is a repeat citation from the July 11, 2024 annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
To ensure compliance with state regulations and Pyramid Healthcare policies, we will implement the Hillside Initial Clinical Documentation Tracking System, effective September 14, 2025. This system will monitor all required initial clinical documentation for each client, including the initial case consultation, DAP note, treatment plan, and Level of Care Assessment (LOCA), which encompasses a comprehensive biopsychosocial evaluation. If the LOCA remains incomplete by the end of the business day, an automated notification will be sent to nighttime staff with clear instructions and deadlines to ensure its completion. Staff training on the system and compliance requirements will begin September 1, 2025, and regular audits will be conducted by the Clinical Director to evaluate system effectiveness and compliance rates, with adjustments made as needed. Executive Director will perform biweekly audits as a secondary measure. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 ensure a complete client record included information relative to the client's involvement with the project, to include case consultation notes, at discharge, per facility policy, in two of six applicable records reviewed.
Client # 8 was admitted to the inpatient non-hospital rehabilitation level of care on February 16, 2025 and was discharged on March 1, 2025. The record did not contain documentation of a case consultation.
Client # 11 was admitted to the inpatient non-hospital rehabilitation level of care on May 7, 2025 and was discharged on May 21, 2025. The record did not contain documentation of a case consultation.
This is a repeat citation from the July 11, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Case Coordination Manager will implement a Clinical Discharges tracker to monitor and track all Discharge Management Plans (DMPs). This digital tool must be completed prior to a client's discharge by case coordinators and ensures compliance with regulations by verifying the following: proper completion of DMPs (which includes the case consultation). Case Coordination Manager will educate all case coordinators on the system by 9/4/2025. The system will go live on September 14, 2025. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include a discharge summary, in two of five applicable records reviewed.
Client # 8 was admitted to the inpatient non-hospital rehabilitation level of care on February 16, 2025 and was discharged on March 1, 2025. The record did not contain documentation of a discharge summary.
Client # 11 was admitted to the inpatient non-hospital rehabilitation level of care on May 7, 2025 and was discharged on May 21, 2025. The record did not contain documentation of a discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Case Coordination Manager will implement a Clinical Discharges tracker to monitor and track all Discharge Management Plans (DMPs). This digital tool must be completed prior to a client's discharge by case coordinators and ensures compliance with regulations by verifying the following: proper completion of DMPs (which includes the discharge summary). Case Coordination Manager will educate all case coordinators on the system by 9/4/2025The. The system will go live on September 14, 2025.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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 ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in two of five applicable records reviewed.
Client # 8 was admitted to the inpatient non-hospital rehabilitation level of care on February 16, 2025 and was discharged on March 1, 2025. The record did not contain documentation of follow-up information.
Client # 11 was admitted to the inpatient non-hospital rehabilitation level of care on May 7, 2025 and was discharged on May 21, 2025. The record did not contain documentation of follow-up information.
This is a repeat citation from the July 11, 2024, August 3, 2023, and September 6, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To enhance the 7-Day Follow-Up process for clients discharged from the residential and withdrawal management programs, the case coordination team, led by the Case Coordination Manager, will oversee the implementation of an updated Standard Operating Procedure (SOP) with training completed by 09/14/2025. Effective immediately, upon finalization of a discharge plan, the Case Coordination Manager will ensure each client is added to the 7-Day Follow-Up tracker, documenting the client's name, Carelogic ID, level of care, discharge date, scheduled follow-up call date, responsible case coordinator, and task completion status, with all calls (successful or not) recorded exclusively in a memo-to-chart in the EMR to streamline documentation. The tracker will include an automated notification system, requiring the Case Coordination Manager to confirm call completion within 24 hours on the 7th day from the entered discharge date, or an alert will be sent to the Executive Director for added accountability. The Case Coordination Manager, along with the Intake Supervisor, will audit the Smartsheet every Monday and Friday starting 9/15/2025 to ensure timely additions and task completion, while the Executive Director will conduct random chart audits of active and discharged clients to verify compliance. Weekly compliance reviews will be reported during monthly management meetings, with any issues addressed through additional staff training or process adjustments, beginning 09/16/2025, to ensure complete client records and adherence to facility policy and regulatory requirements. |
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 the review of client and personnel records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction for mandatory communicable disease training was submitted and approved by the Department for the July 11, 2024, August 3, 2023, and September 6, 2022 annual licensing inspections. Mandatory communicable disease trainings was again found to be a deficiency in the July 31, 2025 through August 1, 2025 licensing inspection.
A plan of correction for a complete client record that includes follow-up information was submitted and approved by the Department for the July 11, 2024, August 3, 2023 and September 6, 2022 annual licensing inspections. Follow-up information was again found to be a deficiency in the July 31, 2025 through August 1, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Executive Director will ensure plans of corrections are implemented and followed. The Executive Director will monitor the implementation of the plans of corrections bi-weekly to ensure the plans continue to be followed.This will be effective 9/14/2025. |