INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 10, 2025 through June 11, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Consortium 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection on June 11, 2025, the facility failed to keep the ground of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
Multiple areas of the building had evidence of water damage from roof leakage; one area was used for a group counseling space.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The multiple areas of the building with water damage are on the list of needed repairs by the City of Philadelphia. Multiple items from the list were satisfied prior to the licensing visit.The remaining items are expected to be completed by 9/30/2025.
The group room identified has not been utilized since November 2024,when the damage occurred. It was also omitted from the clinic's monthly group schedule as an available room at that time. The Facility Director conducting the facility tour was mistaken in his statement regarding that particular group room.
Responsibility:
The City of Philadelphia is responsible for the the needed building repairs.
The Facilities Director is responsible to ensure all current and future building issues are reported to the Interim CEO, the CFO, and the City of Philadelphia.
The Division Director is responsible to monitor the needed repairs to completion.
POC Completion Date: 9/30/2025
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection on June 11, 2025, the facility failed to ventilate bathrooms by exhaust fan or window.
Two client bathrooms on the first floor of the facility did not have a functioning exhaust fans.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The two client bathrooms on the first floor with non-working ventilators are now on the list of building repairs by the City of Philadelphia.
Responsibility:
The City of Philadelphia is responsible for the the needed building repairs.
Responsibility:
The Facilities Director is responsible to monitor the status of the clinic's equipment monthly.
The Facilities Director is responsible to ensure all current and future building issues are reported to the Interim CEO, the CFO, and the City of Philadelphia.
The Division Director is responsible to monitor the needed repairs to completion.
POC Completion Date: 9/30/2025 |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of eleven personnel records and staff training records, the project failed to instruct all staff in the use of the fire extinguisher upon employment.
Employee #8 was hired as a counselor on November 18, 2024, and was current in that position at the time of the inspection. The employee was to be instructed in the use of the fire extinguisher upon employment; however, the employee did not receive this training as of the date of the licensing inspection.
Employee #11 was hired at the facility on October 14, 2024 and promoted to a counselor on November 22, 2024. The employee was to be instructed in the use of the fire extinguisher upon employment; however, the employee did not receive this training as of the date of the licensing inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Employees #8 and #11 have missing from their Employee Files, On-Site Orientation packets which document the Fire Safety Training on the first day of presenting to the clinic. Both employees currently have a documented annual Fire Safety training.
Effective 7/7/2025, the Clinical Supervisor will present the On-Site Orientation Packet to the Program Manager before the end of the new hire's first shift. The Program Manager will ensure that the Fire Safety Training was facilitated, initialed and dated by the new hire and supervisor. The Program Manager will also add their initials and date to the document before presenting the packet back to the Clinical Supervisor to continue the the On-Site Training process on day 3@.
The Program Manager will redirect the Clinical Supervisor if the Fire Safety Training was not completed and personally monitor the supervisor and new hire as the process is completed.
The Clinical Supervisor will submit the On-Site Training packet to the Program Manager when all elements are completed.
The Program Manager will submit the packet to TSS Department to be entered onto the new hire's employee files.
Responsibility:
The Clinical Supervisor
The Program Manager
The TSS Director
The Division Director is responsible to monitor this process to completion.
POC Effective Date 7/14/2025
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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 the review of eleven personnel records and staff training records, the project failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Employee #8 was hired as the counselor on November 18, 2024, and was current in that position at the time of the inspection. The employee was to be trained to perform assigned tasks during emergencies prior to working a shift; however, the employee did not receive this as of the date of the inspection.
Employee #11 was hired at the facility on October 14, 2024 and promoted to a counselor on November 22, 2024. The employee was to be trained to perform assigned tasks during emergencies prior to working a shift; however, the employee did not receive this as of the date of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Employees #8 and #11 have missing from their Employee Files, On-Site Orientation packets which document the Fire Safety Training on the first day of presenting to the clinic. Both employees currently have a documented annual Fire Safety training.
BOTH EMPLOYEES ARE NOE TRAINED TO PERFORM ASSIGNED TASKS DURING AN EMERGENCY.
Effective 7/7/2025:
ON DAY ONE FOR A NEW HIRE the Clinical Supervisor will COMPLETE THE FIRE SAFETY TRAINING COMPLETE WITH EXPLANATION OF ASSIGNED TASKS REQUIRED OF THEM DURING EMERGENCIES.
The Clinical Supervisor present the On-Site Orientation Packet to the Program Manager before the end of the new hire's first shift.
The Program Manager will ensure that the Fire Safety Training, AND DIRECTION OF ASSIGNMENTS DURING AN EMERGENCY, was facilitated, initialed and dated by the new hire and supervisor.
The Program Manager will also add their initials and date to the document before presenting the packet back to the Clinical Supervisor to continue the the On-Site Training process on day 3@.
The Program Manager will redirect the Clinical Supervisor if the Fire Safety Training was not completed and personally monitor the supervisor and new hire as the process is completed.
The Clinical Supervisor will submit the On-Site Training packet to the Program Manager when all elements are completed.
The Program Manager will submit the packet to TSS Department to be entered onto the new hire's employee files.
Responsibility:
The Clinical Supervisor
The Program Manager
The TSS Director
The Division Director is responsible to monitor this process to completion.
POC Effective Date 7/14/2025 |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosures will be made to in three of eight records reviewed.
Client #1 was admitted on February 14, 2025 and was active at the time of the inspection. A release of information form, signed by the client on February 14, 2025, did not specify the name of the person, agency or organization to whom disclosure is to be made.
Client #5 was admitted on March 14, 2025 and was active at the time of the inspection. A release of information form, signed by the client on March 14, 2025, did not specify the name of the person, agency or organization to whom disclosure is to be made.
Client #6 was admitted on December 10, 2024 and was active at the time of the inspection. A release of information form, signed by the client on December 13, 2024, did not specify the name of the person, agency or organization to whom disclosure is to be made.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Effective 7/14/2025:
The treatment files for Patients #1 #5, and #6, will be made whole by ensuring that the identified incomplete Consent Forms are again reviewed with the Patients and signed and dated by the Patient and Clinical Supervisor.
Effective 7/14/2025:
The Business Office Registration staff will review the Consent Forms with the new admissions and ensure that all required elements are completed and all forms are signed and dated by them and the new admits.
Before the close of business on the day after admissions, the Business Office Supervisor will review the section of the Patient's file that is completed by the Registration staff. The B/O Supervisor will address any identified issues with the Registration staff. The B/O Supervisor will be responsible for ensuring the Patient is met with to complete the missing information.
The Clinical Assessor will review the Consents prepared by the Business Office Registration staff prior to completing the Clinical Assessment appointment with the new admit. The Clinical Assessor will discuss any blank information with the new admit and complete any missing information and missing signatures with the new admit. The Clinical Assessor will inform the Admissions Clinical Supervisor of the missing elements identified during the appointment.
At the end of each week, the Admissions Clinical Supervisor will audit the Admissions section of the Patient's file that is completed by both the Business Office Registration staff and the Clinical Assessor to ensure that all requirements are completed. The Admissions Clinical Supervisor will address any missing elements with the responsible staff.
The B/O Registration Staff's documents will be audited by B/O Supervisor and the Admissions Clinical Supervisor.
The Clinical Assessor's requirements will be monitored by the Admissions Clinical Supervisor.
The Program Manager will monitor the the requirements of the Admissions Clinical Supervisor.
The Division Director will monitor the compliance to the requirements.
POC Effective Date: 7/14/2025
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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in one of eight client records reviewed.
Client #6 was admitted on December 10, 2024 and was active at the time of the inspection. Two release of information forms signed by the client on December 13, 2024, did not specify the specific information to be disclosed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The treatment file for Patient #6 can not be made whole as the Patient was Discharged from the program on May 11, 2025.
Effective 7/14/2025:
The Primary Therapist will review the Patient's Consents with the Patient during the first Individual Treatment Session. The Primary Therapist will discuss, sign, and date any blank ConsentS with the Patient during the session. The Primary Therapist will send an email to their Clinical Supervisor and the Admissions Clinical Supervisor detailing their findings.
The Admissions Clinical Supervisor will alert the Division Director who will conduct a review of the process stated below and facilitate a fact finding to determine where the process fell short and if further staff training or closer monitoring is necessary.
Responsibility:
Primary Therapist
Clinical Supervisors
Division Director
AS PREVIOUSLY STATED:
The Business Office Registration staff will review the Consent Forms with the new admissions and ensure that all required elements are completed and all forms are signed and dated by them and the new admits.
Before the close of business on the day after admissions, the Business Office Supervisor will review the section of the Patient's file that is completed by the Registration staff. The B/O Supervisor will address any identified issues with the Registration staff. The B/O Supervisor will be responsible for ensuring the Patient is met with to complete the missing information.
The Clinical Assessor will review the Consents prepared by the Business Office Registration staff prior to completing the Clinical Assessment appointment with the new admit. The Clinical Assessor will discuss any blank information with the new admit and complete any missing information and missing signatures with the new admit. The Clinical Assessor will inform the Admissions Clinical Supervisor of the missing elements identified during the appointment.
At the end of each week, the Admissions Clinical Supervisor will audit the Admissions section of the Patient's file that is completed by both the Business Office Registration staff and the Clinical Assessor to ensure that all requirements are completed. The Admissions Clinical Supervisor will address any missing elements with the responsible staff.
The B/O Registration Staff's documents will be audited by B/O Supervisor and the Admissions Clinical Supervisor.
The Clinical Assessor's requirements will be monitored by the Admissions Clinical Supervisor.
The Program Manager will monitor the the requirements of the Admissions Clinical Supervisor.
The Division Director will monitor the compliance to the requirements.
POC Effective Date: 7/14/2025 |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
The facility failed to document an annual evaluation of each patient's status that was completed by the patient's counselor and was reviewed, dated and signed by the medical director in two applicable patient records reviewed.
Patient #4 was admitted on September 16, 2020 and was a current patient at the time of the inspection. An annual evaluation was due in September 2024, per the program ' s policy and procedure of completion within their anniversary month; however, there was no documentation in the patient record of an annual evaluation at the time of the inspection.
Patient #6 was admitted on December 10, 2019 and was a current patient at the time of the inspection. An annual evaluation was due in December 2024, per the program ' s policy and procedure of completion within their anniversary month; however, there was no documentation in the patient record of an annual evaluation 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 Treatment File for Patient #6 can not be made whole as the Patient was Discharged form the program on May 11, 2025.
Effective 7/21/2025:
The Treatment File for Patient #4 will be made whole by completing the missing Annual Evaluation, utilizing the treatment documentation entered in the Patient's File prior to the 9/2024 Annual Consultation due date.
Effective 7/21/2025:
The Primary Therapist will review their Documentation Trackers to ensure that each assigned Patient has a timely Annual Consultation.
The Clinical Supervisor will monitor the Documentation Trackers weekly to ensure all Annual Evaluations are completed, signed, and submitted timely.
Responsibility:
Primary Therapist
Clinical Supervisor
Division Director is responsible to monitor compliance with this requirement.
POC Date: 7/21/2025
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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 the review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in two of six applicable records reviewed.
Client #2 was admitted on March 21, 2006, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan update was documented in the record on October 30, 2024, with the next updated treatment and rehabilitation plans due no later than December 30, 2024; however, there were no updated treatment and rehabilitation plans documented in the client record until January 17, 2025.
Client #6 was admitted on December 10, 2024 and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan update was documented in the record on December 9, 2024, with the next updated treatment and rehabilitation plans due no later than February 9, 2025; however, there were no updated treatment and rehabilitation plans documented in the client record until February 19, 2025. The next treatment and rehabilitation plan update was due no later than April 19, 2025; however, there were no treatment and rehabilitation plan update documented in the client record until April 22, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Treatment Plans for Patient #2 are now current. Patient #6 was Discharged 1n May-2025
Effective 7/21/2025:
The Program Manager will work closely with the agency's EMR Administrator to ensure that the NEW ELECTRONIC MEDICAL RECORDS SYSTEM will consistently ensure that "Treatment Plan Due Reports" are accurate and the "Treatment Plan Due Alerts" are functioning as required to ensure accurate information for timely Treatment Plan submissions.
The Division Director will ensure that the Therapists and Clinical Supervisors continue to utilize and update the program's manual Excel Documentation Tracker until the New EMR System's data mirrors the accurate dates of the documentation due.
Responsible:
Therapist
Clinical Supervisor
EMR Administrator
Program Manager
Division Director
POC Darte: 7/21/2025 |