INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 26, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Three Rivers Youth 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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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 one of fourteen records.
Client #1 was admitted to outpatient on September 25, 2024 and was still active at the time of the inspection. There was documentation of information released to a government agency on February 11, 2025, but there was no documentation of a consent in the record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
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.
Three Rivers Youth (TRY) understand the importance of confidentiality and will adhere accordingly as it relates to obtaining informed and voluntary consent from clients for disclosure of information. TRY has set policies and procedures that adhere to Confidentiality 709.28-federal, state and local laws and entities. All TRY staff are expectation to follow the procedure set forth in the confidential policies and procedures related to 709.28.
The Facility Director will reiterate the confidentiality policy and procedures with all staff during weekly supervision by 5/2/25. Also, The Facility Director will provide a refresher training to staff related to confidentiality by 5/2/25. The Treatment staff will attend the DDAP Confidentiality on-demand again as a point of reference and information by 5/30/25. The Director and/or Quality Assurance Team will conduct files reviews more closely on a monthly basis to ensure confidentially is followed by staff. The program staff will obtain proper consent prior to disclosure and follow policies, procedures and best practices as it relates to client confidentiality. On 3/31/25, Client #1 as referenced in the review has proper consent of information from government agency for future disclosures as per consent documentation.
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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of administrative information and client records, the facility failed to utilize a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the projects performance in relationship to its stated goals and objectives.
The facility is currently utilizing hybrid paper records and an electronic health record system. The facility did not provide the Department with access to the electronic health record system. The facility printed all documentation from the electronic system after client records were chosen to review. This process took several hours before the records were provided to the Department.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
§ 709.31. Data collection system. (a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
Three Rivers Youth (TRY)currently utilize a hybrid system to offset ongoing technical assistance needed to keep new and existing staff efficient and effective in system navigation and usage. TRY will limit the hybrid model and use the electronic health record system (Insync) fully on July 1, 2025. During the transition to fully utilize Insync, TRY will be timelier with client record reviews and retrieval of data needed to measure project performance in stated goals and objectives.
The Facility Director will provide ongoing support to staff during this transition from hybrid to Insync through weekly supervisions by 6/30/25. The staff will take refresher trainings through the Insync University by 6/30/25. All client files will be uploaded to Insync by staff and quality assurance team by 6/30/25. |
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 applicable client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client in five of five records.
Client #1 was admitted to outpatient on September 25, 2024 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed on September 27, 2024, however there was no documentation in the record indicating the plan was developed with the client.
Client #3 was admitted to outpatient on July 5, 2024 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed on July 22, 2024, however there was no documentation in the record indicating the plan was developed with the client.
Client #5 was admitted to outpatient on July 19, 2024 and was discharged on October 22, 2024. The comprehensive treatment and rehabilitation plan was developed on July 8, 2024, prior to admission to outpatient. There was no documentation in the record indicating the plan was developed with the client.
Client #6 was admitted to outpatient on December 23, 2024 and was discharged on March 12, 2025. The comprehensive treatment and rehabilitation plan was developed on December 27, 2024, however there was no documentation in the record indicating the plan was developed with the client.
Client #7 was admitted to outpatient on January 21, 2025 and was discharged on March 14, 2025. The comprehensive treatment and rehabilitation plan was developed on January 21, 2025, however there was no documentation in the record indicating the plan was developed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Three River Youth have polices and procedures related to treatment planning process with clients. Clients must be involved in their treatment plan as it is individualized and based their needs and strengths. Client must sign their treatment plans to ensure their collaborative involvement and development.
The Facility Director will review treatment plan process with staff during weekly supervision by 5/1/25. The Facility Director will provide a refresher training on treatment plans to all staff on 4/23/25. TRY staff will complete comprehensive treatment plans with clients and document accordingly with client signature and progress notes.
The quality assurance team will provide random and monthly client file reviews to monitor that treatment plans are developed with clients. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include short and long-term goals in four of five records.
Client #1 was admitted to outpatient on September 25, 2024 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on September 27, 2024, however, there was no documentation of short and long-term goals.
Client #3 was admitted to outpatient on July 5, 2024 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on July 22, 2024, however, there was no documentation of short and long-term goals.
Client #6 was admitted to outpatient on December 23, 2024 and was discharged on March 12, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on December 27, 2024, however, there was no documentation of short and long-term goals.
Client #7 was admitted to outpatient on January 21, 2025 and was discharged on March 14, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on January 21, 2025, however, there was no documentation of short and long-term goals.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92(a)(1) 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: (1) Short and long-term goals for treatment as formulated by both staff and client.
Three River Youth have polices and procedures related to treatment planning process with clients based on 709.92. Based on polies clients must be involved in their treatment plan as it is individualized and based their needs and strengths. The treatment plan must include short and long terms goals as formulated by both staff and client. Client must sign their treatment plans to ensure their collaborative involvement and development.
The Facility Director will review treatment plan process with staff during weekly supervision by 5/1/25. The Facility Director will provide a refresher training on treatment plans to all staff on 4/23/25. TRY staff will complete comprehensive treatment plans with clients to include short term and long term goals. The staff will document accordingly with client signature and progress notes.
The quality assurance team will provide random and monthly client file reviews to monitor that treatment plans are developed with clients and include short and long term goals. |
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 applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services in four of five records.
Client #1 was admitted to outpatient on September 25, 2024 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on September 27, 2024, however, there was no documentation of type and frequency of services.
Client #3 was admitted to outpatient on July 5, 2024 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on July 22, 2024, however, there was no documentation of type and frequency of services.
Client #6 was admitted to outpatient on December 23, 2024 and was discharged on March 12, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on December 27, 2024, however, there was no documentation of type and frequency of services.
Client #7 was admitted to outpatient on January 21, 2025 and was discharged on March 14, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on January 21, 2025, however, there was no documentation of type and frequency of services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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.
Three River Youth adhered to and have written polices and procedures in place related to treatment planning process with clients based on 709.92 (a) (2). Based the above mentioned polices, clients must be involved in their treatment plan as it is individualized and based their needs and strengths. The treatment plan must include the type and frequency of treatment and rehabilitation services formulated by both staff and client. Client must sign their treatment plans to ensure their collaborative involvement and development.
The Facility Director will review treatment plan process with staff during weekly supervision by 5/1/25. The Facility Director will provide a refresher training on treatment plans to all staff on 4/23/25. TRY staff will complete comprehensive treatment plans with clients to include the type and frequency of treatment and rehabilitation services during the treatment planning process. The staff will document accordingly with client signature and progress notes.
The quality assurance team will provide random and monthly client file reviews to monitor that treatment plans are developed with clients and include the type and frequency of treatment and rehabilitation services. |
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 applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the proposed type of support service in five of five records.
Client #1 was admitted to outpatient on September 25, 2024 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on September 27, 2024, however, there was no documentation of support services.
Client #3 was admitted to outpatient on July 5, 2024 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on July 22, 2024, however, there was no documentation of support services.
Client #5 was admitted to outpatient on July 19, 2024 and was discharged on October 22, 2024. A comprehensive treatment and rehabilitation plan was developed with the client on July 8, 2024, prior to admission to outpatient. There was no documentation of support services.
Client #6 was admitted to outpatient on December 23, 2024 and was discharged on March 12, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on December 27, 2024, however, there was no documentation of support services.
Client #7 was admitted to outpatient on January 21, 2025 and was discharged on March 14, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on January 21, 2025, however, there was no documentation of support services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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
Three River Youth adheres to and have written polices and procedures in place related to treatment planning process with clients based on 709.92 (a). Based the above mentioned polices, clients must be involved in their treatment plan as it is individualized and based their needs and strengths. The treatment plan must include but not limited to the type of support service as formulated by both staff and client. Client must sign their treatment plans to ensure their collaborative involvement and development.
The Facility Director will review treatment plan process with staff during weekly supervision by 5/1/25. The Facility Director will provide a refresher training on treatment plans with added attention to support services to all staff on 4/23/25. TRY staff will complete comprehensive treatment plans with clients to include type of support service during the treatment planning process. The staff will document accordingly with client signature and progress notes.
The quality assurance team will provide random and monthly client file reviews to monitor that treatment plans are developed with clients and include type of support service. |
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 client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in five of five applicable records.
Client #1 was admitted to outpatient on September 25, 2024 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on September 27, 2024. A treatment and rehabilitation plan update was due no later than November 27, 2024, but was not completed until December 13, 2024.
A treatment and rehabilitation plan update was completed on December 13, 2024. A treatment and rehabilitation plan update was due no later than February 13, 2025, but was not completed until March 13, 2025.
Client #3 was admitted to outpatient on July 5, 2024 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on July 22, 2024. A treatment and rehabilitation plan update was due no later than September 22, 2024, but was not completed until September 23, 2024.
A treatment and rehabilitation plan update was completed on September 23, 2024. A treatment and rehabilitation plan update was due no later than November 23, 2024, but was not completed at the time of the inspection.
Client #4 was admitted to outpatient on July 1, 2024 and was discharged on January 17, 2025. A treatment and rehabilitation plan update was completed on August 27, 2024. A treatment and rehabilitation plan update was due no later than October 27, 2024, but was not completed until December 25, 2024.
Client #5 was admitted to outpatient on July 19, 2024 and was discharged on October 22, 2024. A treatment and rehabilitation plan was developed on July 8, 2024, prior to admission to outpatient. A treatment and rehabilitation plan update was due no later than September 8, 2024, but was not completed until prior to discharge.
Client #6 was admitted to outpatient on December 23, 2024 and was discharged on March 12, 2025. A treatment and rehabilitation plan was developed on December 27, 2024. A treatment and rehabilitation plan update was due no later than February 27, 2025, but was not completed until prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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
Three River Youth adheres to and have written polices and procedures in place related to treatment planning process with clients based on 709.92 (b). Based the above mentioned polices, clients must be involved in their treatment plan as it is individualized and based their needs, strengths and be time sensitive. The treatment plan must be reviewed and updated at least every 60 days as formulated by both staff and client. Client must sign their treatment plan update to ensure their collaborative involvement in the development within 60 days.
The Facility Director will review treatment plan process with staff during weekly supervision by 5/1/25. The Facility Director will provide a refresher training on treatment plans with added attention to time sensitivity on updates to track progress within the 60 day period with all staff on 4/23/25. TRY staff will complete comprehensive treatment plans with clients to include target date of 60 days for updates. The staff will document accordingly with client signature and progress notes.
The quality assurance team will provide random and monthly client file reviews to monitor that treatment plans are developed with clients and include an update within 60 days. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on applicable client records reviewed, the facility failed to provide a complete client record to include progress notes that are reflective of the clients record of service in three of six records.
Client #1 was admitted to outpatient on September 25, 2024 and was still active at the time of the inspection. A review of the record of service indicates a group session occurred on November 20, 2024, however, the progress note for that date was blank.
Client #5 was admitted to outpatient on July 19, 2024 and was discharged on October 22, 2024. A review of the record of service indicates a group session occurred on August 19, 2024, however, the progress note for that date was blank.
Client #6 was admitted to outpatient on December 23, 2024 and was discharged on March 12, 2025. A review of the record of service indicates a group sessions occurred on January 7, 2025 and January 9, 2025, however, the progress notes for those dates were blank.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.93(a)(5) 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: (5) Progress notes.
Three Rivers Youth adhere to and have written policies and procedures in place related to client records and progress notes with clients based on 709.93(a)(5) ). Based the above mentioned polices, a complete client record must include progress notes that are reflective of the clients record of service.
The Facility Director will review client records related to progress notes with staff during weekly supervision by 5/1/25. The Facility Director will provide a refresher training on 4/23/25 to all staff on progress notes with added attention to ensuring notes are completed accurately and timely within 24 hours of services. TRY staff will complete progress notes on time and accurately using the Insync system properly to avoid blank notes.
The quality assurance team will provide random and monthly client file reviews to monitor progress notes are completed effectively and within 24 hours of service delivery. |
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 client records reviewed, the facility failed to provide case consultations in four of four applicable records.
The facility policy and procedure indicates a case consultation is to occur every ninety days.
Client #1 was admitted to outpatient on September 25, 2024 and was still active at the time of the inspection. case consultation was due to occur no later than December 25, 2024, however this was not completed until March 24, 2025.
Client #3 was admitted to outpatient on July 5, 2024 and was still active at the time of the inspection. A case consultation was due to occur no later than October 5, 2024, however this was not completed until March 24, 2025.
Client #4 was admitted to outpatient on July 1, 2024 and was discharged on January 17, 2025. A case consultation was due to occur no later than October 1, 2024, however this was not completed prior to discharge.
Client #5 was admitted to outpatient on July 19, 2024 and was discharged on October 22, 2024. A case consultation was due to occur no later than October 19, 2024, however this was not completed prior to discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
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.
Three Rivers Youth adhere to and have written policies and procedures in place related to client records and case consultations with clients based on 709.93. Based the above mentioned polices, a complete client record must include case consultations
The Facility Director will review client records related to progress notes with staff during weekly supervision by 5/1/25. The Facility Director will provide a refresher training on 4/23/25 to all staff on case consultation and documentation of services. TRY staff will complete case consultation every 90 days and document accordingly.
The quality assurance team will provide random and monthly client file reviews to monitor case consultations are completed within 90 days and documented.
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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 applicable client records reviewed, the facility failed to provide follow-up contact in three of three records.
The policy and procedure indicates follow-up contact must be made at thirty, sixty, and ninety days after discharge.
Client #2 was admitted to outpatient on September 13, 2024 and was discharged on September 27, 2024. There was no documentation of follow-up contact being completed in the record.
Client #4 was admitted to outpatient on July 1, 2024 and was discharged on January 17, 2025. There was no documentation of follow-up contact being completed in the record.
Client #5 was admitted to outpatient on July 19, 2024 and was discharged on October 22, 2024. There was no documentation of follow-up contact being completed in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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.
Three Rivers Youth adhere to and have written policies and procedures in place related to client records and follow-up information with clients based on 709.93 (a) (11). Based the above mentioned polices, a complete client record must include client follow-up within 30, 60 and 90 days after discharge. Three Rivers Youth will review its polices by 6/30/25 to make adjustments to follow-ups timeframe to include up to 90 days.
The Facility Director will review client records related to client follow-up after discharge with staff during weekly supervision by 5/1/25. The Facility Director will provide a refresher training on 4/23/25 to all staff on follow-up after discharge and documentation of services. TRY staff will complete client follow-up after discharge within 30, 60 and 90 days and document accordingly.
The quality assurance team will provide random and monthly client file reviews to monitor case client follow-up are completed within 30, 60 and 90 days after discharge and documented. |