INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 30, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, 717 Health LLC dba Northeast Wellness Collective 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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705.28 (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 review of five personnel records the facility failed to ensure that all personnel are trained in the use of fire extinguishers upon staff employment.
Employee #4 was hired as a counselor on February 10, 2025, and was still in the position at the time of the inspection. Employee #4 was due to be trained in the use of fire extinguishers upon employment; however, it was not completed until December 30, 2025.
Employee #5 was hired as a counselor on October 13, 2025 and was still in the position at the time of the inspection. Employee #5 was due to be trained in the use of fire extinguishers upon employment; however, it was not completed until January 20, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Who will correct the deficiency (job title, not name) - Chief Admin
2. How the deficiency will be corrected (staff meeting, training, etc.) Fire Safety training will be part of the onboarding process for the employees' first day.
3. When will they be corrected (corrective action date) All new hire staff will be trained in facility fire safety on their first day of employment. Fire Safety training was integrated into the first day of onboarding paperwork and training moving forward for any new staff. This was corrected on 2/6/2026.
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc) Chief Admin will conduct HR audits and be sure that all proper training's are completed.
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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 review of five personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies upon employment.
Employee #4 was hired on February 10, 2025, as a counselor and was still in the position as of the date of the inspection. Employee #4 was due to be trained to perform assigned tasks during emergencies upon employment; however, it was not completed until December 31, 2025.
Employee #5 was hired on October 13, 2025 as a counselor and was still in the position as of the date of the inspection. There was no documentation that employee #5 was trained to perform assigned tasks during emergencies upon employment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Who will correct the deficiency (job title, not name) - Chief Admin
2. How the deficiency will be corrected (staff meeting, training, etc.) Emergency Procedures training will be part of the onboarding process for the employees' first day.
3. When will they be corrected (corrective action date) All new hire staff will be trained in facility emergency procedures on their first day of employment. This training has been moved to the first day of onboarding for all new staff moving forward. This was corrected on 2/6/2026
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc) Chief Admin will conduct HR audits and be sure that all proper training's are completed. |
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 informed and voluntary consent from the client for the disclosure of information in one of fourteen records reviewed.
Client #12 was admitted to the outpatient level of care on January 31, 2025, and discharged May 2, 2025. There was documentation that was disclosed to two family members during family sessions on March 5, 2025, April 3, 2025, and April 10, 2025; however, the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information. The facility confirmed disclosure occurred.
This is a repeat citation from the January 15, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Who will correct the deficiency (job title, not name) - Chief Admin
2. How the deficiency will be corrected (staff meeting, training, etc.) Staff were trained on 2/2/2026 in relation to how to properly complete a consent and also reminded about the regulations as to when a consent is needed. Staff were given different scenarios to test their knowledge.
3. When will they be corrected (corrective action date) Staff were asked to go through their charts and to make sure all consents are completed appropriatly and also all relevant individuals that the staff are speaking to in relationto the client to have a consent on file.
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc) Chief Admin will make consents part of the weekly chart audits. |
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 review of client records, the facility failed to obtain a completed informed and voluntary consent which included the specific information to be disclosed in one out fourteen records reviewed.
Client #3 was admitted to the partial hospitalization level of care on June 17, 2025, and discharged on August 20, 2025. A release of information form for a family member, was signed and dated on June 17, 2025; however, it did not include the specific information to be disclosed.
This is a repeat citation from the January 15, 2025 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Who will correct the deficiency (job title, not name) - Chief Admin
2. How the deficiency will be corrected (staff meeting, training, etc.) Staff were trained on 2/2/2026 in relation to how to properly complete a consent and also reminded about the regulations as to when a consent is needed. Staff were provided copies of a valid consent and one that was not valid.
3. When will they be corrected (corrective action date) Staff were asked to go through their charts and to make sure all consents are completed appropriately. Staff were told to update any consents that were not completed correctly.
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc) Chief Admin will make consents part of the weekly chart audits. |
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 obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the purpose of the disclosure in one out of fourteen records reviewed.
Client #11 was admitted to the outpatient level of care on February 17, 2025, and was discharged on June 13, 2025. An informed and voluntary consent from the client for the disclosure of information to an outside therapist office, signed and dated April 04, 2025, did not include the purpose of disclosure.
This finding was reviewed with facility staff during licensing process.
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Plan of Correction
1. Who will correct the deficiency (job title, not name) - Chief Admin
2. How the deficiency will be corrected (staff meeting, training, etc.) Staff were trained on 2/2/2026 in relation to how to properly complete a consent and also reminded about the regulations as to when a consent is needed.
3. When will they be corrected (corrective action date) Staff were asked to go through their charts and to make sure all consents are completed appropriately. Staff were told to update any consents that were not completed correctly and to make sure that any individuals they are speaking to regarding the client that a consent is on file.
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc) Chief Admin will make consents part of the weekly chart audits. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in two out of fourteen client records reviewed.
Client #3 was admitted to the partial hospitalization level of care on June 17, 2025, and discharged on August 20, 2025. A consent form signed and dated February 17, 2025, for a funding source, did not have documentation that the client was offered a copy of the consent form.
Client #6 was admitted to the partial hospitalization level of care on October 30, 2025, and discharged on December 19, 2025. A consent form signed and dated October 30, 2025, for a funding source, did not have documentation that the client was offered a copy of the consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Who will correct the deficiency (job title, not name) - Chief Admin
2. How the deficiency will be corrected (staff meeting, training, etc.) Staff were trained on 2/2/2026 in relation to how to properly complete a consent. Specifically, in documenting whether a client was offered a copy of the consent form.
3. When will they be corrected (corrective action date) The staff were asked to go through their charts and to make sure all consents are completed appropriately and that all consents have documentation that the consent was offered and the client accepted or didn't. This needed to be completed by end of business on 2/4/2026.
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc) Chief Admin will make consents part of the weekly chart audits. |
709.82(a) 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:
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Observations
Based on a review of outpatient client records, the facility failed to document a comprehensive treatment plan with the client within the guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within five days following admission.
Client #1 was admitted on December 19, 2025 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than December 24, 2025; however, it was not completed until January 2, 2026.
Client #2 was admitted on November 14, 2025, and discharged on December 16, 2025. A comprehensive treatment plan was due no later than November 19, 2025; however, it was not completed until November 24, 2025.
Client #4 was admitted on July 7, 2025 and discharged on July 18, 2025. A comprehensive treatment plan was due no later than July 12, 2025; however, it was not completed until July 14, 2025.
Client #7 was admitted on October 20, 2025 and discharged on November 26, 2025. A comprehensive treatment plan was due no later than October 25, 2025; however, it was not completed until October 28, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Who will correct the deficiency (job title, not name) - Chief Admin
2. How the deficiency will be corrected (staff meeting, training, etc.) Chief Admin had a staff training on 2/2/2026 to review all documentation expectations specifcally the comprehensive treatment plans.
3. When will they be corrected (corrective action date) Staff were asked to go in and get all there current treatment plans up to date by end of business on 2/4/2026.
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc) Chief Admin will conduct chart aduits on all charts moving foward. |
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 seven partial hospitalization client records, the facility failed to document treatment plan updates within the 30-day regulatory timeframe in one out of two applicable records reviewed.
Client #3 was admitted on June 17, 2025 and was discharged on August 20, 2025. The individual treatment and rehabilitation plan was completed on June 20, 2025, and the treatment plan update was due no later than July 20, 2025; however, the update was not completed prior to the client's discharge.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Who will correct the deficiency (job title, not name) - Chief Admin
2. How the deficiency will be corrected (staff meeting, training, etc.) Chief Admin had a staff training on 2/2/2026 to review all documentation expectations specifcally the treatment plan reviews.
3. When will they be corrected (corrective action date) Staff were asked to go in and get all there current treatment plans up to date by end of business on 2/4/2026.
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc) Chief Admin will conduct chart aduits on all charts moving foward. |
709.83(a)(9) 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:
(9) Progress notes.
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Observations
Based on a review of partial hospitalization client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project in four out of seven records reviewed. The facility's policy and procedures manual states progress notes to be completed within 24 hours after therapy sessions.
Client # 1 was admitted on December 19, 2025 and was still active at the time of the inspection. The record contained progress notes for an individual session occurring on January 15, 2025, January 16, 2025, and January 22, 2025, that were not completed until January 18, 2025, January 18, 2025, and January 26, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on December 22, 2025, December 26, 2025, January 09, 2026, January 16, 2026, January 22, 2026, and January 23, 2026 that were not completed until December 24, 2025, December 29, 2025, January 11, 2026, January 20, 2026, January 25, 2026, and January 25, 2026, respectively. .
Client # 2 was admitted on November 14, 2025 and was discharged on December 16, 2025. The record contained progress notes for group sessions occurring on November 16, 2025 and November 19, 2025 that were not completed until November 20, 2025 and November 24, 2025, respectively.
Client #3 was admitted on June 17, 2025 and was discharged on August 20, 2025. The record contained progress notes for individual sessions occurring on June 17, 2025, June 20, 2025, June 30, 2025, and Jule 03, 2025, that were not completed until June 24, 2025, June 24, 2025, July 09, 2025, and July 10, 2025, respectively.
Client #6 was admitted on October 30, 2025 and was discharged on December 19, 2025. The record contained progress notes for individual sessions occurring on November 16, 2025, November 17, 2025, November 20, 2025, November 25, 2025, December 01, 2025, December 02, 2025, December 05, 2025, December 05, 2025, December 09, 2025, December 12, 2025, December 12, 2025, and December 16, 2025, that were not completed until November 10, 2025, November 21, 2025, November 24, 2025, November 30, 2025, December 03, 2025, December 05, 2025, December 08, 2025, December 08, 2025, December 15, 2025, December 15, 2025, December 14, 2025, and December 19, 2025, respectively.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Who will correct the deficiency (job title, not name) - Chief Admin
2. How the deficiency will be corrected (staff meeting, training, etc.) Chief Admin had a staff training on 2/2/2026 to review all documentation expectations specifcally the timeframe of when individual session notes need to be completed.
3. When will they be corrected (corrective action date) Staff were asked to go into the charts and get all there current open notes up to date by end of business on 2/4/2026.
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc) Chief Admin will conduct chart aduits on all charts moving foward. |
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 document follow-up information within guidelines established by the facility's policy and procedures manual in five out of six applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed 7 days following discharge.
Client #2 was admitted on November 14, 2025 and discharged on December 16, 2025. The client record did not contain any documentation of a follow up.
Client #3 was admitted on June 17, 2025 and discharged on August 20, 2025. The client record did not contain any documentation of a follow up.
Client #4 was admitted on July 7, 2025 and discharged on July 18, 2025. The client record did not contain any documentation of a follow up.
Client #5 was admitted on July 18, 2025 and discharged on August 15, 2025. The client was due to have a follow up by August 22, 2025; however, it was not completed until December 2, 2025.
Client #6 was admitted on October 30, 2025 and discharged on December 19, 2025. The client was due to have a follow up by December 26, 2025; however, it was not completed until January 7, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Who will correct the deficiency (job title, not name) - Chief Admin
2. How the deficiency will be corrected (staff meeting, training, etc.) Chief Admin had a staff training on 2/2/2026 to review all documentation expectations specifcally the timeframe of when follow up calls need to be completed.
3. When will they be corrected (corrective action date) Staff were asked to go into the discharge clients that have discharged this year 2026 and make sure that a follow up call was completed and this needed to be completed by end of business on 2/4/2026.
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc) Chief Admin will conduct chart audits on all charts moving forward. |
709.92(a) 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:
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Observations
Based on a review of outpatient client records, the facility failed to document a comprehensive treatment plan with the client within the guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within five days following admission.
Client #8 was admitted on November 12, 2025 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than November 17, 2025; however, it was not completed until January 21, 2026.
Client #10 was admitted on September 30, 2025 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than October 5, 2025; however, it was not completed until October 31, 2025.
Client #11 was admitted on February 17, 2025 and discharged on June 13, 2025. The comprehensive treatment plan was due no later than February 22, 2025; however, there was no documentation one was completed.
Client #12 was admitted on January 31, 2025 and discharged on May 2, 2025. The comprehensive treatment plan was due no later than February 5, 2025; however, it was not completed until March 25, 2025.
This is a repeat citation from the January 15, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Who will correct the deficiency (job title, not name) - Chief Admin
2. How the deficiency will be corrected (staff meeting, training, etc.) Chief Admin had a staff training on 2/2/2026 to review all documentation expectations specifcally the comprehensive treatment plans.
3. When will they be corrected (corrective action date) Staff were asked to go in and get all there current treatment plans up to date by end of business on 2/4/2026.
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc) Chief Admin will conduct chart aduits on all charts moving foward.
Back to Survey Selection Back to Deficiency Listing
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of outpatient client records, the facility failed to document a discharge summary within guidelines established by the facility's policy and procedures manual in two out of four applicable records reviewed. The facility's policy and procedures manual states the that discharge summary must be completed 7 days following discharge.
Client #11 was admitted on February 17, 2025 and discharged on June 13, 2025. The discharge summary was due by June 20, 2025; however, it was not completed until July 10, 2025.
Client #12 was admitted on January 31, 2025 and discharged on May 2, 2025. The discharge summary was due by May 9, 2025; however, it was not completed until July 11, 2025.
This is a repeat citation from the January 15, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Who will correct the deficiency (job title, not name) - Chief Admin
2. How the deficiency will be corrected (staff meeting, training, etc.) Chief Admin had a staff training on 2/2/2026 to review all documentation expectations specifcally the follow-up calls.
3. When will they be corrected (corrective action date) Staff were asked to go into the discharge clients and make sure that any clients who have discharged this year there was a follow up note completed within 7 days. This needed to be completed by end of business 2/4/2026.
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc) Chief Admin will conduct chart aduits on all charts moving foward.
Back to Survey Selection Back to Deficiency Listing
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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 outpatient client records, the facility failed to document follow-up information within guidelines established by the facility's policy and procedures manual in four out of five applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed 7 days following discharge.
Client #11 was admitted on February 17, 2025 and discharged on June 13, 2025. The client was due to have a follow up by June 20, 2025; however, one was not documented until December 02, 2025.
Client #12 was admitted on January 31, 2025 and discharged on May 02, 2025. The client record did not contain any documentation of a follow up.
Client #13 was admitted on May 30, 2025 and discharged on July 18, 2025. The client was due to have a follow up by July 25, 2025; however, one was not documented until December 01, 2025.
Client #14 was admitted on August 06, 2025 and discharged on November 06, 2025. The client was due to have to a follow up by November 13, 2025; however, one was not documented until December 02, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Who will correct the deficiency (job title, not name) - Chief Admin
2. How the deficiency will be corrected (staff meeting, training, etc.) Chief Admin had a staff training on 2/2/2026 to review all documentation expectations specifcally the follow-up calls.
3. When will they be corrected (corrective action date) Staff were asked to go into the discharge clients and make sure that any clients who have discharged this year there was a follow up note completed within 7 days. This needed to be completed by end of business 2/4/2026.
4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc) Chief Admin will conduct chart audits on all charts moving forward.
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