INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 18, 2025 through August 19, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Hopebridge DT LLC 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) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of fire extinguishers upon staff employment in two of two applicable personnel records reviewed.
Employee # 1 was hired as the project/facility director on December 4, 2024. There was documentation in the personnel record indicating the fire extinguisher training was not completed until January 6, 2025.
Employee # 2 was hired as a counselor on April 15, 2025. There was documentation in the personnel record indicating the fire extinguisher training was not completed until June 9, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director updated the onboarding checklist to require documented fire‑extinguisher training within first week of hire effective immediately. Safety Officer will audit training records monthly and review at Quality Improvement (QI) meetings. HR staff will ensure new‑hire checklists include this requirement. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel, on all shifts, are trained to perform assigned tasks during emergencies in two of two applicable personnel records reviewed.
Employee # 1 was hired as the project/facility director on December 4, 2024. There was documentation in the personnel record indicating the emergency preparedness training was not completed until January 6, 2025.
Employee # 2 was hired as a counselor on April 15, 2025. There was documentation in the personnel record indicating the emergency preparedness training was not completed until June 9, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director revised emergency‑preparedness onboarding checklist to require training for new hires within 7 days effective immediately. The facility director will schedule the drills, maintain documentation, and review compliance quarterly. Training refresher will be provided annually. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on release of information forms in fourteen of fourteen client records reviewed.
In each record reviewed, the release of information form to the funding source did not include documentation of the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, all consent-to-release forms will include a clearly stated and specific purpose of disclosure (e.g., coordination of care, insurance billing, legal documentation, referral purposes, or continuity of treatment).
The purpose will be reviewed with each client at the time of signing to ensure informed and voluntary consent.
Staff will verify that the purpose is explicitly written on the consent form prior to filing it in the client record.
Clinical Director: Oversees compliance with confidentiality standards and reviews all consent form templates.
All Counselors and Intake Staff: Responsible for obtaining written consents that include a clearly defined purpose prior to any release of information.
A mandatory Confidentiality and Documentation Refresher Training will be held by October 21, 2025.
Training topics will include:
Review of § 709.28 confidentiality standards
Proper completion of consent forms
Explanation of "informed and voluntary consent"
Examples of appropriate and inappropriate "purpose of disclosure" entries
All staff will sign a training acknowledgment form verifying understanding and compliance.
The Clinical Director will conduct monthly chart audits for the next 90 days to ensure all consent forms include the required "purpose of disclosure."
Any incomplete forms will be corrected within 24 hours of identification.
Compliance results will be reviewed during supervision meetings and documented in QA reports.
Implementation Date: October 14, 2025
Full Compliance Expected By: October 28, 2025 |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on release of information forms in three of fourteen client records reviewed.
Client # 5 was admitted on May 9, 2025 and was discharged on July 1, 2025. There was a release of information form to the emergency contact signed and dated by the client on May 9, 2025; however, the purpose of the disclosure was not documented on the release form.
Client # 9 was admitted on February 27, 2025 and was active at the time of inspection. There was a release of information form to the emergency contact signed and dated by the client on February 27, 2025; however, the purpose of the disclosure was not documented on the release form.
Client # 11 was admitted on January 21, 2025 and was discharged on February 25, 2025. There was a release of information form to the emergency contact signed and dated by the client on January 21, 2025; however, the purpose of the disclosure was not documented on the release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, all client consent forms must include a clearly stated and specific purpose of disclosure (e.g., coordination of care, communication with legal representatives, billing, or treatment planning).
Staff will ensure that clients understand the purpose of the disclosure at the time of signing, confirming that the consent is informed and voluntary.
A revised Consent for Release of Information form will be implemented to include a designated section for the "Purpose of Disclosure."
All existing consents will be reviewed, and missing information will be updated no later than October 28, 2025.
Clinical Director: Oversees implementation of the corrective action, form revision, and compliance monitoring.
All Clinical and Intake Staff: Responsible for obtaining properly completed consents and ensuring that each includes a documented purpose of disclosure prior to releasing any information.
A mandatory Confidentiality and Documentation Training will be conducted by October 21, 2025, covering:
§ 709.28 confidentiality requirements
How to obtain informed and voluntary client consent
Properly documenting the purpose of disclosure
Examples of compliant vs. noncompliant documentation
All staff will sign an attendance sheet and acknowledgment of understanding.
The Clinical Director will conduct weekly chart audits for 30 days, followed by monthly reviews for three months.
Any identified deficiencies will be corrected within 24 hours.
Results of the audits will be documented in supervision and Quality Assurance (QA) reports.
Implementation Date: October 14, 2025
Staff Training Completion: October 21, 2025
Full Compliance Expected By: October 28, 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 a review of client records, the facility failed to document whether a copy of a consent to release information form was offered to the client in fourteen of fourteen client records reviewed.
In each record reviewed, there was no documentation indicating if a copy of the release of information form to the funding source was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, all staff are required to:
Offer a copy of the signed Consent for Release of Information form to the client at the time of completion.
Document in the client record that a copy was offered and whether the client accepted or declined the copy.
Ensure that a copy of each signed consent is uploaded or filed in the client's electronic or physical chart.
A statement will be added to the consent form confirming:
"A copy of this consent form was offered to the client."
Staff will initial and date this section at each signing.
Clinical Director: Responsible for oversight of implementation, form revision, and compliance monitoring.
Clinical and Intake Staff: Responsible for offering a copy to each client and documenting completion in the record.
All clinical and intake staff will participate in a Confidentiality and Documentation Training by October 22, 2025, to review:
Requirements under § 709.28(d)
Procedures for documenting that a copy was offered
Proper filing and record-keeping protocols
Staff will sign an acknowledgment of training completion and understanding.
The Clinical Director will conduct weekly audits of newly admitted client charts for 30 days to verify compliance, followed by monthly reviews for the next 90 days.
Any identified deficiencies will be corrected within 24 hours of discovery.
Audit findings will be reviewed in weekly clinical supervision and documented in QA reports.
Implementation Date: October 14, 2025
Training Completion Date: October 22, 2025
Full Compliance Expected By: October 29, 2025
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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 30 days in four of four applicable client records reviewed.
Client # 2 was admitted on June 23, 2025 and was active at the time of inspection. The individual treatment plan was completed June 27, 2025 and the first update was due no later than July 27, 2025; however, the update was not completed at the time of inspection.
Client # 5 was admitted on May 9, 2025 and was discharged on July 1, 2025. The individual treatment plan was completed on May 12, 2025 and the first update was due no later than June 12, 2025; however, the update was not completed prior to discharge.
Client # 6 was admitted on January 3, 2025 and was discharged on March 4, 2025. The individual treatment plan was completed on January 13, 2025 and the first update was due no later than February 13, 2025; however, the update was not completed prior to discharge.
Client # 7 was admitted on February 4, 2025 and was discharged on April 28, 2025. A treatment plan update was completed on March 4, 2025 and the next update was due no later than April 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
The Facility Director revised the treatment plan review policy and the schedule to ensure all plans are updated according to DDAP timelines. Clinical staff were retrained on plan review documentation standards. The Facility Director will audit five treatment plans monthly for six months and quarterly thereafter to verify timely updates. Ongoing compliance will be monitored by the Facility Director.
Effective immediately, all treatment and rehabilitation plans must be reviewed and updated at least every 30 days from the date of the initial treatment plan or most recent update.
The following actions will be taken:
A tracking and reminder system will be implemented in the electronic health record (EHR) to alert clinicians 7 days prior to a due date for plan updates.
Counselors will review each client's progress toward goals, revise objectives as needed, and document the updated plan with clinician and client signatures.
Clinical Supervisor will verify compliance during weekly chart reviews.
Clients will be engaged in the review process to ensure treatment remains client-centered and reflective of current needs.
Clinical Director: Oversees implementation, ensures compliance, and reviews updated treatment plans during monthly QA meetings.
Primary Counselors: Responsible for completing treatment plan reviews and updates every 30 days and obtaining signatures.
Clinical Supervisor: Monitors timeliness of updates and provides corrective feedback during supervision.
Implementation Date: October 14, 2025
Full Compliance Expected By: November 14, 2025
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709.82(c) LICENSURE Treatment and rehabilitation services
709.82. 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 counseling services were provided according to the individual treatment and rehabilitation plan in two of five applicable client records reviewed.
Client # 2 was admitted on June 23, 2025 and was still active at the time of inspection. The individual treatment plan, dated June 27, 2025, specified weekly individual and group counseling services. There was no documentation, in the record, of any counseling services occurring from July 18, 2025 to the date of the inspection.
Client # 7 was admitted on February 4, 2025 and was discharged on April 28, 2025. The individual treatment plan, dated February 5, 2025, specified two individual counseling sessions and two group counseling services per week. There was no documentation, in the record, of individual counseling services occurring from April 2, 2025 to discharge and group counseling services from April 7, 2025 to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director implemented weekly caseload reviews by the Clinical Director to confirm that clients are receiving the frequency and type of counseling specified in the clients' treatment plans effective immediately. The Clinical Director will provide training to counselors on scheduling and documentation expectations. The clients that are not compliant with their treatment plans will be discharged from the program. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling on a regular and scheduled basis, specifically, not providing individual counseling services at least twice a week, in two of five applicable client records reviewed.
Client # 2 was admitted on June 23, 2025 and was active at the time of inspection. Individual counseling services are to be provided at least twice weekly; however, the last individual session documented occurred on July 18, 2025.
Client # 5 was admitted on May 9, 2025 and was discharged on July 1, 2025. Individual counseling are to be provided at least twice weekly; however, the last individual session documented occurred on June 6, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director adjusted staffing assignments to ensure adequate availability for twice‑weekly sessions effective immediately. The clinical director implemented a scheduling system that flags clients requiring two individual sessions per week. The counselors will be reminded of requirements in supervision. Clinical Supervisor will review weekly appointment logs and address gaps immediately. |
709.83(a)(11) LICENSURE Client records
709.83. 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 document a complete client record on an individual, which is to include the documentation of follow-up information, in two of four applicable client records reviewed.
Client # 4 was admitted on March 3, 2025 and was discharged on March 30, 2025. There was no follow-up information documented in the record as of the date of the inspection.
Client # 5 was admitted on May 9, 2025 and was discharged on July 1, 2025. There was no follow-up information documented in the record 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 facility director revised the discharge procedure to require follow‑up contact and documentation in the client record effective immediately. The facility director developed a follow‑up tracking log maintained by the clinical director, who will review follow‑up compliance monthly and discuss at clinical meetings. Counselors were trained on new requirements. |
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 the individual treatment and rehabilitation plan in two of six applicable client records reviewed.
Client # 8 was admitted on March 19, 2025 and was still active at the time of inspection. The individual treatment plan was developed on April 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.
Client # 10 was admitted on June 6, 2025 and was still active at the time of inspection. The individual treatment plan was developed on June 12, 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
The Facility Director corrected the issue by revising the individual treatment plan template to include dedicated fields for both the type and frequency of all treatment and services. All existing client treatment plans were reviewed and updated to include the missing details as of 10/16/25. Clinical staff were retrained on documenting type and frequency during treatment planning and plan updates. The Facility Director will audit five randomly selected client records monthly for six months and quarterly thereafter to ensure that all treatment plans include these required elements. Ongoing compliance will be monitored by the Facility Director. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in two of six applicable client records reviewed.
Client # 8 was admitted on March 19, 2025 and was still active at the time of inspection. The individual treatment plan was developed on April 5, 2025; however, there was no documentation on the treatment plan indicating any proposed types of support services for the client.
Client # 10 was admitted on June 6, 2025 and was still active at the time of inspection. The individual treatment plan was developed on June 12, 2025; however, there was no documentation on the treatment plan indicating any proposed types of support services for the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director corrected the deficiency by updating the treatment plan forms and process to ensure that proposed support services are documented for each client. All current treatment plans were reviewed and revised to include appropriate support services as of 10/16/25. Counselors were retrained on identifying and recording proposed support services during treatment planning. The Facility Director will review five client records monthly for six months and quarterly thereafter to confirm that all treatment plans include documented support services. Ongoing compliance will be monitored by the Facility Director. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of four applicable client records reviewed.
Client # 8 was admitted on March 19, 2025 and was active at the time of inspection. The individual treatment plan was completed on April 5, 2025 and the first update was due no later than June 5, 2025; however, the update was not completed at the time of inspection.
Client # 9 was admitted on February 27, 2025 and was active at the time of inspection. The individual treatment plan was completed on March 6, 2025 and the first update was due no later than May 6, 2025; however, the update was not completed at the time of inspection.
Client # 10 was admitted on June 6, 2025 and was active at the time of inspection. The individual
treatment plan was completed on June 12, 2025 and the first update was due no later than August 12, 2025; however, the update was not completed at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director corrected the issue by implementing an electronic tickler system that automatically alerts staff 45 days after the last treatment plan update. All overdue treatment plans were immediately reviewed and brought into compliance as of 10/16/25. Clinical staff were retrained on DDAP's 60-day treatment plan review requirement and the use of the new reminder system. The Facility Director will audit five treatment plans monthly for six months and quarterly thereafter to confirm timely 60-day reviews. Ongoing compliance will be monitored by the Facility Director. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include the documentation of a discharge summary, in two of four applicable client records reviewed.
Client # 12 was admitted on December 24, 2024 and was discharged on March 3, 2025. There was no documentation of a discharge summary in the record at the time of the inspection.
Client # 14 was admitted on February 24, 2025 and was discharged on April 23, 2025. There was no documentation of a discharge summary 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
The facility director developed a discharge checklist that requires completion of a discharge summary prior to case closure effective immediately. The clinical director will verify discharge summaries during chart audits. Counselors received training on preparing comprehensive discharge summaries. |
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, the facility failed to maintain a complete client record on an individual, which is to include the documentation of follow-up information, in three of four applicable client records reviewed.
Client # 12 was admitted on December 24, 2024 and was discharged on March 3, 2025. There was no documentation of follow-up information in the record at the time of the inspection.
Client # 13 was admitted on September 25, 2024 and was discharged on December 24, 2024. There was no documentation of follow-up information in the record at the time of the inspection.
Client # 14 was admitted on February 24, 2025 and was discharged on April 23, 2025. There was no documentation of follow-up information 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
The facility director standardized follow‑up process requiring counselors to make follow‑up contact within seven days of discharge and document outcomes effective immediately. The clinical director created a follow‑up/Alumni log reviewed monthly by the facility director. Staff training emphasized the importance of documenting follow‑up. |