INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Laure Rohrs Gargano was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.28 (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 an informed and voluntary consent from the client for the disclosure of information in one of the seven records reviewed.
Client #6 was admitted on February 03, 2025 and still active at the time of the inspection. There was no documentation of an informed and voluntary consent from the client for the disclosure of information for the funder in the record; however, the facility confirmed billing was occurring.
This is a repeat citation from both the June 29, 2023 and July 16, 2024 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
08/15/25
Client #6 consents have been completed and uploaded as of 08/10/25
Porject director will update Policy and procedural manual addressing:
Completion of Consent to treatment; ROI's.
" Providing clinical team member will review clients chart at the onset of the intake session. Clinical team member will verify completion of electronic Intake packet - which includes Consent to treatment and ROI's. Clinical team member will inquire if any additional ROI's are needed and if so, complete hard copy in session.
If the electronic intake packet is not completed, the client will complete this on their cell phone while in session.
If there are technical issues preventing electronic completion of the Consent to treatment and ROI's - hard copies with be given to the client in the intake session for review and completion prior to the session commencing.
If the intake session is a scheduled virtual session, clinical team member will verify if intake packet complete prior to the scheduled intake. If the packet is not completed - the client will be contacted via text message - informing that the session is canceled and cannot be rescheduled until the intake packet is completed in full."
Project Director will review all new admissions weekly to verify compliance with this policy update." |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in one out of six records reviewed.
Client #2 was admitted on March 19, 2025 and still active at time of the inspection. A consent form signed and dated July 16, 2025, for county probation, did not have documentation that the client was offered a copy of the consent.
This is a repeat citation from the July 16, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
08/21/25
Updated Corrective Action Date
08/15/25
Client #2 has signed the updated consent as of 08/13/2025
Project director has updated all forms to include the statement informing clients they may request a copy of forms.
Project director has removed all versions of non-compliant forms from the EHR, ensuring going forward, ROI's will be in compliance.
Project director will update the electronic ROI for probation departments, adding the confirmation that the client is aware they are allowed to request a copy of the form. This will be confirmed by initialing this statement on the form.
All client are also able to independently down load all forms that have been signed in the EHR for their review and record. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed the same day of therapy sessions, per facility policy, in three of six records reviewed.
Client #4 was admitted on May 13, 2025 and still active at the time of the inspection. The record contained a progress note for an individual session occurring on July 1, 2025, that was not completed until July 07, 2025.
Client #5 was admitted on January 30, 2025 and was still active at the time of inspection. The record contained progress notes for individual sessions occurring on February 12, 2025, March 25, 2025, April 29, 2025, May 13, 2025, May 26, 2025, June 03, 2025, and June 17, 2025, that were not completed until February 17, 2025, March 27, 2025, May 06, 2025, May 16, 2025, June 19, 2025, June 19, 2025, and June 19, 2025, respectively.
Client #6 was admitted on February 03, 2025 and still active at the time of the inspection. The record contained progress notes for individual sessions occurring on February 13, 2025, February 20, 2025, March 13, 2025, April 10, 2025, April 24, 2025, May 08, 2025, May 22, 2025, June 12, 2025, and June 19,2025, that were not completed until February 17, 2025, February 24, 2025, March 17, 2025, April 14, 2025, April 29, 2025, May 12, 2025, May 27, 2025, June 17, 2025 and June 23, 2025 respectively.
This is a repeat citation from the July 16, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
08/22/25
Updated the Corrective Action Date
08/15/25
The project director updated the policy and procedural manual on 08/07/25.
Project director informed clinical team members of the policy update on 08/08/25.
Project director will monitor compliance weekly through a report created in the EHR - which lists:
Missing progress notes
Unsigned progress notes.
Project director will update the policy and procedural manual for progress notes.
The update will state:
" Clinical team member responsible for completed session will have 72 hours to complete the required progress note"
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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 client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failure to obtain informed and voluntary consent from the client in the outpatient records was submitted and approved by the Department for the June 29, 2023, and July 16, 2024, annual licensing inspections. Failure to obtain an informed and voluntary consent was again found to be a deficiency in the July 25, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will be responsible to ensure all POC's are completed and implemented.
PD will complete monthly QA of new client records to ensure all intake paperwork, including the Consent to Treatment are completed; monthly monitoring will occur for a period of six months. At that time, QA audits will occur quarterly.
PD will provide re-education of clinician's of the regulatory required forms to completed in client records; how to verify if the required paperwork is completed, and outline a step by step guide to assist clients in completing the required forms when needed. |