INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 3, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Chester County Intermediate Unit-Changes 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, the facility failed to ensure all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
At the time of the inspection, there were two fire extinguishers, one located by the front door and the other located by the rear doors, that were last inspected in September 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility informed maintenance department on 11/3/2025. The fire extinguishers were inspected and approved by 11/5/2025. Moving forward the facility director will ensure that the fire extinguishers will be inspected on time moving forward. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on an administrative review, the facility failed to ensure the project director annually updated and signed the written manual delineating the project policies and procedures.
At the time of the inspection, the facility provided documentation indicating the written manual was last updated and signed by the project director on August 23, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and Project Director will ensure that the policies and procedure manual is reviewed, approved and signed at the close of each fiscal year moving forward. This will occur in July of each year to ensure regular review and updating of policies. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to include the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in two of thirteen client records reviewed.
Client # 2 was admitted to the outpatient activity on July 8, 2025 and was active at the time of the inspection. A release of information form to the funding source was signed and dated by the client on June 17, 2025; however, the specific name of the agency or organization was not documented on the release form.
Client # 4 was admitted to the outpatient activity on May 14, 2025 and was discharged on August 14, 2025. A release of information form to the funding source was signed and dated by the client on April 30, 2025; however, the specific name of the agency or organization was not documented on the release form.
This is a repeat citation from the November 1, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor at point of intake will ensure that accurate insurance information is documented. Prior to uploading documents, the clinical coordinated will review all forms for completeness. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 client records, the facility failed to document the type and frequency of treatment and rehabilitation services on an individual treatment and rehabilitation plan in two of three applicable client records reviewed.
Client # 11 was admitted to the partial hospitalization activity on February 3, 2025 and was discharged on March 21, 2025. The individual treatment plan was developed on February 25, 2025; however, there was no documentation on the plan indicating the type and frequency of treatment and rehabilitation services the client was to receive.
Client # 12 was admitted to the partial hospitalization activity on January 7, 2025 and was discharged on March 26, 2025. The individual treatment plan was developed on February 4, 2025; however, there was no documentation on the plan indicating the type and frequency of treatment and rehabilitation services the client was to receive.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review all active outpatient client records and ensure that each individualized treatment includes the required documentation of the type and frequency of services by EOD 11/25/25. The missing intervention information related to the type of frequency of treatment for clients #11 and #12 will be amended as allowed on EHR.
All counseling staff will be retrained on treatment plan requirements by Clinical Supervisor, with focus on clearly documenting type and frequency of treatment. This training will occur on 11/25/25 and will include examples to ensure consistency.
To prevent recurrence, the Clinical Supervisor will conduct ongoing chart audits when treatment plans are due for 90 days to verify compliance, followed by monthly QA audits. Any deficiencies identified will result in corrective feedback and retraining.
The Clinical Supervisor collaborated with the EHR vendor on 11/21/25 and updated the treatment plan template to require completion of type and frequency fields before a plan can be finalized.
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in three of three applicable client records reviewed.
Client # 10 was admitted to the partial hospitalization activity on October 16, 2024 and was discharged on June 6, 2025. A treatment plan update was completed on March 27, 2025 and the next update was due no later than April 27, 2025; however, the update was not completed prior to discharge.
Client # 12 was admitted to the partial hospitalization activity on January 7, 2025 and was discharged on March 26, 2025. The individual treatment plan was completed on February 4, 2025 and the first update was due no later than March 4, 2025; however, the update was not completed until March 17, 2025.
Client # 13 was admitted to the partial hospitalization activity on September 18, 2024 and was discharged on April 4, 2025. A treatment plan update was completed on December 4, 2024 and the next update was due no later than January 4, 2025; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.82 was reviewed with all staff that complete treatment plans. Treatment team was reminded that all treatment plans need to be updated on due date regardless of student being in attendance or not. Treatment plans will be reviewed with student on the next day of attendance. If a delay to treatment plan updates occurs, the delay will be document in case note. Clinical supervisor is responsible for ensuring compliance. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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 client records, the facility failed to document the type and frequency of treatment and rehabilitation services on an individual treatment and rehabilitation plan in two of six applicable client records reviewed.
Client # 1 was admitted to the outpatient activity on May 21, 2025 and was still active at the time of inspection. The individual treatment plan was developed on June 2, 2025; however, there was no documentation on the treatment plan indicating the frequency of treatment and rehabilitation services the client was to receive.
Client # 5 was admitted to the outpatient activity on February 19, 2025 and was discharged on August 14, 2025. The individual treatment plan was developed on March 5, 2025; however, there was no documentation on the treatment plan indicating the type and frequency of treatment and rehabilitation services the client was to receive.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review all active outpatient client records and ensure that each individualized treatment includes the required documentation of the type and frequency of services by 11/24/25. Any missing information, including the treatment plan for Client #1, will be corrected or amended no later than 11/26/25. Client #5's record has been discharged.
All counseling staff will be retrained on treatment plan requirements by Clinical Supervisor, with focus clearly documenting type and frequency of treatment. This training will occur on 11/25/25 and will include examples to ensure consistency.
To prevent recurrence, the Clinical Supervisor will conduct ongoing chart audits when treatment plans are due for 90 days to verify compliance, followed by monthly QA audits. Any deficiencies identified will result in corrective feedback and retraining. The Program Director will also work with the EHR vendor to update the treatment plan template to require completion of type and frequency fields before a plan can be finalized, with this change targeted for 11/28/25.
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