INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 9, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Penndel Mental Health Center 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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709.92(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 client records, the facility failed to follow the regulatory requirement to update treatment and rehabilitation plans every sixty days in one out of four applicable records reviewed.
Client #4 was admitted on December 3, 2025, and discharged on April 28, 2026. A treatment plan was completed on December 3, 2025, and the next update was due no later than February 1, 2026; however, the next update was not completed until April 15, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Disciplinary action was taken with the staff member who did not complete the treatment plan on time, as this is in violation of our program policy and procedures, which align full with DDAP regulations.
This staff member has been required to develop and utilize a spreadsheet to track treatment plan due dates, which will be reviewed in weekly supervision.
Lastly, director will increase chart auditing efforts to avoid late treatment plans moving forward. For the next 6 months, director will randomly audit 10% of the census monthly. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that clients received counseling services according to their individual treatment plan in three out of seven records reviewed.
Client #2 was admitted on April 8, 2026, and was still active at the time of the inspection. The treatment plan dated April 8, 2026, indicated one individual and three group sessions a week. There was no documentation of the client receiving any individual sessions the week of May 15, 2026.
Client #3 was admitted on September 15, 2025, and was still active at the time of the inspection. The treatment plan dated September 24, and November 20, 2025, indicated one individual and three group sessions a week. There was no documentation that the client received any individual sessions the weeks of October 20 and November 24, 2025.
Client #4 was admitted on December 3, 2025, and discharged on April 28, 2026. The treatment plan dated December 3, 2025, indicated one individual and three group sessions a week. There was no documentation that the client received any individual sessions the weeks of December 22 and 29, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff has been instructed that if a session is cancelled by staff/Penndel another appointment must be offered for both individual and group within the same week, even if with a different clinician. If the client declines the appointment this will be documented in a contact note in the electronic health record as evidence of the offering of an alternative appointment.
Staff will be reminded of this practice at each weekly team meeting and individual supervisions. If/when staff are going to be out, they will request coverage from the team.
Director will be responsible for oversight and audit this process during chart audits. |
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 the review of client records, the facility failed to document case consultations every quarter, per facility policy, in two out of three applicable records reviewed.
Client #1 was admitted on January 19, 2026, and was still active at the time of the inspection. A case consultation was due no later than April 19, 2026; however, it was not completed until May 4, 2026.
Client #3 was admitted on September 15, 2025, and was still active at the time of the inspection. A case consultation was due no later than December 14, 2025; however, there was no documentation that a case consultation occurred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Penndel will update our policy on case consultations to more fully align with DDAP regulations. The new policy for case consultations will be at least 1 case consultation is to be done between admission and discharge. Additional case consultations may be done on an as needed basis. This policy will be updated and in place by July 4, 2026.
Director will be responsible for oversight to ensure completion of this policy update. Director will monitor during chart audit process. |