INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 1, 2025 through July 2, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PWS Wayne LLC dba Amwell Recovery of Wayne 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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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of personnel records, it was determined that one employee hired as a clinical supervisor did not meet the qualification requirements for the position.
Employee # 2 was promoted to the position of clinical supervisor on May 27, 2025 and was current in that position at the time of the inspection. At the time of promotion, the employee had a qualifying Master's degree, but only one year of clinical experience, not the required minimum of two years.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The said staff member will need to be demoted and her qualifications will need to be demoted to a " Lead Counselor" until she has met the necessary requirements and hit another year of clinical experience. This will occur via Operations Director on 9/1. Current Operations Director will take on the role of Clinical Supervisor in the interim. Moving forward regulatory standards will be reviewed and confirmed and Provive will explore the need for HR support to monitor. The operation director and owners will ensure compliance with regulatory standards and credentialing moving forward. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to provide documentation showing that clinical supervisors had monthly meetings with their supervisors for the first six months of employment in that position, in one of one applicable record reviewed.
Employee # 2 was promoted to the position of clinical supervisor on May 27, 2025. There was no documentation of monthly supervision in the personnel record as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting immediately on 9/1 Operations Director will begin recording supervisions with Clinical Supervisor at minimum monthly. This will be kept and maintained in a Clinical Supervision Binder for next audit. All new staff will be met with weekly for the first 6 months. Policies will be updated to reflect this. |
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 the personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level per the facility ' s policy and procedures manual in five out of seven employee records reviewed.
Employee # 1 was hired in the position of Project Director on February 24, 2025. Employee # 1 was to have an initial individual training plan developed within 30 days of the date of hire, however, no written individual training plan was completed as of the date of the inspection.
Employee # 3 has been in the position of counselor since May 1, 2024. The initial training plan was to be completed within 30 days of hire; however, it was not documented until June 30, 2025.
Employee # 4 was hired in the position of counselor on March 13, 2025. Employee # 4 was to have an initial individual training plan developed within 30 days of the date of hire; however, no written individual training plan was documented as of the date of the inspection.
Employee # 5 was hired in the position of counselor on January 20, 2025. Employee # 5 was to have an initial individual training plan developed within 30 days of the date of hire, however, no written individual training plan was documented as of the date of the inspection.
Employee # 6 was hired in the position of counselor since May 26, 2025. Employee # 6 was to have an initial individual training plan developed within 30 days of the date of hire, however, no written individual training plan was documented as of the date of the inspection.
This is a repeat citation from the June 26, 2024 annual licensing renewal inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Starting 9/1/25; Upon hire, new staff will be given a training plan for the first month of hire. Individual training plans will then be done annually for all staff after the first year of employment and kept in their employee HR file. The hiring manager and the direct report will complete the training plan and be monitor and observed by this Operations Director. All staff missing a training plan will have one on file by 9/30/2025 This will be reviewed with their supervisor. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that one applicable employee received a minimum of 4 hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee # 3 was hired in the position of counselor on May 1, 2024 and was due to have the communicable disease trainings no later than May 1, 2025; however, the TB/STD training was not completed as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting on 9/1; Upon hire staff will be given an individual training plan for the first month of employment. Clinical Supervisor will complete the training plan and or the hireing manager. OPerations Director will review and sign. This will include TB/ STD and HIV training. HR files and charts will be reviewed quarterly for compliance. Employee 3 will complete by 9/30/2025. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in five of seven records reviewed.
Employee # 1 was hired to the project on February 6, 2025 and began the position of Project Director/Facility Director on February 24, 2025 and is current in that position. Employee #1 was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as completed until June 27, 2025.
Employee # 2 was hired as a counselor on July 17, 2024, prior to being promoted to clinical supervisor on May 27, 2025, and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as completed until August 23, 2024.
Employee # 4 was hired as a counselor on March 13, 2025 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as completed until June 27, 2025.
Employee # 5 was hired as a counselor on January 20, 2025 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as completed until June 27, 2025.
Employee # 6 was hired as a counselor on May 26, 2025 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as completed until June 30, 2025.
This is a repeat citation from the June 26, 2024 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting immediately on 9/1 all new hire and current staff will ensure that fire safety training is completed. Staff will complete and sign off on completed form that demonstrates knowledge and education on the location of the fire extinguishers and will be shown how to use them upon hire. This will be recorded and kept in the HR file. Office Manager will ensure the fire safety training is completed and on file. |
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 from July 2024 through June 2025, the facility failed to conduct an unannounced fire drill during May 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills will continue to be completed on a monthly basis and recorded in the Fire Drill log. Operations Director will create a monthly spreadsheet to begin to utilize as of 9/1 to ensure none are missed moving forward. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that five of five applicable staff members were trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 1 was hired to the project on February 6, 2025 and began the position of Project Director/Facility Director on February 24, 2025 and is current in that position. Employee # 1 began working shifts on February 6, 2025, but was not trained to perform assigned tasks during emergencies until June 27, 2025.
Employee # 2 was hired as a counselor on July 17, 2024, prior to being promoted to clinical supervisor on May 27, 2025, and is current in that position. Employee # 2 began working shifts on July 17, 2024, but was not trained to perform assigned tasks during emergencies until August 23, 2024.
Employee # 4 was hired as a counselor on March 13, 2025 and is current in that position. Employee # 4 began working shifts on March 13, 2025, but was not trained to perform assigned tasks during emergencies until June 27, 2025.
Employee # 5 was hired as a counselor on January 20, 2025 and is current in that position. Employee # 5 began working shifts on January 20, 2025, but was not trained to perform assigned tasks during emergencies until June 27, 2025.
Employee # 6 was hired as a counselor on May 26, 2025 and is current in that position. Employee # 6 began working shifts on May 26, 2025, but was not trained to perform assigned tasks during emergencies until June 30, 2025.
This is a repeat citation from the June 26, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting 9/1/ 25.Upon new hire training and new employment, all staff will moving forward completed the " Fire Safety Training". Fire Drill response and procedure will be incorporated into the emergency protocol and procedures. This will be done prior to the first shift of employment. This will be reviewed and signed off at new hire checklist by the operations director and hiring manager. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the July 2024 through June 2025 fire drill logs, the facility failed to document the number of persons in the facility at the time of the drill during the July 2024, August 2024, September 2024, October 2024, December 2024, and March 2025 fire drills.
This is a repeat citation from the June 26, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 9/1 the Fire Drill form will be corrected and edited to notate the number of participants in the drill. The number of participants will be included moving forward. Office manager will review the forms monthly for compliance. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the July 2024 through June 2025 fire drill logs, the facility failed to ensure that a fire alarm or smoke detector was set off during each fire drill. There was no documentation that a fire alarm or a smoke detector was set off during any fire drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 9/30 Operations Director will complete and fill out the waiver for an exemption to not have to set the alarms off. In the event the waiver is denied this Operations Director will need to meet with the landlord and fire department to make determinations on how to safely alarm the system in a way that is not disruptive and or problematic to the fire department. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project, in one of one applicable record reviewed.
Client # 8 was transferred to the outpatient level of care on December 16, 2024 and was involuntarily discharged on February 6, 2025. The record did not contain documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Operations Director will create and update a policy by 9/30 on Administrative Discharges. Clinical Supervisor will review on 9/1 on the various types of discharges and operationally define what is an " Administrative Discharge". Clients who are behavioral issues, repeat substance use and or involuntary discharges will be issues behavioral contracts and issued warnings on three occasions. After the third warning clients will be notified in writing about the involuntary discharge and be given a chance to appeal. This will be record and documented in the EMR record and uploaded. Operations Director will review the appeal and determine whether or not to overturn. |
709.81(b)(2)(iii) LICENSURE Intake and admission
709.81. 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:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document intake procedures that included familiarization with the fee schedule in seven of eight records reviewed.
Client # 2 was admitted on February 3, 2025 and was transferred to a lower level of care on March 13, 2025. There was no documentation in the client record that the client was familiarized with the fee schedule.
Client # 3 was admitted on May 22, 2025 and was discharged on June 18, 2025. There was no documentation in the client record that the client was familiarized with the fee schedule.
Client # 4 was admitted on December 2, 2024 and was discharged on January 24, 2025. There was no documentation in the client record that the client was familiarized with the fee schedule.
Client # 5 was admitted on February 27, 2025 and was transferred to a lower level of care on April 18, 2025. There was no documentation in the client record that the client was familiarized with the fee schedule.
Client # 6 was admitted on December 4, 2024 and was transferred to a lower level of care on February 3, 2025. There was no documentation in the client record that the client was familiarized with the fee schedule.
Client # 7 was admitted on April 21, 2025 and was active at the time of the inspection. There was no documentation in the client record that the client was familiarized with the fee schedule.
Client # 15 was admitted on January 31, 2025 and was transferred to a lower level of care on February 13, 2025. There was no documentation in the client record that the client was familiarized with the fee schedule.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 9/1 Intake Coordinator will begin using and recording the " payment plan form" to document the clients expected expenses and fee schedule. Clients will begin signing off on this document as of 9/1/2025. Clinical Supervisor will monitor this and review with all new admissions. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of seven applicable records reviewed.
Client # 2 was admitted on February 3, 2025 and was transferred to a lower level of care on March 13, 2025. The individual treatment and rehabilitation plan was completed on February 13, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 6 was admitted on December 4, 2024 and was transferred to a lower level of care on February 3, 2025. The individual treatment and rehabilitation plan was completed on December 5, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 15 was admitted on January 31, 2025 and was transferred to a lower level of care on February 13, 2025. The individual treatment and rehabilitation plan was completed on January 31, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services
This is a repeat citation from the June 26, 2024 annual licensing renewal inspection.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Operations Director will work with EMR system to update the Master Treatment plan form to include the type, frequency, and duration of treatment. This will be done by 9/30/25. Master Treatment plans will be signed and reviewed by clinical supervisor to monitor compliance. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two of five applicable records reviewed.
Client # 6 was admitted on December 4, 2024 and was transferred to a lower level of care on February 3, 2025. The individual treatment and rehabilitation plan was completed on December 6, 2024, and the treatment plan update was due no later than January 4, 2025; however, the update was not completed until January 29, 2025.
Client # 7 was admitted on April 21, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 24, 2025, and the treatment plan update was due no later than May 24, 2025; however, the next treatment plan update was not completed until June 3, 2025.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Clinical supervisor will review on 9/1 the duration and expectation of treatment plan time frames. Staff will be sending treatment plans to Supervisor for review and compliance and they will sign. Clinical Supervisor will review daily the Treatment Plan report to see what client is out of compliance. Clinical Supervisor will bring the report to every clinical supervision meeting on Tuesdays at 3:30 to review outstanding treatment plans. Clinical supervisor will continue to conduct monthly chart audits at random for inspection and to review compliance. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling services to the client on a regular and scheduled basis to include individual counseling, at least twice weekly in three of seven client records reviewed.
Client # 2 was admitted on February 3, 2025 and was transferred to a lower level of care on March 13, 2025. The record contained documentation of only one individual counseling session for the week of February 24, 2025.
Client # 6 was admitted on December 4, 2024 and was transferred to a lower level of care on February 3, 2025. The record contained documentation of only one individual counseling session for the weeks of December 9, 2024, December 16, 2024, and January 20, 2025. There were no individual counseling sessions documented for the weeks of December 23, 2024, December 30, 2024, January 6, 2025, and January 13, 2025.
Client # 7 was admitted on April 21, 2025 and was active at the time of the inspection. The record contained documentation of only one individual counseling session for the weeks of April 28, 2025, May 5, 2025, and May 12, 2025.
This is a repeat citation from the June 26, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Operations Director will start on 9/1 to review the census report weekly to ensure all clients in PHP are seen twice a week for IOP once a week. All PHP clients will be seen twice a week based on policy and this will be monitored weekly. Clinical Supervisor will conduct chart audits monthly to ensure compliance. |
709.83(a)(4) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(4) Case consultation notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in five of seven records reviewed. The facility policy manual indicates that case consultation notes will be completed at level of care change and discharge.
Client # 1 was admitted on November 12, 2024 and was transferred to a lower level of care on December 16, 2024. The record did not contain documentation of case consultation notes.
Client # 2 was admitted on February 3, 2025 and was transferred to a lower level of care on March 13, 2025. The record did not contain documentation of case consultation notes.
Client # 4 was admitted on December 2, 2024 and was discharged on January 24, 2025. The record did not contain documentation of case consultation notes.
Client # 6 was admitted on December 4, 2024 and was transferred to a lower level of care on February 3, 2025. The record did not contain documentation of case consultation notes.
Client # 15 was admitted on January 31, 2025 and was transferred to a lower level of care on February 13, 2025. The record did not contain documentation of case consultation notes.
This is a repeat citation from the June 26, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Operations Director will update the Policy and Procedure manual by 9/30 to reflect that case consultations will be due every60 days, step downs, and at discharge. All staff will review with Clinical Supervisor at step down and discharge and Clinical Supervisor will sign for confirmation. Chart audits monthly will be conducted for review and follow up by Clinical Supervisor starting immediately. |
709.83(a)(6) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, in one of one applicable record reviewed.
Client # 4 was admitted on December 2, 2024 and was discharged on January 24, 2025. The client record did not contain documentation of an aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be notified immediately on 8/12 to begin completeing in the discahrge summary the aftercare section as well as the " Continueing Care Plan" form. Clinical Supervisor will review at time of discharge to ensure completion. |
709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in two of two applicable records reviewed.
Client #3 was admitted on May 22,2025 and discharged on June 18, 2025. The record did not contain documentation of follow-up information.
Client # 4 was admitted on December 2, 2024 and was discharged on January 24, 2025. The record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 8/12 the team will be notified to complete follow up w ith in 7 days of post discharge. The policy and procedure manual will be updated to reflect the same. CLinical Supervisor will review at discharge. Clinical Supervisor will complete monthly chart audits to ensure compliance. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in two of four applicable records reviewed.
Client # 10 was admitted on October 8, 2024 and was discharged on April 29, 2025. The individual treatment and rehabilitation plan was completed on October 15, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 17 was admitted on November 25, 2024 and was discharged on March 8, 2025. The individual treatment and rehabilitation plan was completed on December 9, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Operations Director will work with EMR system to change the Master Treatment Plan form. The form will include a drop down and will add the " recommendation for service", the " type" " Frequency" and " amount" and " duration" of group. This will be done by 9/30. |
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 within the regulatory timeframe in three of eight applicable records reviewed.
Client # 10 was admitted on October 8, 2024 and was discharged on April 29, 2025. The individual treatment and rehabilitation plan was completed on October 15, 2024, and the treatment plan update was due no later than December 14, 2024; however, no treatment plan updates were completed prior to the client ' s discharge.
Client # 13 was transferred from a higher level of care on January 31, 2025 and was active at the time of the inspection. A treatment plan update was completed on March 19, 2025, and the treatment plan update was due no later than May 18, 2025; however, no additional treatment plan updates were completed prior to the date of the inspection.
Client # 17 was admitted on November 25, 2024 and was discharged on March 8, 2025. The individual treatment and rehabilitation plan was completed on December 9, 2024, and the treatment plan update was due no later than February 7, 2025; however, no treatment plan updates were completed prior to the client ' s discharge.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Clinical Supervisor and Operations Director will review Treatment Plan timeline and work flow on 8/12 and review compliance standards. At every clinical supervisor meeting moving forward Clincal Supervisor will pull a report of clients with outstanding and or late treatment plans to review in clinical supervision. Clinical Supervisor will do monthly chart audits on 10 charts a month to ensure compliance. This will be implemented on 9/1/25 |
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 and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in five of seven applicable records reviewed. The facility policy manual indicates that case consultation notes will be completed at level of care change and discharge.
Client # 9 was transferred from a higher level of care on March 17, 2025 and discharged on May 19, 2025. The record did not contain documentation of case consultation notes.
Client # 10 was admitted on October 8, 2024 and was discharged on April 29, 2025. The record did not contain documentation of case consultation notes.
Client #11 was admitted on April 18, 2025 and discharged on June 30, 2025. The record did not contain documentation of case consultation notes.
Client # 12 was transferred from a higher level of care on February 3, 2025 and was discharged on March 14, 2025. The record did not contain documentation of case consultation notes.
This is a repeat citation from the June 26, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Operation Director will review on 8/12 the need for Case Consultation Review Forms to be done. Staff will begin to immediately complete this every 60 days, and at step down and discharge. Operations Director will update the policy by 9/1/25 to reflect the same. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, in two of two applicable records reviewed.
Client # 10 was admitted on October 8, 2024 and was discharged on April 29, 2025. The client record did not contain documentation of an aftercare plan.
Client # 17 was admitted on November 25, 2024 and was discharged on March 8, 2025. The client record did not contain documentation of an aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Operations Director will review in Clinical Supervision on 8/12 the need for utilizing the " Continum After Care Plan" form in the EMR system immediately for post discharges. Clinical Supervisor will complete monthly chart audits to ensure completion and compliance. She will review at time of discharge to ensure discharge checklist is completed including the aftercare plan. |
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 ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in four of four applicable records reviewed.
Client # 8 was transferred to the outpatient level of care on December 16, 2024 and was discharged on February 6, 2025. The record did not contain documentation of follow-up information.
Client # 9 was transferred from a higher level of care on March 17, 2025 and discharged on May 19, 2025. The record did not contain documentation of follow-up information.
Client # 10 was admitted on October 8, 2024 and was discharged on April 29, 2025. The record did not contain documentation of follow-up information.
Client # 17 was admitted on November 25, 2024 and was discharged on March 8, 2025. The record did not contain documentation of follow-up information.
This is a repeat citation from the June 26, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Per supervision on 8/12; Clinical Supervisor and this Operation Director will review the need for aftercare and discharge follow up with in 7 days of discharge. Operations Director will work with EMR team to create a " Post Discharge Follow Up" form. In the interim staff will complete a general documentation note to check in with in seven days post discharge and document status. This will be implemented immediately. |
709.14(b)(2) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(2) Change in name of the facility.
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Observations
Based on an administrative review of documents, the facility failed to notify the Department within 90 days of a change in name of the facility. The facility changed its name on July 19, 2024; however, the Department was not notified until June 26, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Notification has since been submitted for a name change and corresponding tax documents are being sent to complete the review. This will be completed by the end of August 31, 2025. Operations Director will follow up with completion and submission of the name change. Operations Director will take lead on changes to the program moving forward. |