INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 17-19, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pinnacle Treatment Centers PA-V, 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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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative information, the facility failed to document an annual evaluation of the overall training plan. The facility ' s policy and procedures state the facility training year is based on calendar year.An annual evaluation of the overall training plan was not documented for the January - December 2024 training year. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director will complete training on writing the annual evaluation of the overall training plan based on the calendar year.
1. Executive Director will complete training on the annual evaluation of the overall training plan provided by Pinnacle Treatment Centers in coordination with PA Quality Director by 11/30/25 in preparation for writing the evaluation for the 2025 calendar year. 2. Executive director will complete the annual evaluation by January 15, 2026, for the 2025 calendar year and write the overall training plan for 2026 by January 15, 2026. 3. Annual monitoring of evaluation training plans will be completed by executive director at the end of quarter |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure the FTE counselor caseload in outpatient programs did not exceed 35 active clients in two of seven caseloads. The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE. Employee #5 was hired as a counselor on April 28, 2025. The employee's ratio calculation was as follows: 40/40= 1(FTE); 41/1 = 41, which equals a client/counselor FTE ratio of 41:1. Employee #6 was hired as a counselor on April 29, 2025. The employee's ratio calculation was as follows: 5/40=0.125(FTE); 5/0.125=40, which equals a client/counselor FTE ratio of 40:1.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive director and clinical supervisor will review DDAP regulation and licensing alert related to caseload sizes. Executive Director will consult with PA Quality Director to ensure that counselor caseloads are in compliance with DDAP regulations.1. Executive director will review with clinical supervisor the licensing alert related caseload sizes in supervision by 10/15/25. 2. Clinical supervisor will review caseload sizes for each counselor to ensure that the ratio is in compliance by 10/31/25 and reassign any patients as appropriate. 3. Executive director and clinical supervisor will review caseloads and required counseling hours on a monthly basis to ensure that the ratio remains in compliance when new patients are being admitted to the program or if required counseling changes for individual patients. 4. Clinical supervisor will also review with counselors the DDAP standards and regulations to ensure all staff aware of the ration in the clinical meeting by 11/3/25. 5. Executive director and clinical supervisor will ensure that any telehealth counselor who is assisting with patient care/ counseling sessions does not exceed the ratio of patients for the time assigned to facility per week. |
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 consent to release information form prior to releasing information in two of six applicable records. Client #4 was admitted on January 21, 2025, and discharged on July 11, 2025. There was no consent to release information form for the funding source in client #4 ' s record. Client #5 was admitted on April 1, 2025, and discharged on August 15, 2025. There was no consent to release information form for the funding source in client #5 ' s record.Facility staff confirmed billing had occurred.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director will review with office manager, clinical supervisor, and counselors the DDAP standard for release of information for funding source (at intake and anytime there is a change in funding source at staff meeting on 10/9/25.
1. Executive director will review with the office manager, receptionist, clinical supervisor, and counselors about the need to obtain releases of information for all patients at intake and when insurance providers change for all patients for billing purposes in staff meeting by 10/9/25. 2. Clinical supervisor will complete chart audits for all intakes within 24 hours of admission to ensure that there is a release completed in accordance with DDAP standards for each patient. 3. Office manager and receptionist will alert counselors of any changes in funding sources for patients at the time a new insurance card or authorization is received in order to obtain a release. 4. Counselors or office manager will stop the patient to obtain the required, updated release upon report of funding changes. 5. Executive director and clinical supervisor will check the chart to confirm that a new release has been entered within 24 hours of the reported change. 6. If any deficits are found, review of the DDAP standard will be reviewed with staff in individual and group supervisions and all staff meetings. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of client records, the facility failed to ensure a verbal order for medication was authenticated in writing, by a physician or other medical professional authorized by State and Federal law to prescribe medication, within 3 business days from the time the order was given, in three of six applicable records. Client #3 was admitted on March 29, 2023, and was still active at the time of the inspection. Verbal orders were given on February 14, 2025, and February 18, 2025, were not signed by the physician. Client #4 was admitted on January 21, 2025, and discharged on July 11, 2025. Verbal orders given on February 25, 2025, March 11, 2025, and March 18, 2025, were not signed by the physician. A verbal order given on April 29, 2025, was due to be signed by the physician no later than May 1, 2025; however, it was signed on May 16, 2025. A verbal order given on May 6, 2025, was due to be signed by the physician no later than May 9, 2025; however, it was signed on May 16, 2025. A verbal order given on June 3, 2025, was due to be signed by the physician no later than June 6, 2025; however, it was signed on June 4, 2025.Client #6 was admitted on January 15, 2025, and discharged on September 8, 2025. Verbal orders given on February 12, 2025, February 19, 2025, and February 24, 2025, were not signed by the physician. A verbal order given on July 3, 2025, was due to be signed by the physician no later than July 8, 2025; however, it was signed August 8, 2025.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Training & Education Efforts
1. Review of DDAP standard for verbal orders and required signatures with nurses, medical director, staff physician, nurse practitioner to be completed by 10/17/25. 2. Medical staff will continue to attend bi-weekly provider meetings. 3. Nurses will attend monthly nursing professional development and training meetings.
1. Executive director will review DDAP standard for verbal orders and signatures in nursing supervision by and leadership meeting by 10/17/25. 2. Staff physician(s) will review digital signing daily and ensure that all orders are signed within 3 business days after the order is given. 3. Executive director will check digital signing on a daily basis to ensure that all orders are signed in compliance with DDAP standard. 4. Nurse Practitioner will complete 5 medical chart audits per month. 5. QI director will review medical charts 1 per site monthly. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of medical staff coverage, the facility failed to provide narcotic treatment physician services for at least 1 hour per week onsite for every ten patients for one of eighteen weeks.Physician service hours were reviewed from April 27-August 30, 2025. For the week of June 29, 2025, through July 5, 2025, the facility's census was 281 patients. The facility was required to provide 28.1 hours of onsite physician services; however, the physician hours totaled 7.52 hours.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Training & Education Efforts:
1. Executive director reviewed DDAP standard for physician services with medical director and nurse practitioner on 10/7/25. 2. Executive director will review schedule with regional director to address any medical provider coverage needs during bi-weekly meetings.
Action Steps:
1. Executive director will review weekly physician schedule to ensure that there are adequate physician service in accordance with DDAP standards related to current patient census. 2. Staff physicians will inform executive director of any planned or unplanned time off to ensure that there is adequate physician services each week. 3. Executive director will consult with regional director and regional medical director if additional physician coverage is required in any specific week. 4. Executive director with hold a weekly medical check-in to make any coverage changes to ensure compliance with DDAP standards. 4. Documentation will be provided for any coverage utilized by telehealth. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of medical staff coverage, the facility failed to ensure one-third of all required narcotic treatment physician time was provided by a narcotic treatment physician for three of eighteen weeks.Physician service hours were reviewed from April 27-August 30, 2025. During the week of June 15, 2025, through June 21, 2025, the facility's census was 283 patients. The facility was required to provide 28.3 hours of onsite physician services. One-third of 28.1 is 9.4. The narcotic treatment physician hours should have been 9.4 hours; however, the physician hours totaled 8 hours.During the week of June 22, 2025, through June 28, 2025, the facility's census was 281 patients. The facility was required to provide 28.1 hours of onsite physician services. One-third of 28.1 is 9.3. The narcotic treatment physician hours should have been 9.3 hours; however, the physician hours totaled 6 hours.During the week of June 29, 2025, through July 5, 2025, the facility's census was 281 patients. The facility was required to provide 28.1 hours of onsite physician services. One-third of 28.1 is 9.3. The narcotic treatment physician hours should have been 9.3 hours; however, the physician hours totaled 7.52 hours.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Training & Education Efforts:
1. Executive director reviewed DDAP standard for physician services with medical director and nurse practitioner on 10/7/25. 2. Executive director will review schedule with regional director to address any medical provider coverage needs during bi-weekly meetings.
Action Steps:
1. Executive director will review weekly schedules for physicians and nurse practitioner on weekly basis to ensure that the physician hours total 1/3 of the required hours per patient census. 2. Physicians and nurse practitioner will inform executive director of any planned or unplanned hours of service that deviate from the scheduled hours in advance so executive director can ensure that there are adequate hours of physician services to remain in compliance with DDAP standards. 3. Executive Director will consult with regional director and regional medical director if additional coverage is needed to ensure that physician services are in compliance. 4. Executive director with hold a weekly medical check-in to make any coverage changes to ensure compliance with DDAP standards. 5. Documentation will be provided for any telehealth hours utilized. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient in one of one applicable record. Patient #5 was admitted on April 1, 2025, and discharged on August 15, 2025. A fax was sent to the receiving facility and did not include medical and psychosocial summaries.This finding was reviewed with the facility staff during the licensing process. This is a repeat citation from the September 10-12, 2024, licensing inspection.
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Plan of Correction
Training & Education Efforts:
1. Executive director will review with clinical supervisor by 10/17/25. 2. Clinical supervisor will present to clinical staff in weekly meeting on 10/20/25 and then in all staff meeting on 10/23/25.
Action Steps:
1. Executive director and clinical supervisor will review the DDAP standard for patient transfers in individual supervision by 10/17/25. 2. Executive director and clinical supervisor will review the existing "transfer out" patient checklist to ensure that it has all required items by 10/17/25. 3. Clinical supervisor will review the approved transfer out checklist and procedure with clinical staff in group supervision on 10/20/25. 4. Executive director will present the approved checklist to clinical staff during all staff meeting on 10/23/25. 5. Clinical supervisor will confirm that all documents are printed, faxed, and scanned into the patient chart within 7 days of the transfer notification. 6. Clinical supervisor will complete chart audits for all patients who transfer out of the facility within 10 days of the transfer date. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in two of two applicable records. Patient #1 was admitted on December 24, 2024, and was still active at the time of the inspection. Patient #4 was admitted on January 21, 2025, and discharged on July 11, 2025.These findings were reviewed with the facility staff during the licensing process.This is a repeat citation from the September 10-12, 2024, licensing inspection.
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Plan of Correction
Training & Education Efforts:
1. Executive director and clinical supervisor will review DDAP standard by 10/17/25 and review existing checklist to ensure it meets standard. 2. Clinical supervisor will review approved checklist with clinical staff in group supervision on 10/20/25. Executive director will review with nursing staff on by 10/20/25. 4. Executive director will review at all staff meeting on 10/23/25.
Action Steps:
1. Executive director and clinical supervisor will review the DDAP standard for patient transfers in to the facility in individual supervision by 10/17/25. 2. Executive director and clinical supervisor will review the existing "transfer in" patient checklist to ensure that it has all required items by 10/17/25. 3. Clinical supervisor will review the approved transfer in checklist and procedure with clinical staff in group supervision on 10/20/25. 4. Executive director will present the approved checklist to clinical staff during all staff meeting on 10/23/25. 5. Nursing staff ensure that there is written documentation of the admission of the patient and date of initial dose given to patient in the patient chart in compliance with DDAP standards. 6. Executive director and clinical supervisor will audit chart to ensure that documentation in writing was sent and acknowledged in the patient chart for all transfer patients within 7 days of the transfer in including the fax confirmation page and/ or email. |
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
Based on a review of patient records, the facility failed to include the results of an annual clinical evaluation in one of two applicable records.Patient #3 was admitted on March 29, 2023, and was still active at the time of the inspection.The annual clinical evaluation was due no later than March 29, 2025; however, it was documented on April 14, 2025.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Training & Education Efforts:
1. Executive director will meet with clinical supervisor to review deficiency by 10/17/25. 2. Clinical supervisor will provide training to clinical staff and implement tracking system using power tools and spreadsheet by 10/27/25.
Action Steps:
1. Executive director will ensure that that the plan of correction is implemented by the corrective action date and the clinical supervisor will assist in monitoring of the completion of annual clinical reviews to ensure timely completion per DDAP standards. 2. Clinical supervisor will provide training to clinical staff around the DDAP standard of the information required and the time frame that the review must be completed in group supervision on 10/27/25. 3. Clinical supervisor will track when annual clinical reviews are due and confirm that they are completed by the due date. 4. Clinical supervisor will complete 5 per month to ensure clinical annual reviews are completed in compliance with DDAP regulation. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in six of six applicable records.Client #1 was admitted on December 24, 2024, and was still active at the time of the inspection. An initial treatment plan was developed on January 24, 2025, and an update was due no later than March 24, 2025; however, it was completed on April 2, 2025.Client #2 was admitted on April 24, 2024, and was still active at the time of the inspection. A treatment plan update was completed on November 12, 2024, and the next update was due no later than January 12, 2025; however, it was completed on January 15, 2025. Another treatment plan update was completed on May 8, 2025, and the next update was due no later than July 8, 2025; however, it was completed on July 10, 2025. The next update was due no later than September 10, 2025; however, there were no further updates in client #2 ' s record. Client #3 was admitted on March 29, 2023, and was still active at the time of the inspection. A treatment plan update was completed on October 30, 2024, and the next update was due no later than December 30, 2024; however, it was completed on February 4, 2025.Client #4 was admitted on January 21, 2025, and discharged on July 11, 2025. A treatment plan update was completed on March 21, 2025, and the next update was due no later than May 21, 2025; however, there were no further updates in client #4 ' s record.Client #5 was admitted on April 1, 2025, and discharged on August 15, 2025. A treatment plan update was completed on April 21, 2025, and the next update was due no later than June 21, 2025; however, it was completed on June 23, 2025.Client #6 was admitted on January 15, 2025, and discharged on September 8, 2025. A treatment plan update was completed on June 6, 2025, and the next update was due no later than August 6, 2025; however, it was completed on August 8, 2025.These findings were reviewed with the facility staff during the licensing process. This is a repeat citation from the November 15, 2023, and September 10-12, 2024, licensing inspections.
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Plan of Correction
Training & Education Efforts:
1. Clinical supervisor has provided 2 weeks of treatment plan related review/ training on 9/22/25 and 10/6/25. 2. Clinical supervisor will provide an additional training on 10/20/25 to review again the expectation that treatment plans must be completed and signed within the 60 days per DDAP and state regulations. 3. Executive director will review DDAP regulation with all staff at meeting on 10/23/25
Action Steps:
Pinnacle Aliquippa clinical supervisor will review completing/ updating treatment plans in a timely manner at an upcoming clinical meeting on 10/20/25. Executive Director will again at all staff meeting on 10/23/25 to ensure that all staff members understand the necessity of the treatment plans being completed within each 60-day time frame. Ongoing individual and group supervisions will occur to address progress in completion of treatment plan updates to meet DDAP standards and regulations and that POC is being followed.
1. Executive Director will ensure plan of correction are implemented by the corrective action date and clinical supervisor will assist in monitoring the process. 2. Clinical supervisor will address treatment plan completion at clinical meeting on 10/20/25. 3. Executive director will again address the completion of treatment plans on all staff meeting on 10/23/25. 4. Monthly individual supervision meetings with each counselor will address completion of treatment plans (scheduling sessions and obtaining signatures). 5. Individual patient charts will be reviewed during supervisions as well as weekly reports for tracking purposes. 6. Executive Director will review patient chart audits (no less than 3/ quarter) and review findings with clinical supervisor and clinical supervisor will re-address with staff monthly if needed. 7. Executive director and clinical supervisor will address any non-compliance in this area and discuss any additional training or focus that is required to improve the process. 8. QI director will complete 1 comprehensive chart review per month to identify training needs. |
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 the clients received counseling services according to their individual treatment plan in three of six applicable records.Client #1 was admitted on December 24, 2024, and was still active at the time of the inspection. Type and frequency on treatment plans indicate three individual counseling sessions per month. Client #1 ' s record had one session documented in January, February, and March 2025, zero sessions documented in April 2025, one session documented in May and June 2025, zero sessions documented in July 2025, and two sessions documented in August 2025.Client #3 was admitted on March 29, 2023, and was still active at the time of the inspection.Type and frequency on treatment plans indicate one individual counseling session per month. Client #3 ' s record had zero sessions documented in December 2024, January 2025, and March 2025.Client #6 was admitted on January 15, 2025, and discharged on September 8, 2025. Type and frequency on treatment plans indicate two individual counseling sessions per month. Client #6 ' s record had one session documented in March 2025, and zero sessions documented in April 2025. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Training & Education Efforts:
1. Executive Director will meet with clinical supervisor to review DDAP regulation regarding required counseling according the treatment plan as well as documentation of scheduled and missed counseling sessions by 10/24/25. 2. Clinical supervisor will review required counseling hours with counselors in group clinical meeting on 10/27/25. 3. Executive director will review in all staff meeting the DDAP regulation related to counseling time in all staff meeting on 10/30/25.
Action Steps:
1. Executive director will review counseling requirements and tracking spreadsheet with clinical supervisor by 10/24/25. 2. Clinical supervisor will review required counseling for all patients according to their treatment plans including documentation of scheduled and missed sessions with counselors in clinical meeting on 10/24/25. 3. Executive director will review again in all staff meeting on 10/30/25. 4. Clinical supervisor will hold monthly individual supervisions and address completion of counseling services according to the treatment plan as well as completion of the DAP note with signature. 5. Individual patient charts will be reviewed during supervision sessions. 6 Executive director will review patient chart audits (no less than 3 per quarter) and review findings with clinical supervisor. 7. Clinical supervisor will re-address with staff through monthly requirement reports. 8. Executive director and clinical supervisor will address any issues of non-compliance in this area and discuss any additional training or focus that is required to improve the process. |
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 document case consultations in four of six applicable records. The facility's policy and procedures state case consults will be completed quarterly during the first year of treatment and annually thereafter. Client #1 was admitted on December 24, 2024, and was still active at the time of the inspection. A quarterly case consult was due no later than March 24, 2025; however, it was completed June 17, 2025. Client #4 was admitted on January 21, 2025, and discharged on July 11, 2025. A quarterly case consult was due no later than April 21, 2025; however, it was completed July 11, 2025.Client #5 was admitted on April 1, 2025, and discharged on August 15, 2025. There were no case consults in client #5 ' s record. Client #6 was admitted on January 15, 2025, and discharged on September 8, 2025. A quarterly case consult was due no later than April 15, 2025; however, it was completed July 1, 2025.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Training & Education Efforts:
1. Executive director will review DDAP and state regulation with clinical supervisor by 10/24/25. 2. Clinical supervisor will review in clinical meeting with counselors the DDAP/ state regulation related to quarterly clinical reviews in the first year and then annually after the first year by 10/27/25. 3. QI director will schedule training for staff to review important reports in Methasoft by November 14, 2025.
Action Steps:
1. Executive director will meet with clinical supervisor to review the DDAP/ state regulation related to quarterly case consultations by 10/24/25. 2. Clinical supervisor will review standard in group clinical meeting on 10/27/25. 3. Clinical supervisor will monitor quarterly case consultations for all patients and complete chart inspections during individual monthly supervisions to ensure that the quarterly clinical case consultations are being completed on time. 4. Clinical supervisor will continue to monitor quarterly case consultations by spot checking 5 charts (at least monthly) to ensure patients in treatment under a year in treatment are being completed. 5. QI will provide training on important reports to be pulled from methasoft including case consultations. |
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 document follow-up information in three of five applicable records.The facility's policy and procedures state follow up contact is to be completed for all discharges at 7, 30, and 60 days.Client #6 was admitted on January 15, 2025, and discharged on September 8, 2025. There was no follow-up in the record. Client #7 was admitted on May 1, 2019, and discharged on August 20, 2025. The 7-day follow up was due no later than August 27, 2025; however, it was completed September 4, 2025.Client #8 was admitted on July 6, 2020, and discharged on May 1, 2025. There was no 7-day follow-up in the record. The 30-day follow-up was due no later than June 1, 2025; however, it was completed on June 9, 2025. The 60-day follow-up was due no later July 1, 2025; however, it was completed on July 29, 2025.These findings were reviewed with the facility staff during the licensing process. This is a repeat citation from the November 15, 2023, and September 10-12, 2024, licensing inspections.
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Plan of Correction
Training & Education Efforts:
1. Executive Director will review DDAP regulation for contacting discharged patients with clinical supervisor by 10/17/25. 2. Executive director and clinical supervisor will review spreadsheet used to track discharge follow ups by 10/17/25.
Action Steps:
1. Executive Director will review DDAP regulation for contacting discharged patients with clinical supervisor by 10/17/25. 2. Executive director and clinical supervisor will review spreadsheet used to track discharge follow ups by 10/17/25. 3. Clinical supervisor will manage tracking of discharge calls to patient at 7, 30, and 60 days. 4. Executive director will assist in tracking by meeting with clinical supervisor to assist in managing discharge calls on a monthly basis. 5. Clinical supervisor will complete chart audits for discharged patients to ensure discharge calls are completed in compliance with DDAP standards. |
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 treatment plan updates was submitted and approved by the Department for the November 15, 2023, and September 10-12, 2024, annual licensing inspections. Treatment plan updates were again found to be a deficiency in the September 17-19, 2025, licensing inspection.A plan of correction for follow-ups was submitted and approved by the Department for the November 15, 2023, and September 10-12, 2024, annual licensing inspections. Follow-ups were again found to be a deficiency in the September 17-19, 2025, licensing inspection.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Training & Education Efforts:
1. Executive Director and clinical supervisor reviewed the expectation and regulation for comprehensive treatment plans and the use of tracking tools (Power Tools, Tableau, Methasoft reports in monthly supervisions.
2. Executive director and clinical supervisor will review chart audits related to treatment plan compliance in monthly supervisions.
3. Executive Director and clinical supervisor will review expectations and regulation for compliance for discharge follow ups in monthly supervisions.
4. Executive Director and clinical supervisor will review chart audits related to discharge follow ups for compliance in monthly supervisions.
Action Steps:
1. Executive director and clinical supervisor will continue to review regulations related to comprehensive treatment plans and education on timely completion of comprehensive treatment plans in clinical group and individual supervisions.
2. Executive director and clinical supervisor will review treatment plan compliance in scheduled events in Methasoft Power Tools and correct inaccurate dates as well as track compliance in Tableau weekly.
3. Clinical Supervisor will provided lists of past due, pending, and upcoming treatment plan updates to counseling staff to assist with tracking.
4. Clinical supervisor will double check for treatment plan compliance and review any barriers to meeting facility policy and procedure in individual counselor supervision then review with executive director to determine a corrective measure.
5. Clinical supervisor will manage excel spread sheet for discharges and executive director will assist in implementation of corrective action for tracking and completion of discharge follow up calls.
6. Due to this being an administrative corrective action, executive director will meet with assistant regional director weekly to review corrective measures and consultation for implementing plan of correction.
7. Executive director will meet with regional director bi-weekly for consultation and review of corrective measures and consultation for implementing the administrative plan of correction.
8. Executive director will meet with QI director monthly to review documentation and trends for training opportunities. |