INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clinical Outcome Group, 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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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection conducted on February 19, 2026, the facility failed to ensure fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
A fire extinguisher located in the hallway of the facility was last inspected in May 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director notified the head of building maintenance on 02/19/2026 that the fire extinguisher at the end of the hall was not inspected since last year. The maintenance department will contact the agency that takes care of the fire extinguishers to ensure the extinguisher is inspected timely.
The fiscal director will work with the agency that inspects the fire extinguishers annually to ensure that all extinguishers are up to date. This will occur annually in the month of April. |
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 five of seven records reviewed.
Client #1 was admitted on April 25, 2025 and was active client at the time of the inspection. A comprehensive treatment and rehabilitation plan update was documented in the record on December 4, 2025, with the next update due no later than February 4, 2026; however, there was no updated treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client #2 was admitted on July 21, 2025 and was active client at the time of the inspection. A comprehensive treatment and rehabilitation plan was documented in the record on July 24, 2025, with the next update due no later than September 24, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until January 9, 2026.
Client #5 was admitted on February 13, 2025 and was discharged July 24, 2025. A comprehensive treatment and rehabilitation plan was documented in the record on February 26, 2025, with the next update due no later than April 26, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until May 14, 2025.
Client #6 was admitted on February 20, 2025 and was discharged July 7, 2025. A comprehensive treatment and rehabilitation plan update was documented in the record on March 6, 2025, with the next update due no later than May 6, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client #7 was admitted on March 10, 2025 and was discharged August 28, 2025. A comprehensive treatment and rehabilitation plan update was documented in the record on April 21, 2025, with the next update due no later than June 21, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record at the time of the inspection.
This is a repeat citation from the January 15, 2025 and February 21, 2024, annual licensing renewal inspections.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
Clinical Supervisor reviewed in staff meeting on February 26, 2026. It was explained that all treatment plan updates were due every 60 days, regardless of the date the client signs the form.
A review of clients 1, 2, 5, 6 & 7 will be done to ensure that a treatment plan update is completed every 60 days schedule going forward. All clients listed will have their current due treatment plan updates completed by their effective dates.
By 3/30/2026, a review of the client charts 1, 2, 5, 6, 7 will be reviewed by the team to ensure compliance.
A quality assurance team was developed in November 2025 to complete random chart audits. Each month the team reviews 80 client charts for regulation compliance.
Beginning November 1, 2025, a system was put in place within the ECR to fail claims that do not have an active treatment plan. An active treatment plan is a plan updated every 60 days and must have the client, the counselor and the doctor's signature. |
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 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 case consultation notes entered every 90 days, per the facility's policy, in four of seven records reviewed.
Client #2 was admitted on July 21, 2025 and was active client at the time of the inspection. A case consultation note was not documented in the record within 90 days of the date of service, per the facility's policy.
Client #5 was admitted on February 13, 2025 and was discharged July 24, 2025. A case consultation note was not documented in the record within 90 days of the date of service, per the facility's policy.
Client #6 was admitted on February 20, 2025 and was discharged July 7, 2025. A case consultation note was not documented in the record within 90 days of the date of service, per the facility's policy.
Client #7 was admitted on March 10, 2025 and was discharged August 28, 2025. A case consultation note was not documented in the record within 90 days of the date of service, per the facility's policy.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
The Executive Director reviewed this finding with staff during our staff meeting on February 26, 2026.
Our quality assurance team will conduct an audit on clients2, 5, 6, 7 to determine whether the case consult was completed. If the client was discharged from services prior to case consult completion, a note will be made on our audit forms.
All staff will be trained and directed in Clinical Supervision on 3/5/2026 about the guidelines and time frames of completing case consults timely.
The quality assurance team will be completing a minimum of 80 chart reviews to ensure compliance. This has been occurring since November 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 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 three to six months of the client's discharge, per the facility's policy, in two applicable records reviewed.
Client #5 was admitted on February 13, 2025 and was discharged July 24, 2025. There was no follow-up contact information documented in the client record at the time of the inspection.
Client #6 was admitted on February 20, 2025 and was discharged July 7, 2025. There was no follow-up contact information documented in the client record at the time of the inspection.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
Executive Director discussed the follow up findings with the staff on February 26, 2026.
During our clinical supervision on 3/5/2026, the outreach and follow-up policy will be reviewed.
Each month our fiscal director will be printing out a list of all clients that were discharged the previous month. The office admin staff member will send follow up letters to all clients that were admitted into our program. The follow ups will be completed within 3-6 months from discharge. |
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 failing to review and update treatment and rehabilitation plans at least every 60 days was submitted and approved by the Department for the February 21, 2024, and January 15, 2025, annual licensing inspections. Failing to review and update treatment and rehabilitation plans at least every 60 days was again found to be a deficiency in the February 19, 2026, licensing inspection.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
With the systems that were put into place on November 1, 2025, the issue with treatment plan updates should be lessened. The quality assurance team will be working monthly on reviewing/auditing charts for compliance.
Beginning February 23, 2026, the individual that is completing the chart audits will be reviewing past chart audits to ensure on-going compliance.
Beginning Nov 2025, the system within the ECR will fail claims if a treatment plan is not updated. This will be an extra reminder to complete the task timely. |