INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on April 22 - 23, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System at Williamsburg 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 the review of personnel records, the facility failed to document that a clinical supervisor met the educational experience for the position.Staff # 12 was promoted to clinical supervisor on October 26, 2025 and was still in the position at the time of the inspection. The person does not have a qualifying degree.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
An exception request was submitted on May 7, 2026. Documentation regarding this clinical supervisor's background and training was submitted along with the exception request.
If the exception is not granted, this clinical supervisor will obtain a qualifying PCB certification within the next 4 months.
The CEO will ensure compliance with obtaining a qualifying PCB certification should the exception request be denied. |
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 and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.Staff # 44 was hired on January 2, 2024 and was due to have the communicable disease trainings no later than January 2, 2026. The employee received HIV/AIDS training on April 7, 2026 and TB/STD training on April 8, 2026.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CEO will review the requirement and time frames regarding mandatory communicable disease training with the leadership team.
A quality coordinator was hired to keep track of all trainings, including the communicable disease trainings. She will provide a list of staff who need required trainings to the leadership team on a quarterly basis.
The quality coordinator will alert the COO and CEO when a staff member only has 6 months left to complete required trainings.
The COO will monitor compliance with all required trainings.
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure all stairways, hallways and exits are unobstructed. In the administration building, the staircase to the third floor was blocked.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The landing was cleared prior to the end of the licensing inspection. The clearance of items was acknowledged on 4/23/26 by the inspector.
A lock was also placed on the doorway to the attic and a fire alarm, and a fire extinguisher, were placed in the attic.
The CEO will ensure the landing is kept free of items. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to include specific information to be disclosed on a release of information form in one out of fourteen records reviewed. Client # 13 was admitted on March 9, 2026 and discharged on April 16, 2026. A release of information form was signed and dated on March 21, 2026 to a friend that did not include specific information to be released.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor who supervises this counselor will meet with her individually by 5/22/26 to review how to complete a consent appropriately and in its entirety. A supervision will be documented from this meeting.
The clinical supervisor will monitor the next 15 consents this counselor completes to ensure appropriate completion.
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709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of partial hospitalization clients, the facility failed to document a preliminary treatment plan in seven out of seven records reviewed. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
PHP Clinical Supervisor will complete supervision and re-education with Individual Counselors on completion of the preliminary treatment plan.
PHP Clinical Supervisor will create a spreadsheet which lists each PHP patient with their name, admit date and preliminary treatment plan due date. This spreadsheet will be sent out daily with the PHP assignments and reviewed each morning at shift report.
Clinical Supervisor will monitor 15 charts for the next 4 months to ensure the spreadsheet is being followed and timely completion of preliminary treatment plans |
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 partial hospitalization client records, the facility failed to document treatment plan updates in three out of seven records reviewed. The facility's policy and procedures manual states that treatment plan updates will be completed every 14 days. Client #10 was admitted on October 9, 2025, and was discharged on November 17, 2025. The individual treatment plan was completed on October 09, 2025, and a treatment plan update was due no later than October 23, 2025; however, one was not completed until November 03, 2025. Client #12 was admitted on February 25, 2026, and was discharged on April 15, 2026. The individual treatment plan was completed on February 26, 2026, and a treatment plan update was due no later than March 12, 2026; however, one was not completed until March 13, 2026. Client #13 was admitted on March 09, 2026, and was discharged on April 16, 2026. The individual treatment plan was completed on March 19, 2026, and a treatment plan update was due no later than April 02, 2026; however, one was not completed until April 09, 2026.The finding was reviewed with facility staff during the licensing inspection.This is a repeat citation from the March 27, 2025 licensing inspection.
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Plan of Correction
PHP Clinical Supervisor will complete supervision and re-education with Individual Counselors on treatment plan updates.
PHP Clinical Supervisor will create a spreadsheet which lists each PHP patient with their name, admit date, date of last update and due date of next update. This spreadsheet will be sent out daily with the PHP assignments and reviewed each morning at shift report.
Clinical Supervisor will monitor 15 charts for the next 4 months to ensure the spreadsheet is being followed and timely completion of treatment plan updates.
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of buprenorphine patient records, the facility failed to maintain onsite a photograph of each patient in six out of fourteen records reviewed.Patient #1 was admitted on July 8, 2025 and discharged on August 6, 2025. Patient #4 was admitted on July 4, 2025 and discharged on August 1, 2025.Patient #6 was admitted on August 21, 2025 and discharged on September 11, 2025.Patient #7 was admitted on March 20, 2026 and discharged on April 1, 2026.Patient #15 was admitted on October 24, 2025 and discharged on October 17, 2025.Patient #19 was admitted on December 25, 2025 and discharged on December 29, 2025.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A procedure for recalling a patient's photo was provided by the corporate IT department so photos are able to be retrieved after discharge. This procedure has been tested and works.
The IT department will be making a permanent change so photos stay on the record.
The DON/designee will pull 15 discharge records to ensure photos on discharged patient charts are present upon the aforementioned change. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of buprenorphine patient records, the facility failed to transfer patient files to the new facility in one out of two applicable records reviewed.Patient #1 was admitted on July 8, 2025 and discharged on August 6, 2025. No documentation was sent to the receiving facility.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The case management supervisor will develop a policy/procedure related to patient transfers to ensure compliance with regulatory requirements.
The policy will require that all patient transfer requests for continued maintenance be completed within 7 calendar days of request.
The transfer procedure will require the receiving narcotic treatment program with complete patient documentation, including: Admission date, Medical summary, Psychosocial summary, Current dosage level, Urinalysis reports or summary, Exception requests, Current patient status, Signed written patient consent for release of information
The assigned Case Manager will obtain the fax number/email address for the receiving treatment facility and will fax or email all required transfer documentation to the receiving facility.
Upon completion, the Case Manager will scan the complete transfer packet and fax confirmation sheet or printed email confirmation into the client's chart to verify compliance and maintain documentation of the transfer.
Staff responsible for patient records and transfer coordination will receive notification/education on the policy/procedure.
The case management director will monitor 15 records for the next 4 months to ensure compliance.
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715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of buprenorphine patient records, the facility failed to document a physical examination according to the facility's policy and procedures manual in four out of fourteen records reviewed. The manual states the physical exam must be completed within 72 hours. Patient # 6 was admitted on August 21, 2025 and discharged on September 11, 2025. A physical exam was due on August 24, 2025; however, it was not completed until August 26, 2025.Patient # 15 was admitted on October 24, 2025 and discharged to a lower level of care on October 27, 2025. A physical exam was due on October 27, 2025; however, it was completed on October 28, 2025. Patient # 20 was admitted on March 27, 2026 and discharged to a lower level of care on April 2, 2026. A physical exam was due on March 30, 2026; however, it was completed on April 1, 2026.Patient # 21 was admitted on March 26, 2026 and discharged to a lower level of care on March 31, 2026. A physical exam was due on March 29, 2026; however, it was completed on March 31, 2026.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CEO and/or DON will re-educate the medical providers on the policy and importance of completing the history and physical, in its entirety, within 72 hours of admission.
If a provider is unable to complete the history and physical within 72 hours, the medical director should be notified so he can complete the physical timely.
The DON/designee will review 10 charts per week for the next 12 weeks, and randomly thereafter, to ensure timely completion of updates. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of rehab client records, the facility failed to document a preliminary treatment plan in five out of seven applicable records reviewed. The facility's policy and procedures manual states a preliminary treatment plan must be completed within 48 hours of admission.Client #1 was admitted on July 8, 2025 and discharged on August 6, 2025. There was no preliminary treatment plan documented.Client #3 was admitted on November 12, 2025 and discharged on November 25, 2025. The preliminary treatment plan was due on November 14, 2025; however, it was completed on November 26, 2025.Client #4 was admitted on July 4, 2025 and discharged on August 1, 2025. The preliminary treatment plan was due on July 6, 2025; however, it was completed on July 7, 2025.Client #5 was admitted on July 28, 2025 and discharged on August 27, 2025. The preliminary treatment plan was due on July 30, 2025; however, it was completed on August 6, 2025.Client #6 was admitted on August 21, 2025 and discharged on September 11, 2025. The preliminary treatment plan was due on August 23, 2025; however, it was completed on August 25, 2025.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Intake nurses will be educated on and required to complete the preliminary treatment plan at the time of admission.
This education will take place individually and in the next scheduled nurses meeting.
The DON/designee will monitor 15 charts for the next 4 months to ensure preliminary treatment plans are being completed timely. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of rehab client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of six applicable records reviewed.Client #1 was admitted on July 8, 2025 and discharged on August 6, 2025. An individual treatment plan dated July 23, 2025 indicated group sessions five times per week and individual sessions weekly. The week of July 27 - August 2, 2025 only documented group sessions on July 29, July 30 and August 1, 2025. Additionally, there were no documented individual sessions the week of July 27 - August 2, 2025.Client #4 was admitted on July 4, 2025 and discharged on August 1, 2025. An individual treatment plan dated July 7, 2025 indicated group sessions five times per week and individual sessions weekly. There were no documented individual sessions the week of July 20 - 26, 2025. In addition, the weeks of July 13-19 and July 20-26, 2025 did not have five group sessions documented. Group sessions occurred on July 18, 19 and 20, 2025. Client #5 was admitted on July 28, 2025 and discharged on August 27, 2025. An individual treatment plan dated August 6, 2025 indicated group sessions five times per week and individual sessions weekly. There were no individual sessions documented the week of August 10 - 16, 2025. In addition, the week of August 10-26, 2025, had documented group sessions on August 11 and two sessions on August 15, 2025.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Residential counseling staff will be re-educated on the importance of complying with the agreed upon treatment plan and documenting all services offered/provided.
If a patient is not attending the sessions agreed upon in the treatment plan, a note will be placed in the chart as to what session(s) the patient did not attend.
The re-education will occur in clinical staffing and shift report(s).
Counselors struggling with documentation will be met with individually and a supervision session will be documented.
The residential clinical supervisors will audit 20 charts per month for the next 4 months of the counselors they supervise, and randomly thereafter, to ensure treatment plans are being followed. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 rehab client records, the facility failed to document a case consultation in four out of seven records reviewed.Client #2 was admitted on July 3, 2025 and discharged on July 11, 2025.Client #3 was admitted on November 12, 2025 and discharged on November 25, 2025.Client #5 was admitted on July 28, 2025 and discharged on August 27, 2025.Client #6 was admitted on August 21, 2025 and discharged on September 11, 2025.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Residential counseling staff will be re-educated on the case consult policy and the requirement of a minimum of one case consult per treatment episode.
The re-education will occur in clinical staffing and shift report(s).
The residential clinical supervisors will audit 20 charts per month for the next 4 months of the counselors they supervise, and randomly thereafter, to ensure treatment plans are being followed. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of rehab client records, the facility failed to document a discharge summary in three out of seven records reviewed. The facility's policy and procedures manual states the discharge summary must be completed with seven days of discharge.Client #3 was admitted on November 12, 2025 and discharged on November 25, 2025. There was no discharge summary documented in the record.Client #4 was admitted on July 4, 2025 and discharged on August 1, 2025. There was no discharge summary documented in the record.Client #5 was admitted on July 28, 2025 and discharged on August 27, 2025. The discharge summary was completed on April 2, 2026.The finding was reviewed with facility staff during the licensing inspection.This is a repeat citation from the March 27, 2025 licensing inspection.
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Plan of Correction
Clinical Supervisors will track discharges through weekly supervision meetings and discuss clients who are discharging throughout the week. Clinical supervisors will identify priority discharge summaries during these meetings.
Clinical Supervision will send a task to the clinicians they supervise to complete the discharge summary.
Clinical Supervisors will collaborate with Medical Records who will maintain and share the list of completed discharge summaries.
Clinical supervisors will track all daily discharges and announce expectations during morning and afternoon shift reports of what discharge summaries are due.
Each clinical supervisor will audit 15 charts of clinicians on their caseload for the next 4 months to ensure discharge summaries are completed timely.
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