INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on June 15, 2026, 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, 2026-December 31, 2026.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 25 and December 15, 2025, licensing inspection.
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Plan of Correction
Regulation: §704.11(a)(1) ? Training Needs Assessment
1. How the facility will correct the deficiency
The facility will complete and document the 2026 annual staff training needs assessments. All applicable staff will review and sign the assessments, and completed documentation will be maintained in personnel/training records.
2. How the facility will ensure the deficiency does not recur
Annual training needs assessments will be completed by December 15 each year in accordance with facility policy. The Project Director will verify that all assessments are completed, reviewed, signed, and documented to prevent recurrence.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action will be completed by:
10/15/2026
By this date, all current applicable staff training needs assessments will be completed, reviewed, signed, and documented.
5. Reasonable timeframe for correcting the deficiency
The deficiency will be corrected by the stated date, with annual monitoring thereafter to ensure continued compliance.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
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, 2026-December 31, 2026.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 25 and December 15, 2025, licensing inspection.
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Plan of Correction
Regulation: §704.11(a)(2) ? Overall Training Plan
1. How the facility will correct the deficiency
The facility will complete and document the 2026 overall training plan addressing identified staff training needs. Applicable staff will review and sign the training plan, and the completed documentation will be maintained in the facility's training records.
2. How the facility will ensure the deficiency does not recur
The overall training plan will be completed by December 31 each year in accordance with facility policy. The Project Director will verify that the plan is completed, reviewed, signed, and properly documented to prevent recurrence.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action will be completed by: 10/15/2026
By this date, the 2026 overall training plan will be completed, reviewed, signed, and documented.
5. Reasonable timeframe for correcting the deficiency
The deficiency will be corrected by the stated date, with annual monitoring thereafter to ensure continued compliance.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
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, 2026-December 31, 2026.
There were no 2026 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, and November 25 and December 15, 2025, licensing inspection.
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Plan of Correction
Regulation: §704.11(b)(1) ? Individual Training Plans
1. How the facility will correct the deficiency
The facility will develop and document a 2026 individual training plan for each current employee based on the employee's role and skill level. Each plan will include documented input and signatures from both the employee and supervisor.
2. How the facility will ensure the deficiency does not recur
Individual training plans will be completed annually for all employees and upon hire for new employees, with documented employee and supervisor input. Because this is a repeat citation, the Project Director will verify that each plan is completed, signed, and maintained in the employee's personnel/training record.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action will be completed by: 10/15/2026
By this date, all current employees will have completed, reviewed, and signed 2026 individual training plans.
5. Reasonable timeframe for correcting the deficiency
The deficiency will be corrected by the stated date, with annual monitoring and verification thereafter to ensure continued compliance.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
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.
The Staff Training Acknowledgement-Fire Extinguisher Safety Training form was not signed by the employee.
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 the facility staff during the licensing process.
This is a repeat citation from the November 25 and December 15, 2025, licensing inspection.
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Plan of Correction
Regulation: §705.28(c)(4) ? Fire Safety / Fire Extinguisher Training
1. How the facility will correct the deficiency
Staff #3 and Staff #4 will review the required fire extinguisher safety training and sign the Staff Training Acknowledgement form. Documentation will be maintained in each employee's personnel/training record.
2. How the facility will ensure the deficiency does not recur
All new employees will receive documented fire extinguisher instruction upon hire and sign the required acknowledgement. The Project Director will verify completion and signatures before the training requirement is considered complete.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action for Staff #3 and Staff #4 will be completed by: 9/26/2026
All future employees will receive and document fire extinguisher training upon hire.
5. Reasonable timeframe for correcting the deficiency
The current deficiency will be corrected by the stated date. Future compliance will be maintained through verification of fire extinguisher training and documentation upon hire.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
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.
The Staff Training Acknowledgement-Emergency Responsibility Training form was not signed by the employee.
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 the facility staff during the licensing process.
This is a repeat citation from the November 25 and December 15, 2025, licensing inspection.
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Plan of Correction
Regulation: §705.28(d)(3) ? Fire Safety / Emergency Responsibility Training
1. How the facility will correct the deficiency
Staff #3 and Staff #4 will review their assigned emergency responsibilities and sign the Staff Training Acknowledgement?Emergency Responsibility Training form. Documentation will be maintained in each employee's personnel/training record.
2. How the facility will ensure the deficiency does not recur
All new employees will receive emergency responsibility training upon hire and sign the required acknowledgement. The Project Director will verify completion and signatures before the training requirement is considered complete.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action for Staff #3 and Staff #4 will be completed by: 9/26/2026
All future employees will receive and document emergency responsibility training upon hire.
5. Reasonable timeframe for correcting the deficiency
The current deficiency will be corrected by the stated date. Future compliance will be maintained through verification of emergency responsibility training and documentation upon hire.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
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. The personnel record failed to document an annual staff performance evaluation for the period of March 1, 2025 - February 27, 2026.
Staff #2 was hired as the facility director on March 1, 2024, and still employed at the time of inspection. The personnel record failed to document an annual staff performance evaluation for the period of March 1, 2025 - February 27, 2026.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 25 and December 15, 2025, licensing inspection.
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Plan of Correction
Regulation: §709.26(b)(3) ? Personnel Management / Annual Staff Performance Evaluations
1. How the facility will correct the deficiency
Annual written performance evaluations will be completed for Staff #1 and Staff #2. Each evaluation will be reviewed and signed by the employee and maintained in the personnel record.
2. How the facility will ensure the deficiency does not recur
Annual performance evaluations will be completed for each applicable employee, reviewed and signed by the employee, and maintained in the personnel record. The Project Director will monitor evaluation due dates and verify completion and signatures annually.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action for Staff #1 and Staff #2 will be completed by: 9/26/2026
By this date, both applicable personnel records will contain completed, reviewed, and signed annual performance evaluations.
5. Reasonable timeframe for correcting the deficiency
The deficiency will be corrected by the stated date, with annual monitoring thereafter to ensure continued compliance.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on observation, the facility failed to secure hard copy client records within locked storage containers.
At the time of the inspection, staff arrived carrying unsecured client records into the facility.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Regulation: §709.28(b) ? Confidentiality / Security of Client Records
1. How the facility will correct the deficiency
All hard-copy client records will be secured in locked storage containers. Staff will be instructed that client records may not be transported or carried outside secured storage unless they are maintained in a locked container.
2. How the facility will ensure the deficiency does not recur
Staff will be trained on the proper storage and transportation of confidential client records. The Project Director will monitor compliance and verify that hard-copy records are secured in locked storage containers.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action will be completed by: 9/26/2026
By this date, staff will be trained and all hard-copy client records will be maintained and transported in compliance with §709.28(b).
5. Reasonable timeframe for correcting the deficiency
The deficiency will be corrected by the stated date, with ongoing monitoring thereafter to ensure continued compliance.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
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 three of three records.
The plan of correction that was approved on January 15, 2026 indicated that all current clients would be in compliance by January 31, 2026.
There was no consent to release information forms for the funding source.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 25 and December 15, 2025, licensing inspection.
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Plan of Correction
Regulation: §709.28(c) ? Confidentiality / Consent to Release Information
1. How the facility will correct the deficiency
The clients identified in the citation are no longer active with the facility. For all future clients, an informed and voluntary consent to release information will be obtained and documented prior to disclosure of client information, including disclosure to a funding source.
2. How the facility will ensure the deficiency does not recur
The consent to release information form will be incorporated into the intake and billing process. The Project Director will verify that a valid consent is present in the client record before information is released to a funding source or other authorized recipient.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action will be implemented by: 9/26/2026
Beginning on this date, all future client disclosures will require documented informed and voluntary consent prior to release of information.
5. Reasonable timeframe for correcting the deficiency
The corrective process will be implemented by the stated date and applied to all future clients to ensure continued compliance.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
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 three of three records.
The plan of correction that was approved on January 15, 2026 indicated that all current clients would be in compliance by January 31, 2026.
As of the date of inspection, three of three records did not include written acknowledgement of their rights.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 25 and December 15, 2025, licensing inspection.
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Plan of Correction
Regulation: §709.30 ? Client Rights
1. How the facility will correct the deficiency
The clients identified in the citation are no longer active with the facility. For all future clients, Client Rights will be reviewed at admission, and a signed written acknowledgement will be obtained and maintained in the client record.
2. How the facility will ensure the deficiency does not recur
The Client Rights acknowledgement will be required as part of the intake process. The Project Director will verify that each new client has reviewed and signed the acknowledgement and that it is maintained in the client record.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action will be implemented by: 9/26/2026
Beginning on this date, all future clients will receive Client Rights and provide written acknowledgement during the intake process.
5. Reasonable timeframe for correcting the deficiency
The corrective process will be implemented by the stated date and applied to all future admissions to ensure continued compliance.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a record keeping system which allowed for the identification of clients ' admissions and discharges within a specified time period.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Regulation: §709.31(b) ? Data Collection System / Admissions and Discharges
1. How the facility will correct the deficiency
The facility will establish and maintain an admission and discharge log that identifies each client's admission date and discharge date within the applicable time period.
2. How the facility will ensure the deficiency does not recur
The admission and discharge log will be updated whenever a client is admitted or discharged. The Project Director will review the log routinely to verify that admission and discharge information is complete and current.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action will be completed by: 9/26/2026
By this date, the facility's admission and discharge recordkeeping system will be current and compliant.
5. Reasonable timeframe for correcting the deficiency
The deficiency will be corrected by the stated date, with ongoing review thereafter to ensure continued compliance.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
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 three of three records.
The plan of correction that was approved on January 15, 2026 indicated that all current clients would be in compliance by February 27, 2026.
As of the date of inspection, three of three records did not include documentation of the disclosure to the clients of the criteria for admission, treatment, completion and discharge
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 25 and December 15, 2025, licensing inspection.
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Plan of Correction
Regulation: §709.91(b)(1) ? Intake and Admission / Admission, Treatment, Completion and Discharge Criteria
1. How the facility will correct the deficiency
The clients identified in the citation are no longer active with the facility. For all future clients, criteria for admission, treatment, completion, and discharge will be reviewed during intake and documented by signed client acknowledgement.
2. How the facility will ensure the deficiency does not recur
The required criteria and acknowledgement will be incorporated into the intake process and Client Handbook. The Project Director will verify that each new client has reviewed and signed the acknowledgement and that it is maintained in the client record.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action will be implemented by: 9/26/2026
Beginning on this date, all future clients will receive and acknowledge the criteria for admission, treatment, completion, and discharge during intake.
5. Reasonable timeframe for correcting the deficiency
The corrective process will be implemented by the stated date and applied to all future admissions to ensure continued compliance.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
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 three of three records.
The plan of correction that was approved on January 15, 2026 indicated that all current clients would be in compliance by January 31, 2026.
As of the date of inspection, three of three records did not include documentation of the familiarization with project policies.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 25 and December 15, 2025, licensing inspection.
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Plan of Correction
Regulation: §709.91(b)(2)(i) ? Intake and Admission / Orientation to Project Policies
1. How the facility will correct the deficiency
The clients identified in the citation are no longer active with the facility. For all future clients, project policies will be reviewed during orientation and documented by signed client acknowledgement.
2. How the facility will ensure the deficiency does not recur
Project policies and the acknowledgement form will be incorporated into the Client Handbook and intake process. The Project Director will verify that each new client has reviewed and signed the acknowledgement and that it is maintained in the client record.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action will be implemented by: 9/26/2026
Beginning on this date, all future clients will receive documented orientation to project policies during the intake process.
5. Reasonable timeframe for correcting the deficiency
The corrective process will be implemented by the stated date and applied to all future admissions to ensure continued compliance.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
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 three of three records.
The plan of correction that was approved on January 15, 2026 indicated that all current clients would be in compliance by January 31, 2026.
As of the date of inspection, three of three records did not include documentation of the familiarization with hours of operation.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 25 and December 15, 2025, licensing inspection.
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Plan of Correction
Regulation: §709.91(b)(2)(ii) ? Intake and Admission / Hours of Operation
1. How the facility will correct the deficiency
The clients identified in the citation are no longer active with the facility. For all future clients, the facility's hours of operation will be reviewed during orientation and documented by signed client acknowledgement.
2. How the facility will ensure the deficiency does not recur
The hours of operation and acknowledgement form will be incorporated into the Client Handbook and intake process. The Project Director will verify that each new client has reviewed and signed the acknowledgement and that it is maintained in the client record.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action will be implemented by: 9/26/2026
Beginning on this date, all future clients will receive documented orientation to the facility's hours of operation during the intake process.
5. Reasonable timeframe for correcting the deficiency
The corrective process will be implemented by the stated date and applied to all future admissions to ensure continued compliance.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
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 three of three records.
The plan of correction that was approved on January 15, 2026 indicated that all current clients would be in compliance by January 31, 2026.
As of the date of inspection, three of three records did not include documentation of the familiarization with the fee schedule.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 25 and December 15, 2025, licensing inspection.
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Plan of Correction
Regulation: §709.91(b)(2)(iii) ? Intake and Admission / Fee Schedule
1. How the facility will correct the deficiency
The clients identified in the citation are no longer active with the facility. For all future clients, the fee schedule will be reviewed during orientation and documented by signed client acknowledgement.
2. How the facility will ensure the deficiency does not recur
The fee schedule and acknowledgement form will be incorporated into the Client Handbook and intake process. The Project Director will verify that each new client has reviewed and signed the acknowledgement and that it is maintained in the client record.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action will be implemented by: 9/26/2026
Beginning on this date, all future clients will receive documented orientation to the facility's fee schedule during the intake process.
5. Reasonable timeframe for correcting the deficiency
The corrective process will be implemented by the stated date and applied to all future admissions to ensure continued compliance.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
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 three of three records.
The plan of correction that was approved on January 15, 2026 indicated that all current clients would be in compliance by January 31, 2026.
As of the date of inspection, three of three records did not include documentation of the familiarization with services provided.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 25 and December 15, 2025, licensing inspection.
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Plan of Correction
Regulation: §709.91(b)(2)(iv) ? Intake and Admission / Services Provided
1. How the facility will correct the deficiency
The clients identified in the citation are no longer active with the facility. For all future clients, the services provided by the facility will be reviewed during orientation and documented by signed client acknowledgement.
2. How the facility will ensure the deficiency does not recur
The services provided and acknowledgement form will be incorporated into the Client Handbook and intake process. The Project Director will verify that each new client has reviewed and signed the acknowledgement and that it is maintained in the client record.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action will be implemented by: 9/26/2026
Beginning on this date, all future clients will receive documented orientation to the services provided during the intake process.
5. Reasonable timeframe for correcting the deficiency
The corrective process will be implemented by the stated date and applied to all future admissions to ensure continued compliance.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
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 three of three records.
The facility ' s policy and procedures state the psychosocial evaluation will be completed within 30 days.
The plan of correction that was approved on January 15, 2026 indicated that all current clients would be in compliance by January 31, 2026.
As of the date of inspection, three of three records did not include documentation of the psychosocial evaluation.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 25 and December 15, 2025, licensing inspection.
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Plan of Correction
Regulation: §709.91(b)(6) ? Intake and Admission / Psychosocial Evaluation
1. How the facility will correct the deficiency
The clients identified in the citation are no longer active with the facility. For all future clients, a psychosocial evaluation will be completed and documented within 30 days in accordance with facility policy.
2. How the facility will ensure the deficiency does not recur
Psychosocial evaluation due dates will be tracked for all new admissions. The Project Director will monitor client records to verify that each psychosocial evaluation is completed and documented within the required 30-day timeframe.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action will be implemented by: 9/26/2026
Beginning on this date, the tracking and verification process will apply to all future client admissions.
5. Reasonable timeframe for correcting the deficiency
The corrective process will be implemented by the stated date and applied to all future admissions to ensure continued compliance.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project 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 document treatment plan updates every 60 days in three of three records.
Client #1 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 update was completed on January 8, 2026, and the next update was due no later than March 8, 2026. There were no further updates documented in the record.
Client #2 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 a treatment plan update was due no later than December 11, 2025; however, it was completed December 13, 2025. The next update was due no later than February 13, 2026. There were no further updates documented in the record.
Client #3 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 update was completed on December 10, 2025, and the next update was due no later than February 10, 2026. There were no further updates documented in the record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Regulation: §709.92(b) ? Treatment and Rehabilitation Services / Treatment Plan Updates
1. How the facility will correct the deficiency
The clients identified in the citation are no longer active with the facility. For all future clients, treatment plan updates will be completed and documented at least every 60 days as required.
2. How the facility will ensure the deficiency does not recur
Treatment plan update due dates will be tracked for all clients. The Project Director will monitor client records and verify that treatment plan updates are completed and documented within the required 60-day timeframe.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action will be implemented by: 9/26/2026
Beginning on this date, the tracking and verification process will apply to all future clients.
5. Reasonable timeframe for correcting the deficiency
The corrective process will be implemented by the stated date and applied to all future clients to ensure continued compliance.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
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.
The plan of correction that was approved on January 15, 2026 indicated that all current clients would be in compliance by February 15, 2026.
As of the date of inspection, three of three records did not include documentation case consults.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 25 and December 15, 2025, licensing inspection.
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Plan of Correction
Regulation: §709.93(a)(8) ? Client Records / Case Consultation Notes
1. How the facility will correct the deficiency
The clients identified in the citation are no longer active with the facility. For all future clients, case consultations will be completed and documented every 60 days in accordance with facility policy.
2. How the facility will ensure the deficiency does not recur
Case consultation due dates will be tracked for all clients. The Project Director will monitor client records and verify that case consultations are completed and documented within the required 60-day timeframe.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action will be implemented by: 9/26/2026
Beginning on this date, the tracking and verification process will apply to all future clients.
5. Reasonable timeframe for correcting the deficiency
The corrective process will be implemented by the stated date and applied to all future clients to ensure continued compliance.
6. Statement of full correction
This Plan of Correction will fully address the identified deficiency.
7. Authorized Provider
Authorized Provider: Project Director |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative information, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for individual training plans were submitted and approved by the Department for the November 25 and December 15, 2025, and the November 13, 2024, annual licensing inspections. Individual training plans was again found to be a deficiency in the June 15, 2026 licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Regulation: Compliance with Department-Approved Plans of Correction
1. How the facility will correct the deficiency
The facility will review all outstanding Department-approved Plans of Correction and verify that each required corrective action has been fully implemented and documented. The 2026 individual training plans will be completed with employee and supervisor input, signatures, and supporting documentation.
2. How the facility will ensure the deficiency does not recur
A written Plan of Correction compliance tracker will be maintained identifying each citation, required corrective action, completion date, and supporting documentation. The Project Director will verify and sign off on each corrective action before it is considered completed.
3. Who is responsible for ensuring corrective action is implemented
Project Director
4. Date corrective action will be completed
Corrective action will be completed by: 1015/2026
By this date, all outstanding corrective actions identified through the facility's review will be completed and supporting documentation verified.
5. Reasonable timeframe for correcting the deficiency
The deficiency will be corrected by the stated date. The compliance tracker will be reviewed routinely thereafter to ensure approved corrective actions remain implemented.
6. Statement of full correction
This Plan of Correction will fully address the facility's compliance with Department-approved corrective actions.
7. Authorized Provider
Authorized Provider: Project Director |