INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 25 and December 15, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Performance Is Attitude LP, 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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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of administrative information, the facility failed to document an assessment of staff training needs. The facility's policy and procedures state an annual assessment of staff training needs will be given to all staff to be completed by December 15 of each year. There was no assessment of staff training needs documented for training year January 1, 2025-December 31, 2025. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Infraction 0055
Regulation: 704.11(a)(1) ? Staff Development Program / Training Needs Assessment
1. How the facility will correct the deficiency
The facility will complete and document an annual staff training needs assessment for all current personnel for the January 1, 2025 through December 31, 2025 training year. The completed assessments will be maintained in each staff member's personnel file and/or the facility's electronic training management system to ensure documentation is readily available for review.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will formalize its annual staff training needs assessment process to ensure completion by December 15 of each calendar year, as required by policy. The facility will utilize Relias as its primary training platform, in conjunction with DDAP-required trainings and Athena Health system-based competencies, to identify individual and program-wide training needs. Completion of the annual assessment will be tracked and verified through supervisory review and ongoing administrative monitoring.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for completing, documenting, and overseeing the staff training needs assessments and for ensuring ongoing compliance with the staff development program requirements.
4. Date corrective action will be completed
Corrective action will be completed by: February 27, 2026
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Compliance will be maintained on an ongoing basis through annual assessments, supervisory oversight, and routine monitoring of staff training documentation.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency related to the assessment of staff training needs.
7. Authorized Provider Name
Authorized Provider: Project Director
Title: Authorized Provider
Date: 2/27/2026 |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of administrative information, the facility failed to document an overall plan addressing staff training needs. The facility's policy and procedures state an overall plan to address staff training needs will be completed by December 31.There was no overall plan documented for training year January 1, 2025-December 31, 2025. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Infraction 0057
Regulation: 704.11(a)(2) ? Staff Development Program / Overall Training Plan
1. How the facility will correct the deficiency
The facility will develop, complete, and document an overall staff training plan addressing identified training needs for the January 1, 2025 through December 31, 2025 training year. The training plan will outline required trainings, applicable timeframes, and methods for addressing individual and program-wide staff development needs. Documentation of the training plan will be maintained in administrative records and/or the facility's electronic training management system.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will formalize its annual staff development planning process to ensure an overall training plan is completed by December 31 of each year, as required by policy. The facility will utilize Relias as its primary training platform, along with DDAP-required trainings and Athena Health system-based competencies, to develop, track, and monitor staff training activities. Supervisory review and administrative oversight will be conducted to verify completion and ongoing compliance.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for developing, documenting, and overseeing the overall staff training plan and for ensuring continued compliance with staff development program requirements.
4. Date corrective action will be completed
Corrective action will be completed by: February 27, 2026
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Compliance will be maintained on an ongoing basis through annual planning, supervisory oversight, and routine monitoring of training documentation.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency related to the development of an overall staff training plan.
7. Authorized Provider Name
Authorized Provider: Project Director
Title: Authorized Provider
Date: 2/27/2026 |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of administrative information, the facility failed to develop a written individual training plan for each employee in four of four records. The current training year is January 1, 2025-December 31, 2025.There were no training plans for any staff.Staff #1 was hired as the project director on March 1, 2024, and still employed at the time of inspection. Staff #2 was hired as the facility director on March 1, 2024, and still employed at the time of inspection. Staff #3 was hired as a counselor on August 1, 2025, and still employed at the time of inspection. Staff #4 was hired as a recovery specialist on November 1, 2025, promoted to counselor on November 26, 2025, and still employed at the time of inspection. These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the November 13, 2024, licensing inspection.
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Plan of Correction
Plan of Correction ? Infraction 0063
Regulation: 704.11(b)(1) ? Staff Development Program / Individual Training Plans
1. How the facility will correct the deficiency
The facility will develop and document a written individual training plan for each current employee for the January 1, 2025 through December 31, 2025 training year. Each individual training plan will be appropriate to the employee's role and skill level and will be developed with documented input from both the employee and the supervisor. Completed individual training plans will be maintained in each employee's personnel file and/or the facility's electronic training management system.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will implement a standardized annual process requiring completion of individual training plans for all employees, including newly hired and promoted staff. The facility will utilize Relias as its primary training platform, in conjunction with DDAP-required trainings and Athena Health system-based competencies, to inform and track individual training needs. Supervisory review and administrative verification will be conducted annually to confirm completion, documentation, and alignment with regulatory requirements.
Given that this is a repeat citation, the facility will also incorporate enhanced monitoring measures, including a documented annual audit of all personnel files to ensure individual training plans are completed timely and maintained appropriately.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring development, documentation, oversight, and ongoing compliance with individual employee training plans.
4. Date corrective action will be completed
Corrective action will be completed by: February 27, 2026
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Ongoing compliance will be maintained through annual training plan development, supervisory oversight, and routine administrative audits.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency related to the development and documentation of individual employee training plans.
7. Authorized Provider Name
Authorized Provider: Project Director
Title: Authorized Provider
Date: 2/27/2026 |
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 administrative information, the facility failed to ensure staff were instructed in the use of fire extinguishers upon employment in two of two records. Staff #3 was hired as a counselor on August 1, 2025, and still employed at the time of inspection. The training was not completed as of the date of the inspection. Staff #4 was hired as a recovery specialist on November 1, 2025, promoted to counselor on November 26, 2025, and still employed at the time of inspection. The training was not completed as of the date of the inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
REVISED Plan of Correction ? Infraction P271
Regulation: 705.28(c)(4) ? Fire Safety / Fire Extinguisher Training
1. How the facility corrected the deficiency
All current staff identified as lacking documentation at the time of inspection, including Staff #3 and Staff #4, have received instruction in the proper use of fire extinguishers. Documentation of this training has been completed and placed in each applicable personnel record.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility has implemented a requirement that fire extinguisher training be completed upon hire for all new staff. Fire extinguisher instruction will occur during onboarding and prior to staff assuming independent job duties. Training completion will be documented at the time of hire and verified through supervisory review. Administrative monitoring of personnel training records will be conducted on an ongoing basis to ensure continued compliance.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that fire extinguisher training is completed upon hire, properly documented, and monitored for all staff.
4. Date corrective action was completed
Corrective action for all current staff was completed.
Ongoing compliance is maintained through training upon hire for all future staff.
5. Reasonable timeframe for correcting the deficiency
The deficiency related to current staff has been corrected. Any staff hired after the inspection date will receive fire extinguisher training upon hire. Compliance will be maintained through onboarding procedures, supervisory oversight, and routine review of personnel training documentation.
6. Statement of full correction
This Plan of Correction fully addresses the identified deficiency related to staff instruction and documentation in the use of fire extinguishers.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: 1/13/2026 |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.The fire drills were reviewed for the period of November 2024-November 2025. There were no fire drills conducted in November 2024, December 2024, January 2025, and February 2025.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the November 13, 2024, licensing inspection.
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Plan of Correction
REVISED Plan of Correction ? Infraction P273
Regulation: 705.28(d)(1) ? Fire Safety / Fire Drills
1. How the facility will correct the deficiency
The facility will conduct and document unannounced fire drills in accordance with regulatory requirements. Fire drills will be conducted at least once per month, unannounced, and documented using standardized fire drill logs. All required elements of each drill will be recorded and maintained in facility safety records.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will implement a formal monthly fire drill process requiring unannounced drills to be conducted and documented every month. Fire drill logs will be reviewed monthly by administration to verify completion and compliance. As this is a repeat citation, enhanced monitoring will be implemented, including supervisory verification and administrative review of fire drill documentation to ensure ongoing adherence to fire safety requirements.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that unannounced fire drills are conducted, documented, reviewed, and maintained in compliance with fire safety regulations.
4. Date corrective action will be completed
Corrective action will begin on: January 20, 2026
Fire drills will be conducted monthly beginning on this date and every month thereafter.
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected beginning January 20, 2026. Ongoing compliance will be maintained through monthly unannounced fire drills, supervisory oversight, and routine administrative review of fire drill documentation.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency related to conducting and documenting unannounced monthly fire drills.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: 1/20/2026 |
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 administrative information, the facility failed to ensure staff were trained to perform assigned tasks during emergencies in two of two applicable records. Staff #3 was hired as a counselor on August 1, 2025, and still employed at the time of inspection. The training was not completed as of the date of the inspection. Staff #4 was hired as a recovery specialist on November 1, 2025, promoted to counselor on November 26, 2025, and still employed at the time of inspection. The training was not completed as of the date of the inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
REVISED Plan of Correction ? Infraction P277
Regulation: 705.28(d)(3) ? Fire Safety / Emergency Responsibilities Training
1. How the facility corrected the deficiency
All current staff identified as lacking documentation at the time of inspection, including Staff #3 and Staff #4, will received training on assigned emergency responsibilities, including tasks to be performed during fire and other emergency situations. Documentation of this training has been completed and placed in each applicable personnel record.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility has implemented a requirement that emergency responsibilities training be completed upon hire for all new staff. Emergency role training will be provided during onboarding and prior to staff assuming independent job duties. Training completion will be documented at the time of hire and verified through supervisory review. Administrative monitoring of personnel training records will be conducted on an ongoing basis to ensure continued compliance for all staff and all shifts.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that emergency responsibilities training is completed upon hire, properly documented, and monitored for all staff.
4. Date corrective action will be completed
Corrective action for all current staff will be completed by 1/14/2026.
Ongoing compliance is maintained through emergency responsibilities training upon hire for all future staff.
5. Reasonable timeframe for correcting the deficiency
The deficiency related to current staff has been corrected. Any staff hired after the inspection date will receive emergency responsibilities training upon hire. Compliance will be maintained through onboarding procedures, supervisory oversight, and routine review of personnel training documentation.
6. Statement of full correction
This Plan of Correction fully addresses the identified deficiency related to staff training on assigned emergency responsibilities.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: 1/14/2026 |
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 administrative information, the facility failed to ensure the personnel records included an annual written individual staff performance evaluation in two of two applicable records. Staff #1 was hired as the project director on March 1, 2024, and still employed at the time of inspection. There was no evaluation in the record.Staff #2 was hired as the facility director on March 1, 2024, and still employed at the time of inspection. There was no evaluation in the record.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Infraction 0205
Regulation: 709.26(b)(3) ? Personnel Management / Annual Performance Evaluations
1. How the facility will correct the deficiency
The facility will complete and document an annual written individual staff performance evaluation for all applicable staff identified as lacking documentation. Each evaluation will be reviewed with the employee, signed by the employee, and maintained in the employee's personnel file to ensure compliance with personnel record requirements.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will implement a standardized annual performance evaluation process for all staff. Performance evaluations will be scheduled, completed, reviewed with staff, and signed annually. Administrative tracking and supervisory review will be used to verify completion and ensure that all required evaluations are documented and maintained in personnel records in accordance with regulatory requirements.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that annual written staff performance evaluations are completed, reviewed with employees, signed, documented, and maintained in personnel records.
4. Date corrective action will be completed
Corrective action will be completed by: February 27, 2026
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Ongoing compliance will be maintained through annual evaluation scheduling, supervisory oversight, and routine review of personnel files.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency related to the completion and documentation of annual individual staff performance evaluations.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: 2/27/2026 |
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 a consent to release information form prior to releasing information in seven of seven records. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.Client #1 was admitted to the outpatient level of care on August 28, 2025, and discharged on September 6, 2025. Client #2 was admitted to the outpatient level of care on September 12, 2025, and discharged on September 27, 2025. Client #3 was admitted to the outpatient level of care on September 30, 2025, and discharged on November 1, 2025. Client #4 was admitted to the outpatient level of care on September 17, 2025, and discharged on October 6, 2025. Client #5 was admitted to the outpatient level of care on October 13, 2025, and was still active at the time of the inspection.Client #6 was admitted to the outpatient level of care on September 30, 2025, and was still active at the time of the inspection.Client #7 was admitted to the outpatient level of care on October 6, 2025, and was still active at the time of the inspection.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
REVISED Plan of Correction ? Infraction 0276
Regulation: §709.28(c) ? Confidentiality / Consent to Release of Information
1. How the facility corrected the deficiency
The facility reviewed all current client records identified as lacking appropriate authorization and obtained informed and voluntary written consent to release information where required. Completed consent to release of information forms have been placed in the applicable client records to document authorization prior to any further disclosure of client information, including disclosures related to billing or funding sources.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility has reinforced intake, billing, and documentation procedures to require a signed consent to release of information prior to any disclosure of client information. Staff are trained on confidentiality and consent requirements, and supervisory review is conducted to verify that valid consents are obtained, completed, and maintained in the client record before information is released. Ongoing monitoring of client charts will be conducted to ensure continued compliance with confidentiality regulations.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that consent to release of information requirements are implemented, staff are trained, and client records are reviewed and maintained in compliance with confidentiality regulations.
4. Date corrective action was completed
Corrective action for all current client records was completed on: January 31, 2026
5. Reasonable timeframe for correcting the deficiency
The deficiency related to current client records has been corrected. Ongoing compliance is maintained through standardized intake and billing procedures, supervisory oversight, and routine review of client records to ensure that consent is obtained prior to any disclosure of information.
6. Statement of full correction
This Plan of Correction fully addresses the identified deficiency related to obtaining and documenting informed and voluntary consent for the release of client information.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: 1/31/2026 |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that they have been notified of their rights in seven of seven records.Client #1 was admitted to the outpatient level of care on August 28, 2025, and discharged on September 6, 2025. Client #2 was admitted to the outpatient level of care on September 12, 2025, and discharged on September 27, 2025. Client #3 was admitted to the outpatient level of care on September 30, 2025, and discharged on November 1, 2025. Client #4 was admitted to the outpatient level of care on September 17, 2025, and discharged on October 6, 2025. Client #5 was admitted to the outpatient level of care on October 13, 2025, and was still active at the time of the inspection.Client #6 was admitted to the outpatient level of care on September 30, 2025, and was still active at the time of the inspection.Client #7 was admitted to the outpatient level of care on October 6, 2025, and was still active at the time of the inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
REVISED Plan of Correction ? Infraction 0296
Regulation: §709.30 ? Client Rights-CURRENT CHARTS ARE NOT COMPLIANT-
1. How the facility will correct the deficiency
At the time of inspection, current client charts were not compliant, as written acknowledgement of Client Rights was not documented in the client records. The facility will obtain written acknowledgement of Client Rights for all current client records identified as lacking documentation. A Client Rights handbook and acknowledgement form will be reviewed with each client, and signed acknowledgements will be obtained and placed in the client record to document that clients have been notified of their rights.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will formalize intake procedures to require review of Client Rights and completion of a signed acknowledgement at the time of admission. The Client Rights handbook will be included in the intake packet and reviewed with each client. Staff will be trained on the revised intake process, and supervisory review will be conducted to verify that signed Client Rights acknowledgements are completed and maintained in the client record. Ongoing monitoring of client records will be implemented to ensure continued compliance.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that Client Rights policies, intake procedures, staff training, and documentation requirements are implemented and maintained in compliance with regulatory standards.
4. Date corrective action will be completed
Corrective action will be completed by: January 31, 2026
By this date, all current client charts will be in compliance with §709.30.
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Ongoing compliance will be maintained through standardized intake procedures, supervisory oversight, and routine review of client records.
6. Statement of full correction
This Plan of Correction fully addresses the identified deficiency related to documenting written acknowledgement that clients have been notified of their rights.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: January 31, 2026 |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document the disclosure to the clients of the criteria for admission, treatment, completion and discharge, during the intake process, in seven of seven outpatient records. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Infraction 1851
Regulation: 709.91(b)(1) ? Intake and Admission / Disclosure of Admission and Discharge Criteria
1. How the facility will correct the deficiency
The facility will implement a documented intake disclosure process to ensure that all clients receive written disclosure of the criteria for admission, treatment, completion, and discharge at the time of intake. This information will be provided to clients in written form, reviewed during the intake process, and documented in the client record to verify disclosure.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will revise and reinforce intake procedures to require documented disclosure of admission, treatment, completion, and discharge criteria for all clients. Although these criteria are outlined in existing policies, staff will be trained to ensure the information is consistently provided to clients and properly documented during intake. Supervisory review will be conducted to verify that disclosures are completed and maintained in the client record. Ongoing monitoring of intake documentation will be implemented to ensure continued compliance.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that intake disclosure procedures are implemented, staff are trained on requirements, and documentation is completed and maintained in compliance with intake and admission regulations.
4. Date corrective action will be completed
Corrective action will be completed by: February 27, 2026
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Ongoing compliance will be maintained through standardized intake procedures, supervisory oversight, and routine review of client records.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency related to disclosure and documentation of admission, treatment, completion, and discharge criteria during the intake process.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: 2/27/2026 |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project which included familiarization with project policies in seven of seven outpatient records.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
FINAL Plan of Correction ? Infraction 1853
Regulation: §709.91(b)(2)(i) ? Intake and Admission / Client Orientation to Project Policies
1. How the facility will correct the deficiency
The facility will provide and document client orientation to the project, including familiarization with project policies, for all current client records identified as lacking documentation. Project policies will be reviewed with each client, and documentation of orientation will be completed and placed in the client record to verify compliance with intake requirements.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will revise and reinforce intake procedures to require documented client orientation to project policies at the time of admission. A Client Handbook containing all applicable project policies will be developed and included in the intake packet. The handbook will be reviewed with each client during orientation, and clients will be required to sign an acknowledgement and signature page confirming receipt and understanding of the project policies. Staff will be trained on the updated intake and documentation requirements, and supervisory review will be conducted to verify that client orientation documentation and signed acknowledgements are completed and maintained in the client record. Ongoing monitoring of intake records will be implemented to ensure continued compliance.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that client orientation procedures, staff training, and documentation requirements related to project policies are implemented and maintained in compliance with intake and admission regulations.
4. Date corrective action will be completed
Corrective action will be completed by: January 31, 2026
By this date, all current client charts will be in compliance with §709.91(b)(2)(i).
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Ongoing compliance will be maintained through standardized intake procedures, supervisory oversight, and routine review of client intake documentation.
6. Statement of full correction
This Plan of Correction fully addresses the identified deficiency related to documenting client orientation to project policies during the intake process.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: January 31, 2026 |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project which included familiarization with hours of operation in seven of seven outpatient records.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Infraction 1855
Regulation: §709.91(b)(2)(ii) ? Intake and Admission / Client Orientation to Hours of Operation
1. How the facility will correct the deficiency
The facility will provide and document client orientation to the project that includes familiarization with the facility's hours of operation for all current client records identified as lacking documentation. Hours of operation will be reviewed with each client, and documentation of orientation will be completed and placed in the client record to verify compliance with intake requirements.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will formalize intake procedures to require documented client orientation to hours of operation at the time of admission. A Client Handbook containing project policies, including hours of operation, will be included in the intake packet. The handbook will be reviewed with each client during orientation, and clients will be required to sign an acknowledgement and signature page confirming receipt and understanding of the information. Staff will be trained on the updated intake and documentation requirements, and supervisory review will be conducted to verify that signed acknowledgements are completed and maintained in the client record. Ongoing monitoring of intake documentation will be implemented to ensure continued compliance.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that client orientation procedures, staff training, and documentation requirements related to hours of operation are implemented and maintained in compliance with intake and admission regulations.
4. Date corrective action will be completed
Corrective action will be completed by: January 31, 2026
By this date, all current client charts will be in compliance with §709.91(b)(2)(ii).
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Ongoing compliance will be maintained through standardized intake procedures, supervisory oversight, and routine review of client intake documentation.
6. Statement of full correction
This Plan of Correction fully addresses the identified deficiency related to documenting client orientation to the facility's hours of operation during the intake process.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: January 31, 2026 |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project which included familiarization with the fee schedule in seven of seven outpatient records.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Infraction 1857
Regulation: §709.91(b)(2)(iii) ? Intake and Admission / Client Orientation to Fee Schedule
1. How the facility will correct the deficiency
The facility will provide and document client orientation to the project that includes familiarization with the facility's fee schedule for all current client records identified as lacking documentation. The fee schedule will be reviewed with each client, and documentation of orientation will be completed and placed in the client record to verify compliance with intake requirements.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will formalize intake procedures to require documented client orientation to the fee schedule at the time of admission. A Client Handbook containing project policies, including the fee schedule, will be included in the intake packet. The handbook will be reviewed with each client during orientation, and clients will be required to sign an acknowledgement and signature page confirming receipt and understanding of the fee schedule. Staff will be trained on the updated intake and documentation requirements, and supervisory review will be conducted to verify that signed acknowledgements are completed and maintained in the client record. Ongoing monitoring of intake documentation will be implemented to ensure continued compliance.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that client orientation procedures, staff training, and documentation requirements related to the fee schedule are implemented and maintained in compliance with intake and admission regulations.
4. Date corrective action will be completed
Corrective action will be completed by: January 31, 2026
By this date, all current client charts will be in compliance with §709.91(b)(2)(iii).
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Ongoing compliance will be maintained through standardized intake procedures, supervisory oversight, and routine review of client intake documentation.
6. Statement of full correction
This Plan of Correction fully addresses the identified deficiency related to documenting client orientation to the facility's fee schedule during the intake process.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: January 31, 2026 |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project which included familiarization with services provided in seven of seven outpatient records.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Infraction 1859
Regulation: §709.91(b)(2)(iv) ? Intake and Admission / Client Orientation to Services Provided
1. How the facility will correct the deficiency
The facility will provide and document client orientation to the project that includes familiarization with the services provided for all current client records identified as lacking documentation. The services provided by the facility will be reviewed with each client, and documentation of orientation will be completed and placed in the client record to verify compliance with intake requirements.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will formalize intake procedures to require documented client orientation to services provided at the time of admission. A Client Handbook containing project policies, including a description of services provided, will be included in the intake packet. The handbook will be reviewed with each client during orientation, and clients will be required to sign an acknowledgement and signature page confirming receipt and understanding of the services provided. Staff will be trained on the updated intake and documentation requirements, and supervisory review will be conducted to verify that signed acknowledgements are completed and maintained in the client record. Ongoing monitoring of intake documentation will be implemented to ensure continued compliance.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that client orientation procedures, staff training, and documentation requirements related to services provided are implemented and maintained in compliance with intake and admission regulations.
4. Date corrective action will be completed
Corrective action will be completed by: January 31, 2026
By this date, all current client charts will be in compliance with §709.91(b)(2)(iv).
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Ongoing compliance will be maintained through standardized intake procedures, supervisory oversight, and routine review of client intake documentation.
6. Statement of full correction
This Plan of Correction fully addresses the identified deficiency related to documenting client orientation to the services provided during the intake process.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: January 31, 2026 |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in four of four applicable records. The facility ' s policy and procedures state the psychosocial evaluation will be completed within 30 days.Client #3 was admitted to the outpatient level of care on September 30, 2025, and discharged on November 1, 2025. Client #5 was admitted to the outpatient level of care on October 13, 2025, and was still active at the time of the inspection.Client #6 was admitted to the outpatient level of care on September 30, 2025, and was still active at the time of the inspection.Client #7 was admitted to the outpatient level of care on October 6, 2025, and was still active at the time of the inspection.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Infraction 1871
Regulation: §709.91(b)(6) ? Intake and Admission / Psychosocial Evaluation
1. How the facility will correct the deficiency
The facility will complete and document psychosocial evaluations for all current applicable client records identified as lacking documentation. Psychosocial evaluations will be completed in accordance with facility policy and maintained in the client record to verify compliance with intake and admission requirements.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will reinforce intake and clinical documentation procedures to ensure psychosocial evaluations are completed within the required 30-day timeframe, as outlined in facility policy. A Client Handbook will be included in the intake packet to inform clients of the assessment process, including the psychosocial evaluation and its role in treatment planning. Clinical staff will be trained on documentation timeframes and requirements, and supervisory review will be conducted to monitor timely completion of psychosocial evaluations. Ongoing chart audits will be implemented to ensure continued compliance.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that psychosocial evaluations are completed timely, documented appropriately, and monitored in compliance with intake and admission regulations.
4. Date corrective action will be completed
Corrective action will be completed by: January 31, 2026
By this date, all current applicable client charts will be in compliance with §709.91(b)(6).
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Ongoing compliance will be maintained through adherence to policy timeframes, supervisory oversight, and routine review of clinical documentation.
6. Statement of full correction
This Plan of Correction fully addresses the identified deficiency related to the completion and documentation of psychosocial evaluations during the intake and admission process.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: January 31, 2026 |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to develop a treatment plan with the client in five of five applicable records. Client #3 was admitted to the outpatient level of care on September 30, 2025, and discharged on November 1, 2025. A treatment plan was developed on October 8, 2025, and did not indicate it was developed with the client.Client #4 was admitted to the outpatient level of care on September 17, 2025, and discharged on October 6, 2025. A treatment plan was developed on September 27, 2025, and did not indicate it was developed with the client.Client #5 was admitted to the outpatient level of care on October 13, 2025, and was still active at the time of the inspection. A treatment plan was developed on October 16, 2025, and did not indicate it was developed with the client.Client #6 was admitted to the outpatient level of care on September 30, 2025, and was still active at the time of the inspection. A treatment plan was developed on October 11, 2025, and did not indicate it was developed with the client.Client #7 was admitted to the outpatient level of care on October 6, 2025, and was still active at the time of the inspection. A treatment plan was developed on October 11, 2025, and did not indicate it was developed with the client.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Infraction 1875
Regulation: §709.92(a) ? Treatment and Rehabilitation Services / Individual Treatment Plan
1. How the facility will correct the deficiency
The facility will ensure that individual treatment and rehabilitation plans are developed with client participation and that such participation is clearly documented in the client record. For all current applicable client records identified as lacking documentation, treatment plans will be reviewed with the client, updated as appropriate, and documented to reflect client involvement in the development of the plan.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will reinforce clinical documentation procedures requiring that treatment plans be developed collaboratively with the client and that client participation be clearly documented, including client signature or documented acknowledgement. Clinical staff will be trained on treatment planning requirements and documentation standards. Supervisory review will be conducted to verify that treatment plans reflect client involvement and are completed in accordance with regulatory and facility policy requirements. Ongoing chart audits will be implemented to ensure continued compliance.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that treatment plans are developed with client participation, documented appropriately, and monitored for compliance with treatment and rehabilitation service requirements.
4. Date corrective action will be completed
Corrective action will be completed by: February 27, 2026
By this date, all current applicable client charts will be in compliance with §709.92(a).
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Ongoing compliance will be maintained through clinical supervision, staff training, and routine review of treatment planning documentation.
6. Statement of full correction
This Plan of Correction fully addresses the identified deficiency related to documenting that individual treatment and rehabilitation plans are developed with the client.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: 2/27/2026 |
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 the client records, the facility failed to include the type and frequency of treatment and rehabilitation services on the treatment plan in five of five applicable records.Client #3 was admitted to the outpatient level of care on September 30, 2025, and discharged on November 1, 2025. A treatment plan was developed on October 8, 2025, with no type or frequency identified.Client #4 was admitted to the outpatient level of care on September 17, 2025, and discharged on October 6, 2025. A treatment plan was developed on September 27, 2025, with no type or frequency identified.Client #5 was admitted to the outpatient level of care on October 13, 2025, and was still active at the time of the inspection. A treatment plan was developed on October 16, 2025, with no type or frequency identified.Client #6 was admitted to the outpatient level of care on September 30, 2025, and was still active at the time of the inspection. A treatment plan was developed on October 11, 2025, with no type or frequency identified.Client #7 was admitted to the outpatient level of care on October 6, 2025, and was still active at the time of the inspection. A treatment plan was developed on October 11, 2025, with no type or frequency identified.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Infraction 1879
Regulation: §709.92(a)(2) ? Treatment and Rehabilitation Services / Type and Frequency of Services
1. How the facility will correct the deficiency
The facility will update individual treatment and rehabilitation plans for all current applicable client records identified as lacking required documentation to clearly include the type and frequency of treatment and rehabilitation services. Treatment plans will be reviewed with the client and revised as appropriate to reflect the specific services to be provided and the planned frequency of those services. Updated treatment plans will be maintained in the client record to verify compliance with regulatory requirements.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will reinforce clinical documentation procedures requiring that all treatment plans include written documentation of the type and frequency of treatment and rehabilitation services, as required by regulation. A Client Handbook will be developed and provided to clients that outlines the types of treatment and rehabilitation services offered by the facility and general expectations regarding service frequency. Clinical staff will be trained on treatment planning standards, documentation requirements, and the use of the handbook as part of client orientation and treatment planning. Supervisory review will be conducted to verify that treatment plans are complete and compliant prior to implementation. Ongoing chart audits will be performed to ensure continued compliance with treatment planning requirements.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that treatment plans include documentation of the type and frequency of services, are developed with the client, and are monitored for compliance with treatment and rehabilitation service requirements.
4. Date corrective action will be completed
Corrective action will be completed by: February 27, 2026
By this date, all current applicable client charts will be in compliance with §709.92(a)(2).
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Ongoing compliance will be maintained through clinical supervision, staff training, and routine review of treatment planning documentation.
6. Statement of full correction
This Plan of Correction fully addresses the identified deficiency related to documenting the type and frequency of treatment and rehabilitation services in individual treatment plans.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: 2/27/2026 |
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 proposed type of support services on individual treatment plans in five of five applicable records.Client #3 was admitted to the outpatient level of care on September 30, 2025, and discharged on November 1, 2025. A treatment plan was developed on October 8, 2025, with no proposed type of support services identified.Client #4 was admitted to the outpatient level of care on September 17, 2025, and discharged on October 6, 2025. A treatment plan was developed on September 27, 2025, with no proposed type of support services identified.Client #5 was admitted to the outpatient level of care on October 13, 2025, and was still active at the time of the inspection. A treatment plan was developed on October 16, 2025, with no proposed type of support services identified.Client #6 was admitted to the outpatient level of care on September 30, 2025, and was still active at the time of the inspection. A treatment plan was developed on October 11, 2025, with no proposed type of support services identified.Client #7 was admitted to the outpatient level of care on October 6, 2025, and was still active at the time of the inspection. A treatment plan was developed on October 11, 2025, with no proposed type of support services identified.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Infraction 1881
Regulation: §709.92(a)(3) ? Treatment and Rehabilitation Services / Proposed Type of Support Service
1. How the facility will correct the deficiency
The facility will update individual treatment and rehabilitation plans for all current applicable client records identified as lacking documentation to clearly include the proposed type of support services. Treatment plans will be reviewed with the client and revised as appropriate to reflect identified support services that align with the client's treatment needs. Updated treatment plans will be maintained in the client record to verify compliance with regulatory requirements.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will reinforce clinical documentation procedures requiring that all treatment plans include written documentation of the proposed type of support services, as required by regulation. A Client Handbook will be developed and provided to clients that outlines the types of support services available or commonly coordinated by the facility. Clinical staff will be trained on treatment planning standards, documentation requirements, and the use of the handbook as part of client orientation and treatment planning. Supervisory review will be conducted to verify that treatment plans are complete and compliant prior to implementation. Ongoing chart audits will be performed to ensure continued compliance with treatment planning requirements.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that treatment plans include documentation of proposed support services, are developed with the client, and are monitored for compliance with treatment and rehabilitation service requirements.
4. Date corrective action will be completed
Corrective action will be completed by: February 27, 2026
By this date, all current applicable client charts will be in compliance with §709.92(a)(3).
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Ongoing compliance will be maintained through clinical supervision, staff training, and routine review of treatment planning documentation.
6. Statement of full correction
This Plan of Correction fully addresses the identified deficiency related to documenting the proposed type of support services in individual treatment plans.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: 2/27/2026 |
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, the facility failed to document case consultations in three of three applicable records. The facility's policy and procedures state case consultations are completed every 60 days.Client #5 was admitted to the outpatient level of care on October 13, 2025, and was still active at the time of the inspection. There were no case consultations documented. Client #6 was admitted to the outpatient level of care on September 30, 2025, and was still active at the time of the inspection. There were no case consultations documented. Client #7 was admitted to the outpatient level of care on October 6, 2025, and was still active at the time of the inspection. There were no case consultations documented. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Infraction 1905
Regulation: §709.93(a)(8) ? Client Records / Case Consultation Notes
1. How the facility will correct the deficiency
The facility will complete and document required case consultation notes for all current applicable client records identified as lacking documentation. Case consultations will be completed in accordance with facility policy and placed in the client record to reflect clinical review and consultation regarding the client's treatment and progress.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will reinforce clinical documentation procedures requiring case consultation notes to be completed at least every 60 days, as outlined in facility policy. A Client Handbook will be developed and provided to clients that outlines the types of support services available or commonly coordinated by the facility. Clinical staff will be trained on documentation requirements, including case consultation timelines, and on the use of the handbook as part of client orientation and treatment planning. Supervisory review will be conducted to verify that case consultations are completed timely and documented appropriately. Ongoing chart audits will be performed to ensure continued compliance with client record documentation requirements.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that case consultation notes are completed in accordance with policy, documented appropriately, and monitored for compliance with client record requirements.
4. Date corrective action will be completed
Corrective action will be completed by: February 15, 2026
By this date, all current applicable client charts will be in compliance with §709.93(a)(8).
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Ongoing compliance will be maintained through adherence to documentation schedules, supervisory oversight, and routine review of client records.
6. Statement of full correction
This Plan of Correction fully addresses the identified deficiency related to documenting required case consultation notes in client records.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: 2/15/2026 |
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 document discharge summary information in four of four applicable records.The facility's policy and procedures state a discharge summary is to be completed within 30 days.Client #1 was admitted to the outpatient level of care on August 28, 2025, and discharged on September 6, 2025. Client #2 was admitted to the outpatient level of care on September 12, 2025, and discharged on September 27, 2025. Client #3 was admitted to the outpatient level of care on September 30, 2025, and discharged on November 1, 2025. Client #4 was admitted to the outpatient level of care on September 17, 2025, and discharged on October 6, 2025. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Infraction 1909
Regulation: §709.93(a)(10) ? Client Records / Discharge Summary
1. How the facility will correct the deficiency
The facility will complete and document discharge summaries for all applicable client records identified as lacking documentation. Discharge summaries will be completed in accordance with facility policy and placed in the client record to reflect the client's course of treatment, progress, and discharge status.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will reinforce clinical documentation procedures requiring discharge summaries to be completed within 30 days of discharge, as outlined in facility policy. Clinical staff will be trained on discharge documentation requirements and timelines. Supervisory review will be conducted to verify that discharge summaries are completed timely and documented appropriately. Ongoing chart audits will be implemented to ensure continued compliance with client record documentation requirements.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that discharge summaries are completed in accordance with policy, documented appropriately, and monitored for compliance with client record requirements.
4. Date corrective action will be completed
Corrective action will be completed by: February 15, 2026
By this date, all current applicable client charts will be in compliance with §709.93(a)(10).
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Ongoing compliance will be maintained through adherence to documentation timelines, supervisory oversight, and routine review of client records.
6. Statement of full correction
This Plan of Correction fully addresses the identified deficiency related to completing and documenting required discharge summaries in client records.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: 2/15/2026 |
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 document follow-up information in four of four applicable records.The facility's policy and procedures state follow-up is to be completed within 7 days.Client #1 was admitted to the outpatient level of care on August 28, 2025, and discharged on September 6, 2025. Client #2 was admitted to the outpatient level of care on September 12, 2025, and discharged on September 27, 2025. Client #3 was admitted to the outpatient level of care on September 30, 2025, and discharged on November 1, 2025. Client #4 was admitted to the outpatient level of care on September 17, 2025, and discharged on October 6, 2025. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Infraction 1911
Regulation: §709.93(a)(11) ? Client Records / Follow-Up Information
1. How the facility will correct the deficiency
The facility will complete and document required follow-up information for all applicable client records identified as lacking documentation. Follow-up documentation will be completed in accordance with facility policy and placed in the client record to reflect post-discharge contact or follow-up efforts with the client.
2. How the facility will ensure the deficiency does not recur
To prevent recurrence, the facility will reinforce clinical documentation procedures requiring follow-up to be completed within 7 days of discharge, as outlined in facility policy. Clinical staff will be trained on follow-up documentation requirements and timelines. Supervisory review will be conducted to verify that follow-up information is completed timely and documented appropriately. Ongoing chart audits will be implemented to ensure continued compliance with client record documentation requirements.
3. Who is responsible for ensuring corrective action is implemented
The Project Director is responsible for ensuring that follow-up documentation is completed in accordance with policy, documented appropriately, and monitored for compliance with client record requirements.
4. Date corrective action will be completed
Corrective action will be completed by: February 15, 2026
By this date, all current applicable client charts will be in compliance with §709.93(a)(11).
5. Reasonable timeframe for correcting the deficiency
The identified deficiency will be corrected by the stated completion date. Ongoing compliance will be maintained through adherence to follow-up timelines, supervisory oversight, and routine review of client records.
6. Statement of full correction
This Plan of Correction fully addresses the identified deficiency related to documenting required follow-up information in client records.
7. Authorized Provider
Authorized Provider: Project Director
Title: Authorized Provider
Date: 2/15/2026 |