INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9, 2026 through July 10, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Hopebridge DT LLC 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(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 specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director and facility director met the minimum qualifications for the position in one of one applicable personnel record reviewed.
Employee #2 was hired as the facility director on June 8, 2026 and was still in the position at the time of the inspection. There was documentation in the personnel record indicating the employee has a doctorate degree with a qualifying major; however, the employee did not have any documented program planning experience in the personnel record as of the date of hire.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director will ensure that all positions are filled according to policy. The facility director will be responsible for monitoring clinical staff requirements and the project director will monitor all other staff. The facility director and project director will interview potential candidates together for any position when applicable. The project director will ensure that the administrative assistant is monitoring the facility's day-to-day activities. The staff requirements will be added to all future job descriptions and also any advertisements for new candidates. |
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 personnel records, the facility failed to ensure an annual written individual training plan was completed for each employee, with input from both the employee and the supervisor in six of six applicable personnel records reviewed.
In each personnel record reviewed, there was no documentation of an annual written individual training plan completed as of the date of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director created a training plan template it was reviewed by DDAP employee on-site during the survey. Implementation of the training plan including obtaining all signatures from staff will be completed no later than 08/30/2026. Renewal will begin on 1/1/2027 and be kept annually thereafter. All individual training plans will be uploaded into the agency's internal storage for future reference. |
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 Staffing Requirement Facility Summary Report, the facility failed to ensure all staff received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health topics training within the regulatory time frame in one of two personnel records reviewed.
Employee #4 was hired as a counselor on September 16, 2024. The HIV/AIDS and the TB/STD and other health topics trainings were due to be completed no later than September 16, 2025: however, there was no documentation in the personnel record indicating either training was completed as of the date of the inspection.
Employee #5 was hired as a counselor on April 15, 2025. The HIV/AIDS and the TB/STD and other health topics trainings were due to be completed no later than April 15, 2026: however, there was no documentation in the personnel record indicating either training was completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director has secured the use of a training system to ensure that policy 704.11(c)(1) is met. All employees now have access to a minimum of 6 hours of HIV/AIDS training and 4 hours of TB/Sexually Transmitted Diseases. All employees must complete all Communicable Disease Training hours within 30 days of the date of hire. All current employees must complete training by 8/30/2026 unless hired in the month of July 2026. The facility director and project director will monitor each staff's training plan. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on an administrative review, the facility failed to ensure that a sufficient number of staff persons were certified in CPR and trained in first aid during the project ' s hours of operation.
As of the date of the inspection, the project's posted hours of operation are Monday through Saturday from 9:00am to 5:00pm and Tuesday through Thursday from 5:30pm - 8:30pm. There was no documentation provided indicating any staff persons were certified in CPR and only three staff persons were trained in first aid.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project will secure certified CPR training for all staff within 30 business days. CPR renewal will occur independently thereafter with reimbursement possible. Staff will complete and provide updated certifications to be added to their employee file annually. This will be monitored by the administrative assistant and reported to the project director who will update employee files accordingly. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training required for counselors during the facility January 2025 through December 2025 training year in one of one applicable personnel record reviewed.
Employee #4 was hired as a counselor on September 16, 2024. There was no documentation of any completed training hours during the period reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has secured the use of trainings system to ensure that 704.11(f)(2) is met in the following areas:
Client recordkeeping
Confidentiality
Pharmacology
Treatment Planning
Counseling Techniques
Drug and Alcohol Assessment
Codependency
Adult Children of Alcoholics Issues
Disease of Addiction
Aftercare Planning
Principles of Alcoholics Anonymous and Narcotics Anonymous
Ethics
Substance Abuse Trends
Interaction of Addiction and Mental Illness
Cultural Awareness
Sexual Harassment
Developmental Psychology
Relapse Prevention
This will be monitored by Facility Director. Fidelity to the training plan will be monitored via tracking sheets and will be the overseen by the Project Director. Project Director and Facility director will meet approximately 21 days after a new hire has begun work to review the progress on the training plan. Disciplinary action will be taken if the staff member does not complete required trainings within 30 days of hire. Annual trainings will be regulated as well by the administrative assistant, project director, and facility 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 personnel records, the facility failed to ensure all staff were instructed in the use of fire extinguishers upon staff employment in five of five applicable personnel records reviewed.
Employee #1 was hired as the project director on April 1, 2026. There was documentation indicating the fire extinguisher training was completed; however, the training was not completed until May 31, 2026.
Employee #2 was hired as the facility director on June 8, 2026. There was no documentation indicating the employee was trained in the use of fire extinguishers as of the date of the inspection.
Employee #3 was hired as a clinical supervisor on June 1, 2026. There was no documentation indicating the employee was trained in the use of fire extinguishers as of the date of the inspection.
Employee #4 was hired as a counselor on September 16, 2024. There was no documentation indicating the employee was trained in the use of fire extinguishers as of the date of the inspection.
Employee #6 was hired as a counselor on October 2, 2025. There was no documentation indicating the employee was trained in the use of fire extinguishers as of the date of the inspection.
This is a repeat citation from the July 17, 2024 and August 19, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and Project Director will ensure moving forward that all staff are trained upon hire on the use of Fire Extinguishers. Administrative Assistants will be tasked with physical training of Fire Extinguishers and RACE on the first day of employment. Signatures will be obtained by both staff and trainer. Project Director has implemented a New Employee Checklist for all staff. Per this survey, this checklist will be completed with all staff to establish compliance with 705.28(c)(4). |
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 the facility's August 2025 through May 2026 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, there was no documentation provided indicating unannounced fire drills were conducted during each of the months of August 2025 through March 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director/Project Director will manage Fire Drill Logs moving forward. This task will be added to the job descriptions of both employees moving forward. The project director will call the facility with unannounced fire drills once a month. These fire drills will be recorded in the Fire Drill Logs. The Fire Drill Logs will be located within internal storage for future reference. |
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 review of personnel records, the facility failed to ensure that all personnel were trained to perform assigned tasks during emergencies in five of five applicable personnel records reviewed.
Employee #1 was hired as the project director on April 1, 2026. There was documentation of the completion of an emergency preparedness training; however, the training was not completed until May 31, 2026.
Employee #2 was hired as the facility director on June 8, 2026. There was no documentation that the employee was trained to perform assigned tasks during emergencies as of the date of the inspection.
Employee #3 was hired as a clinical supervisor on June 1, 2026. There was no documentation that the employee was trained to perform assigned tasks during emergencies as of the date of the inspection.
Employee #4 was hired as a counselor on September 16, 2024. There was no documentation that the employee was trained to perform assigned tasks during emergencies as of the date of the inspection.
Employee #6 was hired as a counselor on October 2, 2025. There was no documentation that the employee was trained to perform assigned tasks during emergencies as of the date of the inspection.
This is a repeat citation from the July 17, 2024 and August 19, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director/Project Director will add Emergency Preparedness to the Individual Training Plan moving forward. All staff will have this training completed no later than 8/30/2026. This training will be added to the New Employee Checklist form and a signature from both the employee and Facility Director will be obtained. |
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 facility's August 2025 through May 2026 fire drill logs, the facility failed to maintain a written fire drill record, which is to include the documentation of the time of the drill.
At the time of the inspection, the written logs for the fire drills conducted during the months of April 2026 and May 2026 did not include documentation of the time the fire drill occurred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director/Project Director will add to the current fire log form a column that indicates the time of the fire drill. This will be added to the form no later than 8/30/2026.The fire log form will be reviewed monthly during leadership meetings to monitor 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 facility's August 2025 through May 2026 fire drill logs, the facility failed to set off a fire alarm or smoke detector during each fire drill.
At the time of the inspection, the only fire drills conducted during the reviewed period were during the months of April 2026 and May 2026; however, there was no documentation, including on the monthly fire drill logs, indicating a fire alarm or a smoke detector was set off during each drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has applied for an exception for this practice and it was approved. Due to the location of the agency, it would not be conducive to the other inhabitants in the building to evacuate each month. A column will be added to the fire log form to indicate that the alternative sound was created during this drill (whistle). |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for the completion of an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities, for the project's 2024 financial year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The owner of the company will hire an independent certified public accountant and the financial audit will be conducted for the following years 2024 and 2025. This will be completed annually by 3/31 of the following year moving forward. |
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 personnel record review, the facility failed to ensure annual written individual staff performance evaluations were completed in two of two applicable personnel records reviewed.
Employee #4 was hired as a counselor on September 16, 2024. There was no documentation indicating an annual performance evaluation was completed as of the date of the inspection.
Employee #5 was hired as the counselor on April 15, 2025. There was no documentation indicating an annual performance evaluation was completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Annual performance evaluations will be completed annually per 709.26(b)(3) moving forward. The Project Director has created a tracking sheet to track employee records, trainings, and performance evaluations. This tracker is stored within the agency's internal storage system. Annual Performance Reviews will be completed no later than January 31 of the following year (2026 annual performances will be due by January 31, 2027). |
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 written informed and voluntary consent from the client for the disclosure of information contained in the client record in twelve of fourteen client records reviewed.
Client #1 was admitted to the outpatient activity on November 2, 2025 and was active at the time of the inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #2 was admitted to the outpatient activity on November 11, 2025 and was active at the time of the inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #3 was admitted to the outpatient activity on January 5, 2026 and was active at the time of the inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #4 was admitted to the outpatient activity on November 8, 2025 and was discharged on March 20, 2026. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #5 was admitted to the outpatient activity on January 12, 2026 and was discharged on April 24, 2026. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #7 was admitted to the outpatient activity on January 8, 2026 and was discharged on May 5, 2026. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures. Additionally, there was documentation of disclosures to a urinalysis laboratory on January 18, 2026, January 28, 2026, February 10, 2026, February 25, 2026, March 4, 2026 and March 10, 2026; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #8 was admitted to the partial hospitalization activity on June 15, 2026 and was active at the time of the inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #9 was admitted to the partial hospitalization activity on January 28, 2026 and was discharged on April 14, 2026. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #10 was admitted to the partial hospitalization activity on February 10, 2026 and was discharged on February 25, 2026. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #11 was admitted to the partial hospitalization activity on November 3, 2025 and was discharged on December 1, 2025. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures. Additionally, there was documentation of disclosures to a urinalysis laboratory on November 4, 2025, November 11, 2025, November 18, 2025, and November 25, 2025; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #13 was admitted to the partial hospitalization activity on November 26, 2025 and was discharged on December 15, 2025. There was documentation of disclosures to a urinalysis laboratory on December 4, 2025 and December 8, 2025; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #14 was admitted to the partial hospitalization activity on February 2, 2026 and was discharged on February 24, 2026. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will create an intake flow sheet that will have check boxes for every document that is needed to begin treatment. Added to the Intake Flow Sheet will be financial payor releases of information and the lab contracted by the agency. The Intake Flow Sheet will be signed by on-site staff when every item has been completed. Every client will sign separate ROI's for their financial guarantor. This will allow for communication related to payor sources etc. This will be completed no later than August 30, 2026. This will be signed on upon intake moving forward. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a consent to release information form in five of fourteen client records reviewed.
Client #1 was admitted to the outpatient activity on November 2, 2025 and was active at the time of the inspection. There was a release of information form to an emergency contact signed and dated by the client on November 3, 2025; however, the purpose of the disclosure was documented as "other" and did not include any other purpose.
Client #2 was admitted to the outpatient activity on November 11, 2025 and was active at the time of the inspection. There was a release of information form to a court services agency signed and dated by the client on November 14, 2025; however, there was no purpose of the disclosure documented on the release form.
Client #8 was admitted to the partial hospitalization activity on June 15, 2026 and was active at the time of the inspection. There were release of information forms to an emergency contact and another individual signed and dated by the client on November 14, 2025; however, there was no purpose of the disclosure documented on either release form.
Client #10 was admitted to the partial hospitalization activity on February 10, 2026 and was discharged on February 25, 2026. There was a release of information form to an emergency contact signed and dated by the client on February 11, 2026; however, there was no purpose of the disclosure documented on the release form.
Client #12 was admitted to the partial hospitalization activity on November 7, 2025 and was discharged on November 25, 2025. There was a release of information form to an emergency contact signed and dated by the client on October 27, 2025; there was no purpose of the disclosure documented on the release form.
This is a repeat citation from the August 19, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will host a training to instruct staff on how to properly fill out a Release of Information. Furthermore, facility director will work with project director to make answering the purpose of the ROI mandatory prior to signatures being accepted. A training will be completed with all staff no later than August 30, 2026. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent to release information form will expire in one of fourteen client records reviewed.
Client #6 was admitted to the outpatient activity on December 16, 2025 and was discharged on April 14, 2026. There was a release of information form to a funding source signed and dated by the client on December 17, 2025; however, there was no date, event, or condition upon which the consent will expire documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and Project Manager will edit the EHR system to only accept completed ROI's with an expiration date, event, or condition upon which the consent will expire. A training will be completed with all staff no later than August 30, 2026. |
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 client records, the facility failed to ensure a copy of a client consent to release information form was offered to the client in nine of fourteen client records reviewed.
Client #2 was admitted to the outpatient activity on November 11, 2025 and was active at the time of the inspection. There were release of information forms to an emergency contact and a urinalysis laboratory signed and dated by the client on November 11, 2025; however, there was no documentation in the record indicating a copy of either release form was offered to the client. Additionally, there was a release of information form to a court services agency signed and dated by the client on November 14, 2025; there was no documentation in the record indicating a copy of the release form was offered to the client.
Client #3 was admitted to the outpatient activity on January 5, 2026 and was active at the time of the inspection. There was a release of information form to an emergency contact signed and dated by the client on January 13, 2026; however, there was no documentation in the record indicating a copy of either release form was offered to the client.
Client #4 was admitted to the outpatient activity on November 8, 2025 and was discharged on March 20, 2026. There were release of information forms to an emergency contact and a urinalysis laboratory signed and dated by the client on November 8, 2025; however, there was no documentation in the record indicating a copy of either release form was offered to the client.
Client #5 was admitted to the outpatient activity on January 12, 2026 and was discharged on April 24, 2026. There was a release of information form to a urinalysis laboratory signed and dated by the client on January 12, 2026; however, there was no documentation in the record indicating a copy of the release form was offered to the client.
Client #6 was admitted to the outpatient activity on December 16, 2025 and was discharged on April 14, 2026. There was a release of information form to a funding source signed and dated by the client on December 17, 2025; however, there was no documentation in the record indicating a copy of the release form was offered to the client.
Client #9 was admitted to the partial hospitalization activity on January 28, 2026 and was discharged on April 14, 2026. There was a release of information form to a urinalysis laboratory signed and dated by the client on January 28, 2026; however, there was no documentation in the record indicating a copy of the release form was offered to the client.
Client #10 was admitted to the partial hospitalization activity on February 10, 2026 and was discharged on February 25, 2026. There were release of information forms to a urinalysis laboratory and an emergency contact signed and dated by the client on February 11, 2026; however, there was no documentation in the record indicating a copy of either release form was offered to the client.
Client #12 was admitted to the partial hospitalization activity on November 7, 2025 and was discharged on November 25, 2025. There was a release of information form for a urinalysis laboratory signed and dated by the client on October 27, 2025; however, there was no documentation in the record indicating a copy of the release form was offered to the client.
Client #14 was admitted to the partial hospitalization activity on February 2, 2026 and was discharged on February 24, 2026. There was a release of information form to a urinalysis laboratory signed and dated by the client on February 6, 2026; however, there was no documentation in the record indicating a copy of the release form was offered to the client.
This is a repeat citation from the August 19, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and Project Manager will edit the EHR system to only accept completed ROI's with a copy of the ROI was offered to the client answered. This will ensure that staff will completely fill out the ROI correctly. A training will be completed with all staff no later than August 30, 2026. |
709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to ensure a medical history was completed, during the intake and admission process, in four of seven client records reviewed.
The facility policy and procedure manual stated that the facility will provide a comprehensive biopsychosocial assessment upon admission to any service program. Additionally, the admissions assessment will be completed within 3 days of admission. The assessment will contain, at a minimum, a physical health history and current status, a history of the use of alcohol, tobacco, and/or other drugs, and current and historical life information.
Client #9 was admitted to the partial hospitalization activity on January 28, 2026 and was discharged on April 14, 2026. The biopsychosocial assessment, including a medical history, was due to be completed no later than January 31, 2026; however, the assessment and medical history was completed late on February 16, 2026.
Client #12 was admitted to the partial hospitalization activity on November 7, 2025 and was discharged on November 25, 2025. There was no documentation in the record indicating the biopsychosocial assessment, including a medical history, was completed prior to discharge.
Client #13 was admitted to the partial hospitalization activity on November 26, 2025 and was discharged on December 15, 2025. The biopsychosocial assessment, including a medical history, was due to be completed no later than November 29, 2025; however, the assessment and medical history was completed late on December 15, 2025.
Client #14 was admitted to the partial hospitalization activity on February 2, 2026 and was discharged on February 24, 2026. There was no documentation in the record indicating the biopsychosocial assessment, including a medical history, was completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director created a new section in the Biopsychosocial Assessment within the EHR system to include the physical health history. This section was added on 3/31/2026. This section includes: 1. Allergies 2. Previous Medical History and 3. Current Medical History. The Biopsychosocial Assessment has been locked to not be able to signed off on until this section has been completed. This will also be monitored by the supervisor to ensure that the documentation contains the relevant information.
To address the late assessments, the intake flow form will be completed no later than 8/30/2026 to ensure that prior to admission the BPS, ASAM, and initial tx plan are completed. This form will have staff signatures to ensure completion of the process. This process will also be monitored by the Project director and the Facility Director. |
709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to ensure a drug or alcohol history was completed, during the intake and admission process, in four of seven client records reviewed.
The facility policy and procedure manual stated that the facility will provide a comprehensive biopsychosocial assessment upon admission to any service program. Additionally, the admissions assessment will be completed within 3 days of admission. The assessment will contain, at a minimum, a physical health history and current status, a history of the use of alcohol, tobacco, and/or other drugs, and current and historical life information.
Client #9 was admitted to the partial hospitalization activity on January 28, 2026 and was discharged on April 14, 2026. The biopsychosocial assessment, including a drug or alcohol history, was due to be completed no later than January 31, 2026; however, the assessment and drug or alcohol history was completed late on February 16, 2026.
Client #12 was admitted to the partial hospitalization activity on November 7, 2025 and was discharged on November 25, 2025. There was no documentation in the record indicating the biopsychosocial assessment, including a drug or alcohol history, was completed prior to discharge.
Client #13 was admitted to the partial hospitalization activity on November 26, 2025 and was discharged on December 15, 2025. The biopsychosocial assessment, including drug or alcohol history, was due to be completed no later than November 29, 2025; however, the assessment and drug or alcohol history was completed late on December 15, 2025.
Client #14 was admitted to the partial hospitalization activity on February 2, 2026 and was discharged on February 24, 2026. There was no documentation in the record indicating the biopsychosocial assessment, including a drug or alcohol history, was completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will monitor intake appointments and admissions to ensure that each client receives their BPS within 3 days of admission. Failure to do so may result in disciplinary action. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to ensure a personal history was completed, during the intake and admission process, in four of seven client records reviewed.
The facility policy and procedure manual stated that the facility will provide a comprehensive biopsychosocial assessment upon admission to any service program. Additionally, the admissions assessment will be completed within 3 days of admission. The assessment will contain, at a minimum, a physical health history and current status, a history of the use of alcohol, tobacco, and/or other drugs, and current and historical life information.
Client #9 was admitted to the partial hospitalization activity on January 28, 2026 and was discharged on April 14, 2026. The biopsychosocial assessment, including a personal history, was due to be completed no later than January 31, 2026; however, the assessment and personal history was completed late on February 16, 2026.
Client #12 was admitted to the partial hospitalization activity on November 7, 2025 and was discharged on November 25, 2025. There was no documentation in the record indicating the biopsychosocial assessment, including a personal history, was completed prior to discharge.
Client #13 was admitted to the partial hospitalization activity on November 26, 2025 and was discharged on December 15, 2025. The biopsychosocial assessment, including a personal history, was due to be completed no later than November 29, 2025; however, the assessment and personal history was completed late on December 15, 2025.
Client #14 was admitted to the partial hospitalization activity on February 2, 2026 and was discharged on February 24, 2026. There was no documentation in the record indicating the biopsychosocial assessment, including a personal history, was completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will monitor intake appointments and admissions to ensure that each client receives their BPS within 3 days of admission. Failure to do so may result in disciplinary action. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to ensure a psychosocial evaluation was completed, during the intake and admission process, in four of seven client records reviewed.
The policy and procedure manual stated that the facility will provide a comprehensive biopsychosocial assessment upon admission to any service program. Additionally, the admissions assessment will be completed within 3 days of admission.
Client #9 was admitted to the partial hospitalization activity on January 28, 2026 and was discharged on April 14, 2026. The psychosocial evaluation was due to be completed no later than January 31, 2026; however, the evaluation was completed late on February 16, 2026.
Client #12 was admitted to the partial hospitalization activity on November 7, 2025 and was discharged on November 25, 2025. There was no documentation in the record indicating the psychosocial evaluation was completed prior to discharge.
Client #13 was admitted to the partial hospitalization activity on November 26, 2025 and was discharged on December 15, 2025. The psychosocial evaluation was due to be completed no later than November 29, 2025; however, the evaluation was completed late on December 15, 2025.
Client #14 was admitted to the partial hospitalization activity on February 2, 2026 and was discharged on February 24, 2026. There was no documentation in the record indicating the biopsychosocial evaluation was completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will monitor intake appointments and admissions to ensure that each client receives their BPS within 3 days of admission. Failure to do so may result in disciplinary action. |
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 client records, the facility failed to ensure a preliminary treatment plan was completed, during the intake and admission process, in five of seven client records reviewed.
The facility policy and procedures manual stated the preliminary treatment plan shall be completed within 3 days of admission.
Client #8 was admitted to the partial hospitalization activity on June 15, 2026 and was active at the time of the inspection. There was no documentation of a completed preliminary treatment plan in the record at the time of the inspection.
Client #9 was admitted to the partial hospitalization activity on January 28, 2026 and was discharged on April 14, 2026. There was no documentation of a completed preliminary treatment plan in the record at the time of the inspection.
Client #12 was admitted to the partial hospitalization activity on November 7, 2025 and was discharged on November 25, 2025. There was no documentation of a completed preliminary treatment plan in the record at the time of the inspection.
Client #13 was admitted to the partial hospitalization activity on November 26, 2025 and was discharged on December 15, 2025. There was no documentation of a completed preliminary treatment plan in the record at the time of the inspection.
Client #14 was admitted to the partial hospitalization activity on February 2, 2026 and was discharged on February 24, 2026. There was no documentation of a completed preliminary treatment plan in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will monitor intakes using a spreadsheet where each component of an intake will be monitored including: consents completed, BPS completed, diagnosis input, ASAM completed, Preliminary Tx Plan completed, Aftercare Plan created, and schedules secured. |
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 one of two applicable client records reviewed.
Client #9 was admitted to the partial hospitalization activity on January 28, 2026 and was discharged on April 14, 2026. The individual treatment plan was completed on February 9, 2026; however, the plan did not include the frequency of treatment and rehabilitation services being provided to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All treatment plans will have the type and frequency of services added to each goal/objective/intervention. Facility director will provide a training on tx plans quarterly beginning immediately in supervisions. Facility Director will monitor full completion of tx plans and prior to signing off on the tx plans to ensure that the frequency is added. |
709.82(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in one of two applicable client records reviewed.
Client #9 was admitted to the partial hospitalization activity on January 28, 2026 and was discharged on April 14, 2026. The individual treatment plan was completed on February 9, 2026; however, the plan did not include documentation of any proposed types of support services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will monitor tx plans through weekly chart audits. Furthermore, Facility director will provide annual tx plan training beginning no later than August 15, 2026. Tx plan compliance will be monitored through chart audits and supervision sessions. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in one of one applicable client record reviewed.
Client #9 was admitted to the partial hospitalization activity on January 28, 2026 and was discharged on April 14, 2026. The individual treatment plan was completed on February 9, 2026, and the first update was due no later than March 11, 2026; however, the update was completed on March 17, 2026.
This is a repeat citation from the August 19, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will monitor tx plans through weekly chart audits. Furthermore, Facility director will provide annual tx plan training beginning no later than August 15, 2026. This training will cover all aspects of the tx plan including due dates. Tx plan compliance will be monitored through chart audits and supervision sessions. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. 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 client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in one of one applicable client records reviewed.
Client #11 was admitted to the partial hospitalization activity on November 3, 2025 and was discharged on December 1, 2025. The individual treatment plan, completed on November 3, 2025, indicated the client was to receive one hour of individual counseling session per week. There was no documentation in the record indicating the client received an individual counseling session during the week of November 23, 2025.
This is a repeat citation from the August 19, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project director prepares a spreadsheet to monitor tx compliance. The facility director will review counselor caseload each week during supervision to ensure that the groups and individual appointments are scheduled according to LOC. If the client did not show for their appointments, absence notes will be entered for those appointments. Furthermore, it is the responsibility of the clinicians to maintain their caseload. This will be communicated to each clinician during the clinical review process and supervisions. Failure to comply could result in disciplinary action. |
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 ensure counseling services were being provided to the client on a regular and scheduled basis, which is to include individual counseling at least twice weekly, in six of seven client records reviewed.
Client #9 was admitted to the partial hospitalization activity on January 28, 2026 and was discharged on April 14, 2026. There was documentation of two individual counseling sessions, on February 19, 2026 and March 18, 2026, during the entire treatment episode. Additionally, there was no documentation within the missed individual therapy session notes indicating the weekly sessions were scheduled.
Client #10 was admitted to the partial hospitalization activity on February 10, 2026 and was discharged on February 25, 2026. There was no documentation of individual counseling sessions occurring during the entire treatment episode. Additionally, there was no documentation in the missed individual therapy session notes, indicating the weekly sessions were scheduled.
Client #11 was admitted to the partial hospitalization activity on November 3, 2025 and was discharged on December 1, 2025. There was documentation of one individual counseling session occurring during the weeks of November 9, 2025 and November 23, 2025. Additionally, there was no documentation in the missed individual therapy session notes, indicating the weekly sessions were scheduled.
Client #12 was admitted to the partial hospitalization activity on November 7, 2025 and was discharged on November 25, 2025. There was no documentation of individual counseling sessions occurring during the entire treatment episode. Additionally, there was no documentation in the missed individual therapy session notes, indicating the weekly sessions were scheduled.
Client #13 was admitted to the partial hospitalization activity on November 26, 2025 and was discharged on December 15, 2025. There was no documentation of individual counseling sessions occurring during the entire treatment episode. Additionally, there was no documentation in the missed individual therapy session notes, indicating the weekly sessions were scheduled.
Client #14 was admitted to the partial hospitalization activity on February 2, 2026 and was discharged on February 24, 2026. There was no documentation of individual counseling sessions occurring during the entire treatment episode. Additionally, there was no documentation in the missed individual therapy session notes, indicating the weekly sessions were scheduled.
This is a repeat citation from the August 19, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director prepares a spreadsheet to monitor tx compliance. Furthermore, it is the responsibility of the clinicians to maintain their caseload. This will be communicated to each clinician during the clinical review process and supervisions. Missed appointment notes will be logged as well. Failure to maintain clinical records could result in disciplinary action. |
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 maintain a complete client record on an individual, which is to include the documentation of an aftercare plan, in one of one applicable client record reviewed.
Client #11 was admitted to the partial hospitalization activity on November 3, 2025 and was discharged on December 1, 2025. There was no documentation of an aftercare plan in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will monitor that each counselor creates the aftercare plans during the intake process and updated with every tx plan. Once the client is discharged for any reason, the aftercare plan will be printed and provided to the client via in-person, mail, or email (with consent). Agency policy will be updated to ensure that this is made active. Each employee will be offered a copy of the updated policy and procedure manual and sign a document indicating that they are aware of the changes. |
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 maintain a complete client record on an individual, which is to include the documentation of follow-up information, in five of six applicable client records reviewed.
Client #10 was admitted to the partial hospitalization activity on February 10, 2026 and was discharged on February 25, 2026. There was no documentation of follow-up information in the record at the time of the inspection.
Client #11 was admitted to the partial hospitalization activity on November 3, 2025 and was discharged on December 1, 2025. There was no documentation of follow-up information in the record at the time of the inspection.
Client #12 was admitted to the partial hospitalization activity on November 7, 2025 and was discharged on November 25, 2025. There was no documentation of follow-up information in the record at the time of the inspection.
Client #13 was admitted to the partial hospitalization activity on November 26, 2025 and was discharged on December 15, 2025. There was no documentation of follow-up information in the record at the time of the inspection.
Client #14 was admitted to the partial hospitalization activity on February 2, 2026 and was discharged on February 24, 2026. There was no documentation of follow-up information in the record at the time of the inspection.
This is a repeat citation from the August 19, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The administrative assistant will ensure that follow-up with discharged clients who are discharged for any reason other than violence towards staff or other individuals completed per agency policy. Current policy states within 30 days. All follow-up attempts will be documented in the EHR. Facility Director and Project Director will create a follow-up form to be completed by designated employee. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to ensure a medical history was completed, during the intake and admission process, in three of seven client records reviewed.
The facility policy and procedure manual stated that the facility will provide a comprehensive biopsychosocial assessment upon admission to any service program. Additionally, the admissions assessment will be completed within 3 days of admission. The assessment will contain, at a minimum, a physical health history and current status, a history of the use of alcohol, tobacco, and/or other drugs, and current and historical life information.
Client #4 was admitted to the outpatient activity on November 8, 2025 and was discharged on March 20, 2026. The biopsychosocial assessment, including a medical history, was due to be completed no later than November 11, 2025; however, the assessment and medical history was completed late on November 25, 2025.
Client #6 was admitted to the outpatient activity on December 16, 2025 and was discharged on April 14, 2026. The biopsychosocial assessment, including a medical history, was due to be completed no later than December 19, 2025; however, the assessment and medical history was completed late on December 24, 2025.
Client #7 was admitted to the outpatient activity on January 8, 2026 and was discharged on May 6, 2026. The biopsychosocial assessment, including a medical history, was due to be completed no later than January 11, 2026; however, the assessment and medical history was completed late on January 13, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will monitor intake appointments and admissions to ensure that each client receives their BPS within 3 days of admission. Failure to do so may result in disciplinary action. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to ensure a drug or alcohol history was completed, during the intake and admission process, in three of seven client records reviewed.
The policy and procedures manual indicates that the facility will provide a comprehensive biopsychosocial assessment upon admission to any service program. Additionally, the admissions assessment will be completed within 3 days of admission. The assessment will contain, at a minimum, use of alcohol, tobacco, and/or other drugs.
Client #4 was admitted to the outpatient activity on November 8, 2025 and was discharged on March 20, 2026. The biopsychosocial assessment, including a drug or alcohol history, was due to be completed no later than November 11, 2025; however, the assessment and the drug or alcohol history was completed late on November 25, 2025.
Client #6 was admitted to the outpatient activity on December 16, 2025 and was discharged on April 14, 2026. The biopsychosocial assessment, including a drug or alcohol history, was due to be completed no later than December 19, 2025; however, the assessment and the drug or alcohol history was completed late on December 24, 2025.
Client #7 was admitted to the outpatient activity on January 8, 2026 and was discharged on May 6, 2026. The biopsychosocial assessment, including a drug or alcohol history, was due to be completed no later than January 11, 2026; however, the assessment and the drug or alcohol history was completed late on January 13, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will monitor intake appointments and admissions to ensure that each client receives their BPS within 3 days of admission. Failure to do so may result in disciplinary action. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to ensure a personal history was completed, during the intake and admission process, in three of seven client records reviewed.
The facility policy and procedure manual stated that the facility will provide a comprehensive biopsychosocial assessment upon admission to any service program. Additionally, the admissions assessment will be completed within 3 days of admission. The assessment will contain, at a minimum, a physical health history and current status, a history of the use of alcohol, tobacco, and/or other drugs, and current and historical life information.
Client #4 was admitted to the outpatient activity on November 8, 2025 and was discharged on March 20, 2026. The biopsychosocial assessment, including a personal history, was due to be completed no later than November 11, 2025; however, the assessment and personal history was completed late on November 25, 2025.
Client #6 was admitted to the outpatient activity on December 16, 2025 and was discharged on April 14, 2026. The biopsychosocial assessment, including a personal history, was due to be completed no later than December 19, 2025; however, the assessment and personal history was completed late on December 24, 2025.
Client #7 was admitted to the outpatient activity on January 8, 2026 and was discharged on May 6, 2026. The biopsychosocial assessment, including a personal history, was due to be completed no later than January 11, 2026; however, the assessment and personal history was completed late on January 13, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will monitor intake appointments and admissions to ensure that each client receives their BPS within 3 days of admission. Failure to do so may result in disciplinary action. |
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 a review of client records, failed to ensure a psychosocial evaluation was completed, during the intake and admission process, in four of seven client records reviewed.
The policy and procedure manual stated that the facility will provide a comprehensive biopsychosocial assessment upon admission to any service program. Additionally, the admissions assessment will be completed within 3 days of admission.
Client #1 was admitted to the outpatient activity on November 2, 2025 and was active at the time of the inspection. There was no documentation in the record indicating the psychosocial evaluation was completed prior to discharge.
Client #4 was admitted to the outpatient activity on November 8, 2025 and was discharged on March 20, 2026. The psychosocial evaluation was due to be completed no later than November 11, 2025; however, the evaluation was completed late on November 25, 2025.
Client #6 was admitted to the outpatient activity on December 16, 2025 and was discharged on April 14, 2026. The psychosocial evaluation was due to be completed no later than December 19, 2025; however, the evaluation was completed late on December 24, 2025.
Client #7 was admitted to the outpatient activity on January 8, 2026 and was discharged on May 6, 2026. The psychosocial evaluation was due to be completed no later than January 11, 2026; however, the evaluation was completed late on January 13, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will monitor intake appointments and admissions to ensure that each client receives their BPS within 3 days of admission. Failure to do so may result in disciplinary action. |
709.91(b)(7) LICENSURE Intake and admission
709.91. 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 client records, the facility failed to ensure a preliminary treatment plan was completed, during the intake and admission process, in four of seven client records reviewed.
The facility policy and procedures manual stated the preliminary treatment plan shall be completed within 3 days of admission.
Client #1 was admitted to the outpatient activity on November 2, 2025 and was active at the time of the inspection. The preliminary treatment plan was due to be completed no later than November 5, 2025; however, the plan was completed late on December 10, 2025.
Client #3 was admitted to the outpatient activity on November 11, 2025 and was active at the time of the inspection. The preliminary treatment plan was due to be completed no later than November 14, 2025; however, the plan was completed late on November 17, 2025.
Client #6 was admitted to the outpatient activity on December 16, 2025 and was discharged on April 14, 2026. There was no documentation of a completed preliminary treatment plan in the record at the time of the inspection.
Client #7 was admitted to the outpatient activity on January 8, 2026 and was discharged on May 6, 2026. The preliminary treatment plan was due to be completed no later than January 11, 2026; however, the plan was completed late on January 13, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will monitor intakes using a spreadsheet where each component of an intake will be monitored including: consents completed, BPS completed, diagnosis input, ASAM completed, Preliminary Tx Plan completed, Aftercare Plan created, and schedules secured. |
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 on the individual treatment and rehabilitation plan in three of six applicable client records reviewed.
Client #2 was admitted to the outpatient activity on November 11, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 17, 2025; however, the plan did not include the frequency of treatment and rehabilitation services being provided to the client.
Client #6 was admitted to the outpatient activity on December 16, 2025 and was discharged April 14, 2026. The individual treatment and rehabilitation plan was completed on December 24, 2025; however, the plan did not include the frequency of treatment and rehabilitation services being provided to the client.
Client #7 was admitted to the outpatient activity on January 8, 2026 and was discharged May 6, 2026. The individual treatment and rehabilitation plan was completed on January 14, 2026; however, the plan did not include the frequency of treatment and rehabilitation services being provided to the client.
This is a repeat citation from the August 19, 2025 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All treatment plans will have the type and frequency of services added to each goal/objective/intervention. Facility director will provide a training on tx plans quarterly beginning immediately in supervisions. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support service on the individual treatment and rehabilitation plan in three of six applicable client records reviewed.
Client #1 was admitted to the outpatient activity on November 2, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 10, 2025; however, the plan did not include the proposed type of support service.
Client #5 was admitted to the outpatient activity on January 12, 2026 and was discharged April 24, 2026. The individual treatment and rehabilitation plan was completed on January 14, 2026; however, the plan did not include the proposed type of support service.
Client #7 was admitted to the outpatient activity on January 8, 2026 and was discharged May 6, 2026. The individual treatment and rehabilitation plan was completed on January 14, 2026; however, the plan did not include the proposed type of support service.
This is a repeat citation from the August 19, 2025 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will monitor tx plans through weekly chart audits. Furthermore, Facility director will provide annual tx plan training beginning no later than August 15, 2026. Tx plan compliance will be monitored through chart audits supervision sessions. |
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 ensure that treatment and rehabilitation plans were reviewed and updated at least every sixty days in five of six applicable client records reviewed.
Client #1 was admitted to the outpatient activity on November 2, 2025 and was active at the time of the inspection. A treatment plan update was completed on January 21, 2026 and the next treatment update was due no later than March 21, 2026; however, this update dated March 21, 2026 was incomplete and blank.
Client #2 was admitted to the outpatient activity on November 11, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 17, 2025 and the first update was due no later than January 17, 2026; however, the update was completed on February 5, 2026. Additionally, the next treatment plan update was due no later than April 6, 2026; however, the update was completed on April 23, 2026. Also, the next treatment plan update was due no later than June 23, 2026; however, the update was not completed at the time of the inspection.
Client #3 was admitted to the outpatient activity on January 5, 2026 and was active at the time of the inspection. A treatment plan update was completed on May 1, 2026 and the next update was due no later than July 1, 2026; however, the update was completed on July 7, 2026.
Client #5 was admitted to the outpatient activity on January 12, 2026 and was discharged on April 24, 2026. The individual treatment and rehabilitation plan was completed on January 14, 2026 and the first update was due no later than March 16, 2026; however, the update was not completed prior to discharge.
Client #6 was admitted to the outpatient activity on December 16, 2025 and was discharged on April 14, 2026. The individual treatment and rehabilitation plan was completed on December 24, 2025 and the first update was due no later than February 24, 2026; however, the update was not completed prior to discharge.
This is a repeat citation from the August 19, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will monitor tx plans through weekly chart audits. Furthermore, Facility director will provide annual tx plan training beginning no later than August 15, 2026. This training will cover all aspects of the tx plan including due dates. Tx plan compliance will be monitored through chart audits supervision sessions. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 client records, the facility failed to ensure that counseling services were being provided according to the individual treatment and rehabilitation plan in four of four applicable client records reviewed.
Client #1 was admitted to the outpatient activity on November 2, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan, completed on December 10, 2025, and the treatment plan update, completed on January 21, 2026, indicated an individual or a group counseling session one time per week. There was only documentation, in the record, of an individual or group counseling session occurring during the weeks of January 18, 2026, February 1, 2026, February 15, 2026, April 5, 2026, April 26, 2026, May 10, 2026, May 24, 2026, June 7, 2026, June 14, 2026, and June 28, 2026.
Client #2 was admitted to the outpatient activity on November 11, 2025 and was active at the time of the inspection. A treatment plan update, completed on February 5, 2026, indicated an individual or a group counseling session one time per week. There was no documentation, in the record, of an individual or group counseling session occurring during the weeks of February 15, 2026 through March 28, 2026.
Client #3 was admitted to the outpatient activity on January 5, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan, completed on January 6, 2026, indicated group counseling sessions three to four times per week. There was no documentation, in the record, of any group counseling sessions occurring during the weeks of February 15, 2026 through February 28, 2026.
Client #5 was admitted to the outpatient activity on January 12, 2026 and was discharged on April 24, 2026. The individual treatment and rehabilitation plan, completed on January 14, 2026, indicated group counseling sessions one to two times per week. There was no documentation, in the record, of group counseling sessions occurring during the weeks of March 22, 2026 through the date of discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director prepares a spreadsheet to monitor tx compliance. Furthermore, it is the responsibility of the clinicians to maintain their caseload. This will be communicated to each clinician during the clinical review process and supervisions. |
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 maintain a complete client record on an individual, which is to include documentation of case consultation notes, in seven of seven applicable outpatient client records reviewed.
The facility's policy and procedures manual indicates that for case consultation regarding client's engagement in treatment is to be completed at minimum once quarterly in the first year, and one time annually after the first year engaged in treatment.
Client #1 was admitted to the outpatient activity on November 2, 2025 and was active at the time of the inspection. There was no documentation of any case consultation note in the record at the time of the inspection.
Client #2 was admitted to the outpatient activity on November 11, 2025 and was active at the time of the inspection. There was no documentation of any case consultation note in the record at the time of the inspection.
Client #3 was admitted to the outpatient activity on January 5, 2026 and was active at the time of the inspection. There was no documentation of any case consultation note in the record at the time of the inspection.
Client #4 was admitted to the outpatient activity on November 8, 2025 and was discharged on March 20, 2026. There was no documentation of any case consultation note in the record at the time of the inspection.
Client #5 was admitted to the outpatient activity on January 12, 2026 and was discharged on April 24, 2026. There was no documentation of any case consultation note in the record at the time of the inspection.
Client #6 was admitted to the outpatient activity on December 16, 2025 and was discharged on April 14, 2026. There was no documentation of any case consultation note in the record at the time of the inspection.
Client #7 was admitted to the outpatient activity on January 8, 2026 and was discharged on May 6, 2026. There was no documentation of any case consultation note in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will monitor counselors case loads to ensure that case consultation notes shall be completed quarterly for every client. Case consultation will be conducted via supervisions or during the weekly Clinical Review meetings. These meetings will be added to the policy and procedures handbook during the update. The documentation will be monitored and sent to the facility director after each meeting. The meeting notes will be stored in the agency internal storage. |
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 maintain a complete client record on an individual, which is to include documentation of an aftercare plan, in two of two applicable client records reviewed.
Client #6 was admitted to the outpatient activity on December 16, 2025 and was discharged on April 14, 2026. There was no documentation in the record indicating an aftercare plan was completed at the time of the inspection.
Client #7 was admitted to the outpatient activity on January 8, 2026 and was discharged on May 6, 2026. There was no documentation in the record indicating an aftercare plan was completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The counselors will complete aftercare plans during the intake process and updated with every tx plan. The facility director will ensure that this process is followed to fidelity. Once the client is discharged for any reason, the aftercare plan will be printed and provided to the client via in-person, mail, or email (with consent). Agency policy will be updated to ensure that this is made active. Each employee will receive a copy of the updated policy and procedure manual and sign a document indicating that they are aware of the changes. |
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 maintain a complete client record on an individual, which is to include documentation of follow-up information, in four of four applicable client records reviewed.
Client #4 was admitted to the outpatient activity on November 8, 2025 and was discharged on March 20, 2026. There was no documentation in the record of follow-up information at the time of the inspection.
Client #5 was admitted to the outpatient activity on January 12, 2026 and was discharged on April 24, 2026. There was no documentation in the record of follow-up information at the time of the inspection.
Client #6 was admitted to the outpatient activity on December 16, 2025 and was discharged on April 14, 2026. There was no documentation in the record of follow-up information at the time of the inspection.
Client #7 was admitted to the outpatient activity on January 8, 2026 and was discharged on May 6, 2026. There was no documentation in the record of follow-up information at the time of the inspection.
This is a repeat citation from the August 19, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow-up with discharged clients who are discharged for any reason other than violence towards staff or other individuals will be followed up per agency policy. Current policy states within 30 days. All follow-up attempts will be documented in the EHR. Facility Director and Project Director will create a follow-up form to be completed by designated employee and monitor completion. |
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 failing to train all staff in the use of fire extinguishers was submitted and approved by the Department for the July 17, 2024 and August 19, 2025 annual licensing inspections. Failing to train all staff in the use of fire extinguishers was again found to be a deficiency in the July 9, 2026 through July 10, 2026, annual licensing inspection.
A plan of correction for failing to train all staff to perform assigned tasks during emergencies was submitted and approved by the Department for the July 17, 2024 and August 19, 2025 annual licensing inspections. Failing to train all staff to perform assigned tasks during emergencies was again found to be a deficiency in the July 9, 2026 through July 10, 2026, annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will ensure all audit findings and plans of correction will be located on the agency's internal storage system. This will allow for all information to be stored in a central location that future employees will still have access to. Disciplinary action will be taken moving forward, according to agency policy. The policy and procedure manual is currently being updated to ensure that the previous and current deficiency do not remain an issue. |