INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 15-16, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cornell Abraxas I 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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709.26 (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 annual written individual staff performance evaluations were completed per the facility's policy and procedure manual in six of eight records reviewed.
The facility's policy and procedure states that the annual job performance evaluations are due at the end of each fiscal year. The following staff did not have a performance evaluation from July 2025.
Employee #2 was hired April 7, 2008 and promoted to clinical supervisor on June 7, 2021.
Employee #5 was hired as counselor assistant July 24, 2023 and promoted to counselor on August 18, 2025.
Employee #6 was hired October 7, 1996 and promoted to counselor on March 9, 2008.
Employee #7 was hired as counselor on October 31, 2022.
Employee #8 was hired as counselor on November 27, 2023.
Employee #9 was hired as counselor assistant July 24, 2023 and promoted to counselor on October 11, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By 2/19/2026, the Human Resources Business Partner will notify the supervisors of the six employees identified during the inspection that their employees' performance evaluations must be completed and submitted by 2/28/2026. By 2/28/2026, the Human Resources Business Partner will complete a review of all employee files to verify all performance evaluations are up to date and filed in personnel records. Supervisors with overdue performance evaluations will be notified immediately and provided with a new due date of 3/13/2026.
By 2/19/2026, the Human Resources Business Partner will create a spreadsheet to track due dates and completion dates of annual employee performance evaluations. Beginning 2/19/2026, the Human Resources Business Partner will send a monthly notification to supervisors who have employee performance evaluations due within 30 days. The Human Resources Business Partner will document completion on the spreadsheet and maintain the performance evaluation in the employee's personnel file.
Beginning with the March 2026 Leadership Team meeting, the Human Resources Business Partner will report monthly to the Leadership Team regarding the status of performance evaluations (number completed/number due). Leadership team members will follow up with individual supervisors who have not submitted performance evaluations on time and document the follow up in a supervisory conference.
By 3/31/2026, the Leadership Team will review the policies regarding completion of annual performance evaluations and competency assessments. Any necessary policy revisions will be completed by 4/15/2026 and communicated to supervisory employees for clarification.
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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 form prior to the disclosure of information in seven of seven records.
The facility switched from paper charts to electronic health records in February 2025. According to staff interviews, no client charts included any consent to release information forms from the start of the electronic health records to August 2025. All records reviewed included disclosures without consent to release information.
Client #1 admitted May 14, 2025 and discharged November 14, 2025. One consent to a government agency was signed by client on September 21, 2025. Disclosures to guardians and multiple agencies were confirmed on May 19, July 8, August 8, September 11, October 13, October 16, October 23, and November 20, 2025. Additionally, billing was confirmed without a consent to release information to the funding source.
Client #2 admitted June 4, 2025 and discharged December 9, 2025. Consents to multiple agencies and funding source were signed by client on August 12 and August 18, 2025. Disclosures to multiple agencies, and funding source were confirmed on June 4, July 3, August 5, and August 11, 2025.
Client #3 admitted July 17, 2025 and discharged December 18, 2025. Consents to multiple agencies, guardians, and funding source were signed by client on August 18, 2025. Disclosures to multiple agencies, guardians, and funding source were confirmed on July 18, July 21, August 1, and August 13, 2025.
Client #4 admitted July 10, 2025 and discharged November 14, 2025. No valid consents to release information in client chart during admission. Disclosures made to funding source throughout stay.
Client #5 admitted June 4, 2025 and discharged December 12, 2025. Consents to multiple agencies, guardians, and funding source were signed by client on August 25, 2025. Disclosures to multiple agencies, guardians, and funding source were confirmed on June 4 and July 17, 2025.
Client #6 admitted May 28, 2025 and discharged December 19, 2025. Consent to release information to funding agency signed on August 25. Consent to release information to government agency signed on September 21, 2025. No consent to release information to clients guardian on file. Disclosures without consents confirmed on June 3, July 2, July 7, and July 21, 2025.
Client #7 admitted May 22, 2025 and discharged October 29, 2025. Consents to multiple agencies, guardians, and funding source were signed by client on August 13 and August 18, 2025. Disclosures without consents confirmed on May 23, July 1, July 13, and July 13, 2025.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the February 25, 2025, February 14, 2024 annual licensure inspections and September 4, 2024 follow up inspection.
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Plan of Correction
709.28 C ? Releases of Information not signed and not obtained
By 2/27/2026, the Clinical Director and Program Manager for D/A Treatment will audit all current drug and alcohol clients' records to verify all applicable consent to release information forms have been completed and signed. Counselors will be assigned to complete missing documents with their clients by 3/6/2026.
By 3/13/2026, the Clinical Director will provide refresher training to clinical staff on the requirements for the use of consent to release information forms. This training will include the applicable drug and alcohol confidentiality law, when consent to release information must be obtained and for whom, instructions on where to find the forms and how to complete them, possible restrictions, and how they will be maintained and updated. The Clinical Director will verify all clinical staff have completed the training. Documentation will be maintained within the employee training record.
Beginning 3/14/2026, the Treatment Supervisor completing the client's admission will obtain signed release of information forms for all required parties. Subsequent releases of information will be identified and obtained by the client's assigned counselor. All releases of information will be maintained within the client's record.
Beginning 3/14/2026, Counselors and Treatment Supervisors will audit their clients' records on a monthly basis to verify releases of information are complete for all required parties. This audit will be conducted on an ongoing basis to verify sustained compliance.
For 60 days, beginning 3/14/2026, the Clinical Director will audit all new client admissions and clinical staff file audits to verify consent to release information has been obtained and signed forms are maintained within the client record. If there are missing releases of information or releases of information are not completed correctly, a supervisory conference will be completed with the employees responsible. The Clinical Director will report findings from these audits at the monthly Leadership Team meeting for a period of 60 days or until compliance is achieved.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on the review of medication administration records, the facility failed to document the administration, or the reason a medication was not administered as prescribed in seven of seven records reviewed.
Client #1 admitted May 14, 2025 and discharged November 14, 2025.
A medication was prescribed to be given once daily at bedtime. The MAR was left blank for the following dates: July 4, July 5, and July 6, 2025.
A second medication was prescribed to be given once daily at bedtime. The MAR was left blank for the following dates: July 27, August 2, August 8, and August 9, 2025.
A third medication was prescribed to be given once daily at bedtime. The MAR was left blank for the following dates: October 18, October 22-27, October 29, October 31, November 1, November 4-9, and November 12-13, 2025.
Client #2 admitted June 4, 2025 and discharged December 9, 2025.
A medication was prescribed to be given once daily in the morning. The MAR was left blank for the following dates: June 21-23, and June 28-30, 2025.
A second medication was prescribed to be given once daily every morning. The MAR was left blank for the following dates: June 14, June 21-23, June 28-30, July 2, July 4, July 6, July 9, July 14, July 17, July 20-21, July 25, July 27, July 31, August 11, August 30, September 5, September 18, and September 21-22, 2025.
A third medication was prescribed to be given once daily every morning. The MAR was left blank for the following dates: July 2, July 4, July 6, July 9, July 11, July 14, July 17, July 21, July 25, July 27, July 31, August 11, August 30, September 5, September 18 and September 21-22, 2025.
Client #3 admitted July 17, 2025 and discharged December 18, 2025.
A medication was prescribed to be given once daily. The MAR was left blank for the following dates: September 5, September 14, September 18, September 21-22, September 30, October 5, October 10, October 11, October 16, October 18-19, October 25, October 27, November 2-3, November 12-14, and November 23, 2025.
Client #4 admitted July 10, 2025 and discharged November 14, 2025.
A medication was prescribed to be injected intramuscular every 4 weeks. The MAR was left blank for the entire month of August. The first recorded injection was given September 3, 2025 and the next injection would have been due by October 1, 2025 but was not recorded until October 22, 2025.
A second medication was prescribed to be given once daily. The MAR was left blank for the following dates: September 18, September 21-22, September 30, October 5, October 16, October 18-19, October 25, November 2-3, November 6-7, and November 9-14, 2025.
Client #5 admitted June 4, 2025 and discharged December 12, 2025.
A medication was prescribed to be given once daily at bedtime. The MAR was left blank for the following dates: August 2, August 8-9, September 1, October 22-27, October 29, October 31, November 1, November 4-9, November 12-15, November 19, November 22, November 25-27, November 29, and November 31, 2025.
A second medication was prescribed to be given once daily every morning. The MAR was left blank for the following dates: August 10, August 23-24, September 5-7, September 13-14, September 20-21, September 27, September 30, October 4-5, October 11, October 18, October 25, November 1, November 3, November 8, November 15, November 22, November 27-31, 2025.
Client #6 admitted May 28, 2025 and discharged December 19, 2025.
A medication was prescribed to be given once daily every morning. The MAR was left blank for the following dates: August 1-2, August 9-11, August 23-24, September 5-7, September 13-14, September 20-21, September 23, September 27, September 30, October 4-5, October 11, October 18, October 25, November1, November 3, November 8, November 15, November 22, November 27-30, 2025.
A second medication was prescribed to be given once daily at bedtime. The MAR was left blank for the following dates: October 18, October 22-27, October 29, October 31, November 1, November 4-9, November 12-15, November 19, and November 25-29, 2025.
Client #7 admitted May 22, 2025 and discharged October 29, 2025.
A medication was prescribed to be given once daily in the morning. The MAR was left blank for the following dates: July 2, July 4, July 6, July 9, July 11, July 14, July 17, July 21, July 25, July 27, August 11, August 23, August 30, October 5, October 16, October 18-20, October 25, and October 27, 2025.
A second medication was prescribed to be given once daily every morning. The MAR was left blank for the following dates: July 2, July 4, July 6, July 9, July 11, July 14, July 17, July 21, July 25, July 27, August 11, August 23, August 30, September 5, September 18, September 21-22, October 5, October 7, October 11, October 18-20, October 25, and October 27, 2025.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the February 25, 2025 annual licensure inspection.
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Plan of Correction
709.32 ? Medication Control
The Leadership Team has determined that one of the root causes of this finding is the shortage of medication administration trained employees, and the fact that the facility currently has employee vacancies in the Medical Department.
Since 1/16/2026, 24 additional personnel have been scheduled to complete Medication Administration Training with the facility's medication administration trainer. Additionally, to recruit and fill Medical Department staff vacancies, on 2/4/2026, hourly wages for part-time Registered Nurses and Medication Technicians were increased and positions were posted for recruitment. Three Medication Technicians have accepted offers and are to begin the onboarding process with a tentative start date of 3/2/2026. Three Registered Nurses have been interviewed. One Licensed Practical Nurse is scheduled for an interview.
On 2/4/2026, employees with current medication administration certification were scheduled for two booster training courses. Topics to be reviewed include the supervision of self-administration procedures, accurate and timely completion of the Medication Administration Record (MAR), and processes before and after medication administration to prevent medication errors.
Since 2/4/2026, MARs for every client who receives medication have been audited by the end of every shift by Management Team members to verify accurate and complete documentation. Additionally, each day, the Leadership Team reviews the past 24 hours of MAR audits to verify ongoing compliance with the auditing process and to address any issues or concerns immediately.
On 2/9/2026, technical assistance with medication administration procedures and records was provided by a Senior Nurse Manager from another Abraxas site. She will continue to provide ongoing support and training to the Medical Department team.
The process of management oversight and auditing will continue until the Medical Department fills key open staff positions. By 4/1/2026, the Nurse Manager will establish an ongoing process for daily monitoring of MARS to be completed by Medical Department employees and medication administration trained employees. The Nurse Manager will report monthly at the Leadership Team meeting regarding compliance with the medication administration process.
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709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan within the policy timeframe in three of seven records.
The facility ' s policy and procedure states the preliminary treatment plan is developed within 72 hours of admission. The following client records did not include preliminary treatment plans.
Client #1 admitted May 14, 2025 and discharged November 14, 2025.
Client #5 admitted June 4, 2025 and discharged December 12, 2025.
Client #6 admitted May 28, 2025 and discharged December 19, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By 2/27/2026, the Clinical Director and Program Manager for D/A Treatment will audit all current drug and alcohol clients' records to verify all clients admitted within the past 30 days have a preliminary treatment plan. Counselors will be assigned to complete missing preliminary treatment plans with their clients by 3/6/2026.
By 3/13/2026, the Clinical Director will provide Case Management training to clinical staff. Training will include applicable requirements, including instructions for the development of a preliminary treatment plan and time frames for completion. Training documentation will be maintained in the employees' training records.
Beginning 3/14/2026, the Clinical Director will audit the clinical records of all new admissions to verify the client's Preliminary Treatment Plan is completed within 72 hours of admission. If there are missing Preliminary Treatment Plans or if plans are not completed correctly, supervisory conferences will be completed with the employees responsible.
The Clinical Director will report findings from these audits at the monthly Leadership Team meeting for a period of 60 days or until compliance is achieved.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to include the type and frequency of treatment and rehabilitation services on the treatment plan in seven of seven records.
Client #1 admitted May 14, 2025 and discharged November 14, 2025. Treatment plan was developed on June 10, 2025 and did not include type and frequency of treatment and rehabilitation services.
Client #2 admitted June 4, 2025 and discharged December 9, 2025. Treatment plan was developed on July 2, 2025 and did not include type and frequency of treatment and rehabilitation services.
Client #3 admitted July 17, 2025 and discharged December 18, 2025. Treatment plan was developed on August 12, 2025 and did not include type and frequency of treatment and rehabilitation services.
Client #4 admitted July 10, 2025 and discharged November 14, 2025. Treatment plan was developed on August 8, 2025 and did not include type and frequency of treatment and rehabilitation services.
Client #5 admitted June 4, 2025 and discharged December 12, 2025. Treatment plan was developed on July 1, 2025 and did not include type and frequency of treatment and rehabilitation services.
Client #6 admitted May 28, 2025 and discharged December 19, 2025. Treatment plan was developed on June 17, 2025 and did not include type and frequency of treatment and rehabilitation services.
Client #7 admitted May 22, 2025 and discharged October 29, 2025. Treatment plan was developed on June 19, 2025 and did not include type and frequency of treatment and rehabilitation services.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By 3/13/2026, the Clinical Director will provide Treatment Planning training to clinical staff. This training will include ensuring that the type and frequency of services provided to clients are incorporated into treatment plans. Training documentation will be maintained within the employees' training record.
Beginning 3/14/2026, Counselors and Treatment Supervisors will complete monthly auditing on their client records to include verifying active treatment plans include the type and frequency of services.
Beginning 3/24/2026, the Clinical Director will review the audit findings. If the Clinical Director identifies treatment plans that do not include the type and frequency of services, supervisory conferences will be completed with the employees responsible. The Clinical Director will provide a monthly compliance summary to the Leadership Team for a period of 60 days or until compliance is achieved.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to update individual treatment plans every thirty days in seven of seven records.
Client #1 admitted May 14, 2025 and discharged November 14, 2025. A treatment plan was completed on July 3, 2025 and an update was due by August 2, 2025 but not completed until August 6, 2025. Another update was due by September 5, 2025 but not completed until September 10, 2025. Additionally, a treatment plan was completed on October 8, 2025 and an update was due by November 7, 2025 but not completed until November 12, 2025.
Client #2 admitted June 4, 2025 and discharged December 9, 2025. A treatment plan was completed on July 2, 2025 and an update was due by August 1, 2025 but not completed until August 4, 2025. Another treatment plan was completed on October 1, 2025 and an update was due by October 31, 2025 but not completed until November 9, 2025.
Client #3 admitted July 17, 2025 and discharged December 18, 2025. A treatment plan was completed October 8, 2025 and an update was due by November 7, 2025 but not completed until November 10, 2025. Another update was due by December 10, 2025 but not completed until December 13, 2025.
Client #4 admitted July 10, 2025 and discharged November 14, 2025. A treatment plan was completed August 6, 2025 and an update was due by September 5, 2025 but not completed until September 6, 2025. Another treatment plan was completed October 3, 2025 and an update was due by November 2, 2025 but not completed until November 6, 2025.
Client #5 admitted June 4, 2025 and discharged December 12, 2025. A treatment plan was completed July 25, 2025 and an update was due by August 24, 2025 but not completed until August 25, 2025. Another treatment plan was completed September 18, 2025 and an update was due by October 18, 2025 but not completed until October 21, 2025. Another update was due by November 20, 2025 but not completed until November 24, 2025.
Client #6 admitted May 28, 2025 and discharged December 19, 2025. A treatment plan was completed July 17, 2025 and an update was due by August 16, 2025 but not completed until August 22, 2025. Another treatment plan was completed September 15, 2025 and an update was due by October 15, 2025 but not completed until October 17, 2025. Another update was due by November 16, 2025 but not completed until November 19, 2025.
Client #7 admitted May 22, 2025 and discharged October 29, 2025. A treatment plan was completed August 19, 2025 and an update was due by September 18, 2025 but not completed until September 19, 2025. Another update was due by October 19, 2025 but not completed until October 26, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By 2/26/2026, the Quality & Compliance Specialist will request that the Electronic Health Record System add alerts within the system every 30 days, providing clinical staff with notifications that their client's treatment plans will require an update within one calendar week.
By 2/27/2026, the Clinical Director and Program Manager for D/A Treatment will audit all current drug and alcohol clients' records to verify all clients have a current treatment plan update (unless an update is not yet due). Counselors will be assigned to complete late treatment plan updates with their clients by 3/6/2026.
By 3/13/2026, the Clinical Director will provide Treatment Planning training to clinical staff. This training will include information regarding the intervals at which treatment plans are updated as well as instruction on how treatment plan updates are completed. Clinical staff will be instructed that they must finalize treatment plan updates four days prior to the date the plan is due. Training documentation will be maintained in the employees' training records.
Beginning 3/14/2026, Counselors and Treatment Supervisors will audit their clients' records on a monthly basis to verify treatment plans are updated at least every 30 days.
Beginning 3/24/2026, the Clinical Director will review the audit findings. If the Clinical Director identifies treatment plans that have not been updated monthly, supervisory conferences will be completed with the employees responsible. The Clinical Director will provide a monthly compliance summary to the Leadership Team for a period of 60 days or until compliance is achieved.
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709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were provided to the client on a regular and scheduled basis in five of seven records.
Client #1 admitted May 14, 2025 and discharged November 14, 2025. There was no individual session scheduled or noted cancelation for the following weeks: June 30, July 14, entire month of August, and September 1.
Client #2 admitted June 4, 2025 and discharged December 9, 2025. There was no individual session scheduled or noted cancelation for the following weeks: June 9, June 16, June 23, Jun30, July 14, July 21, July 28, August 4, August 11, and August 18.
Client #4 admitted July 10, 2025 and discharged November 14, 2025. There was no individual session scheduled or noted cancelation for the following weeks: July 14, July 21, August 4, August 11, September 1, and October 13.
Client #6 admitted May 28, 2025 and discharged December 19, 2025. There was no individual session scheduled or noted cancelation for the following weeks: June 2, June 16, July 7, July 14, July 21, July 28, August 4, August 11 and August 25.
Client #7 admitted May 22, 2025 and discharged October 29, 2025. June 2, June 9, June 16, June 30, July 14, July 21, August 4, August 25, and October 13.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By 2/25/2026, the Program Manager will meet with counselors to review this licensing citation and to clarify the expectation for one counseling session every seven days or less. This review will be documented on a supervisory conference form
By 3/13/2026, the Clinical Director will provide Case Management training to clinical staff. This training will include requirements for providing counseling services on a regular and scheduled basis as well as documentation of the services. Training documentation will be maintained within the employee record.
Beginning 3/14/2026, Counselors and Treatment Supervisors will audit their clients' records on a monthly basis to verify individual counseling sessions are completed and documented at least every seven days.
Beginning 3/24/2026, the Clinical Director will review the audit findings. If the Clinical Director determines individual counseling sessions are not being completed as required, supervisory conferences will be completed with the employees responsible. The Clinical Director will provide a monthly compliance summary to the Leadership Team for a period of 60 days or until compliance is achieved.
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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 document case consultations in four of seven records.
The facility's policy and procedure states a case consultation must be completed quarterly. There was no case consultations in the following client records.
Client #1 admitted May 14, 2025 and discharged November 14, 2025.
Client #3 admitted July 17, 2025 and discharged December 18, 2025.
Client #5 admitted June 4, 2025 and discharged December 12, 2025.
Client #7 admitted May 22, 2025 and discharged October 29, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By 2/27/2026, the Clinical Director and Program Manager for D/A Treatment will audit all current drug and alcohol clients' records to determine when each client is due for a quarterly treatment review. Counselors and Treatment Supervisors will be assigned to schedule quarterly treatment reviews for those who are due or overdue.
By 3/13/2026, the Clinical Director will provide Case Management training for clinical staff. This training will include the purpose for and the process for scheduling, sending invites, and documenting quarterly treatment reviews as case consultations. Training documentation will be maintained in the employees' training records.
Beginning 3/14/2026, Counselors and Treatment Supervisors will audit their clients' records on a monthly basis to verify case consultations are documented at least quarterly.
Beginning 3/24/2026, the Clinical Director will review the audit findings. If the Clinical Director identifies quarterly treatment reviews have not been completed, supervisory conferences will be completed with the employees responsible. The Clinical Director will provide a monthly compliance summary to the Leadership Team for a period of 60 days or until compliance is achieved.
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to provide verification that any work done by the client at the project is an integral part of his treatment and rehabilitation plan, in seven of seven records reviewed.
There was no documentation on any treatment plan that work done by the client while in residential treatment was an integral part of treatment in all records reviewed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By 3/13/2026, the Clinical Director will provide Treatment Planning training to clinical staff. This training will include information related to engaging clients in work activities and documenting verification of how work done by the client at the facility relates to the goals and objectives on their treatment plan.
Beginning 3/14/2026, Counselors and Treatment Supervisors will audit their clients' records on a monthly basis to verify work done by the client at the facility is related to their treatment. This audit will be conducted on an ongoing basis to verify sustained compliance.
Beginning 3/24/2026, the Clinical Director will review the audit findings. If the Clinical Director determines missing or inadequate work-related documentation on their treatment plans, supervisory conferences will be completed with the employees responsible. The Clinical Director will provide a monthly compliance summary to the Leadership Team for a period of 60 days or until compliance is achieved.
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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 obtain an informed and voluntary consent from the client prior to the disclosure of information was submitted and approved by the Department for the February 25, 2025, February 14, 2024 annual inspections and September 4, 2024 follow up inspection.
Failing to obtain an informed and voluntary consent from the client prior to the disclosure of information was again found to be a deficiency in the January 16, 2026 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/20/2026, the facility's Leadership Team discussed this finding, acknowledging the severity of this finding and the implications for repeatedly failing to comply with plans of correction for the same issue. The new Executive Director and the Quality & Compliance Specialist have initiated a process whereby each plan of correction provided to a licensing entity is tracked and monitored monthly by the entire Leadership Team. The Quality & Compliance Specialist maintains a tracking spreadsheet of current and active plans of correction, including them as follow-up items on the monthly Leadership Team's agenda. Discussion, data review, additional corrective actions, and other follow up information are included in the meeting minutes.
Corrective action plans have been assigned to be implemented and monitored by individual Leadership Team members, who will be responsible for providing monthly reports at the Leadership Team meeting until compliance with the cited regulation is verified by the responsible supervisors, managers, and department heads. Processes will be maintained for ongoing monitoring of key processes to prevent recurrence of non-compliance.
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