INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 30, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gemini Recovery Center 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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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection July 30, 2025, the facility failed to not permit heaters that are not permanently mounted or installed.
There was an electric fire place that was not permanently mounted or installed in Facitliy Directors office.
These findings were reviewed with facility staff during licensing process.
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Plan of Correction
This operations director and owners will contact and hire necessary contracting to remove the heaters and determine and alternative heat source. The landlord and property manager will be notified about the need for an alternative solution by 11/1/2025 |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of staff records, the facility failed to instruct all staff in the use of the fire extinguishers upon staff employment in one out of one record reviewed.
Employee #1 was hired as facility director on June 25, 2025, and is current in that position. There was no documentation employee #1 received instruction in the use of the fire extinguisher upon employment.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 29, 2024 licensing inspection.
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Plan of Correction
Current staff and future staff will complete " Fire Safety and Safety Protocols" in Med Trainer/ Training compliance system on the first day of their hire and or by 11/1/2025 if existing hire. Director will oversee completion for compliance. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of administrative documents, the facility failed to conduct unannounced fire drills at least once a month.
The facility did not provide documentation of unannounced monthly fire drills for the months of August 2024 through June of 2025.
These findings were reviewed with facility staff during licensing process.
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Plan of Correction
This Director will utilize and implement a Frie Safety Drill Log. Fire Drills will be conducted by the Office Manager at minimum monthly and at random. Times will be logged as well as participation. A waiver will be requested to not sound the alarms. This will be done by 11/30/2025 |
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 a review of employee records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one out of one record reviewed.
Employee #1 was hired as facility director on June 25, 2025, and is current in that position. There was no documentation employee #1 received instruction in the use of the emergencies upon employment.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 29, 2024 licensing inspection.
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Plan of Correction
Current staff will be trained on " Emergency Preparedness and Safety Protocals" with in the Med Trainer compliance system by 11/1/2025. All new staff on day of hire will complete this training. Record will be kept and maintained in HR file. Director will oversee and sign off on New Hire Checklist for compliance. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on an administrative review the facility failed to maintain a written fire drill record including the date, item, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
Facility was unable to provide a fire drill log during the licensing inspection on July 30, 2025
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This Director will create and begin utilizing the necessary fire drill log. It will include and encompass the following and be administered at minimum monthly. These will be stored in a binder with the office manager who will conduct the fire drills. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on review of administrative documents the facility failed to have the project director prepare, annually update and sign a written manual delineating project policies and procedures.
The project director did not provide an annually signed manual at time of licensing inspection on July 30, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
This director in tandem with ownership will adopt and implement the current Policy and Procedure Manual. Updates will be provided on the Attestation forms. This will be reviewed and signed off on for additions/ edits and changes annually per director. This manual will be completed by 12/31/2025 |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in nine of nine client records reviewed.
Client #1 was admitted to the outpatient program on October 17, 2024, and was discharged on March 13,2025. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Addtionally it was documented on January 14, 2025 that a family member attended a family counsling session, however there was no documentation of an informed and voluntary consent from the client for the disclosure of information
Client #2 was admitted to the outpatient program on September 20, 2024, and was discharged on November 1,2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #3 was admitted to the outpatient program on January 30, 2025, and was discharged on March 3, 2025. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #4 was admitted to the outpatient program on November 25, 2024, and was discharged on June 6, 2025. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Addtionally it was documented on January 29, 2025 and Feburary 12, 2025 that a family member attended a family counsling session, however there was no documentation of an informed and voluntary consent from the client for the disclosure of information.
Client #5 was admitted to the outpatient program on January 7,2025, and was discharged on June 6, 2025. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #6 was admitted to the outpatient program on August 21,2024, and was discharged on September 10,2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #7 was admitted to the outpatient program on October 17,2024 , and was discharged on December 4,2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #8 was admitted to the partial hospitailization program on November 26,2024, and was discharged on December 3, 2024 A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #9 was admitted to the partial hospitailization program on September 3, 2024, and was discharged on October 3,2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The treatment team will be given a training on consents and releases. The EMR system will be updated to include the following necessary electronic consents: HIPAA and Confidentiality, Bill of Write/ Financial Agreements/ Release for PCP/ Release for Funder/ Release for Emergency Contact. Consent for Treatment. Notice of Privacy Practices. This training and review will occur before 11/1/2025 and before seeing active clients. Director of Operations will be orchestrating the trainers. Clinical Supervisor will be in charge of updating the EMR.
Clinical Supervisor will review charting and intake admission upon completion of the intake appointment to ensure compliance. CS will ensure all consents are completed before assigning client to the primary therapist. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement by clients that the clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record nine of nine client records reviewed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Director of Operations will implement and create a Medical Records request form and policy. This will be reviewed with the staff and trained on 11/1/25. This policy will be implemented and added to the Client Handbook and will be given at admission. Clients will sign off on receiving a copy of this. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement by clients that the clients have the right to appeal a decision limiting access to their records to the director in nine of nine client records reviewed.
Client #1 was admitted to the outpatient program on October 17, 2024, and was discharged on March 13,2025. There was no acknowledgement by client they were informed they have the right to appeal a decision limiting access to their records.
Client #2 was admitted to the outpatient program on September 20, 2024, and was discharged on November 1,2024. There was no acknowledgement by client they were informed they have the right to appeal a decision limiting access to their records.
Client #3 was admitted to the outpatient program on January 30, 2025, and was discharged on March 3, 2025. There was no acknowledgement by client they were informed they have the right to appeal a decision limiting access to their records.
Client #4 was admitted to the outpatient program on November 25, 2024, and was discharged on June 5, 2025. There was no acknowledgement by client they were informed they have the right to appeal a decision limiting access to their records.
Client #5 was admitted to the outpatient program on January 7,2025, and was discharged on June 6, 2025. There was no acknowledgement by client they were informed they have the right to appeal a decision limiting access to their records.
Client #6 was admitted to the outpatient program on August 21,2024, and was discharged on September 10,2024. There was no acknowledgement by client they were informed they have the right to appeal a decision limiting access to their records.
Client #7 was admitted to the outpatient program on October 17,2024 , and was discharged on December 4,2024. There was no acknowledgement by client they were informed they have the right to appeal a decision limiting access to their records.
Client #8 was admitted to the partial hospitailization program on November 26,2024, and was discharged on December 3, 2024. There was no acknowledgement by client they were informed they have the right to appeal a decision limiting access to their records.
Client #9 was admitted to the partial hospitailization program on September 3, 2024, and was discharged on October 3,2024. There was no acknowledgement by client they were informed they have the right to appeal a decision limiting access to their records.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Client rights agreement and Client handbook will be created by Operations Director. With in this a policy of request for records and right to appeal will be outlined. Ops director will equally outline in the handbook that the client has the right to appeal the decision to limit access to records. Client will sign a waiver outlining they are aware of these rights. Client will sign a copy of the handbook.
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on the review of client records, the project failed to document written acknowledgement by clients that the clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in nine of nine client records reviewed.
Client #1 was admitted to the outpatient program on October 17, 2024, and was discharged on March 13,2025. There was no documentattion acknowledging that clients were informed they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Client #2 was admitted to the outpatient program on September 20, 2024, and was discharged on November 1,2024. There was no documentattion acknowledging that clients were informed they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Client #3 was admitted to the outpatient program on January 30, 2025, and was discharged on March 3, 2025. There was no documentattion acknowledging clients were informed they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Client #4 was admitted to the outpatient program on November 25, 2024, and was discharged on June 6, 2025. There was no documentattion acknowledging clients were informed they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Client #5 was admitted to the outpatient program on January 7,2025, and was discharged on June 6, 2025. There was no documentattion acknowledging clients were informed they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Client #6 was admitted to the outpatient program on August 21,2024, and was discharged on September 10,2024. There was no documentattion acknowledging clients were informed they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records .
Client #7 was admitted to the outpatient program on October 17,2024 , and was discharged on December 4,2024. There was no documentattion acknowledging clients were informed they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records .
Client #8 was admitted to the partial hospitailization program on November 26,2024, and was discharged on December 3, 2024. There was no documentattion acknowledging clients were informed they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Client #9 was admitted to the partial hospitailization program on September 3, 2024, and was discharged on October 3,2024. There was no documentattion acknowledging clients were informed they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Director of Operations will create an implement a " Bill of Rights and Client Rights Agreement". This will be signed and given at admissions. Clinical director will review monthly for chart audit inspection and compliance to ensure signature. Clinical Director will review all admission content.
A Client oreintation Handbook will be created by Operations Director and will outline the " Bill of Rights"including the right to correct documentation. Client will sing off on recieving this bill of rights and client handbook. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on the review of client records, the project failed to document written acknowledgement by clients that the clients have the right to submit a rebuttal data or memoranda to their own records in nine of nine client records reviewed.
Client #1 was admitted to the outpatient program on October 17, 2024, and was discharged on March 13,2025. There was no acknowledgement by clients that they have the right to submit a rebuttal data or memoranda to their own records.
Client #2 was admitted to the outpatient program on September 20, 2024, and was discharged on November 1,2024. There was no acknowledgement by clients that they have the right to submit a rebuttal data or memoranda to their own records.
Client #3 was admitted to the outpatient program on January 30, 2025, and was discharged on March 3, 2025. There was no acknowledgement by clients that they have the right to submit a rebuttal data or memoranda to their own records.
Client #4 was admitted to the outpatient program on November 25, 2024, and was discharged on June 6, 2025. There was no acknowledgement by clients that they have the right to submit a rebuttal data or memoranda to their own records.
Client #5 was admitted to the outpatient program on January 7,2025, and was discharged on June 6, 2025. There was no acknowledgement by clients that they have the right to submit a rebuttal data or memoranda to their own records.
Client #6 was admitted to the outpatient program on August 21,2024, and was discharged on September 10,2024. There was no acknowledgement by clients that they have the right to submit a rebuttal data or memoranda to their own records.
Client #7 was admitted to the outpatient program on October 17,2024 , and was discharged on December 4,2024. There was no acknowledgement by clients that they have the right to submit a rebuttal data or memoranda to their own records.
Client #8 was admitted to the partial hospitailization program on November 26,2024, and was discharged on December 3, 2024. There was no acknowledgement by clients that they have the right to submit a rebuttal data or memoranda to their own records.
Client #9 was admitted to the partial hospitailization program on September 3, 2024, and was discharged on October 3,2024. There was no acknowledgement by clients that they have the right to submit a rebuttal data or memoranda to their own records.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Director of Operations will create an implement a " Bill of Rights and Client Rights Agreement". This will be signed and given at admissions. Clinical director will review monthly for chart audit inspection and compliance to ensure signature. Clinical Director will review all admission content.
Operations director will create a client oreintation handbook outlining the bill of rights and right to appeal and submit reuttal date or memo on their own record. Clients will sign off on recieving the handbook. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two of two applicable client records reviewed.
Client #3 was admitted to the outpatient level of care on January, 30, 2025 and was involuntarily discharged on March 20, 2025. It was not documented in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.
Client #9 was admitted to the partial hospitalization level of care on Steptember 3, 2024 and was involuntarily discharged on October 3, 2024, 2025. It was not documented in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Director of Operations will create and draft an involuntary discharge policy, and " Involuntary/ Administrative Discharge" Policy. They will be the same. The Policy will be created by 10/15/2025. Clients will be notified in writing and given an appeal form. Director will also implement an Appeal Form and implement with in the EMR system. Staff will be trained and this will be reviewed by 11/1/2025. Clinical Supervisor will train staff.
Primary Therapist will be responsible for notifying the client.
Operations Director and Clinical Supervisor will monitor documentation and review compliance at time and prior to discharge approval.
All staff will review discharges prior to closing the charts and removal. |
709.81(b)(1) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on review of partial hospitalization client records the facility failed to include documentation of disclosure to the client of criteria for admission, treatment, completion and discharge in one out of two records reviewed.
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024. There was no documentation of disclosure to the client of criteria for admission, treatment, completion and discharge in the record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 29, 2024 licensing inspection.
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Plan of Correction
Client Handbook will be created notating the levels of care, diagnosis, and admission criteria for the program and each level of care. Client Handbook will notate discharge and treatment completion goals and criteria for treatment completion. Discharge policy and Admission policy will be created by Director of Operations by 11/1/2025 |
709.81(b)(2)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(i) Project policies.
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Observations
Based on review of partial hospitalization client records the facility failed to provide, a client orientation to the project that included familiarization with project policies in one out of two records reviewed.
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024. There was no documentation of orientation to the project that included familiarization with project policies in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Operations will creation a "Client Orientation" checklist in the EMR system. Clients will sign at admission, and this will be reviewed after admission by the Clinical Director. This will be done 12/1/2025 |
709.81(b)(2)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(ii) Hours of operation.
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Observations
Based on review of partial hospitalization client records the facility failed to provide, a client orientation to the project that included familiarization with project hours of operation in one out of two records reviewed.
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024. There was no documentation of orientation to the project that included familiarization with project hours of operation in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Client Handbook will be created by Clinical Director listing the Operation Hours. This will be given and signed off on at Admission. Both Admission Coordinator and Client will both sign. This will be done by 11/1/2025 |
709.81(b)(2)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(iii) Fee schedule.
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Observations
Based on review of partial hospitalization client records the facility failed to provide, a client orientation to the project that included familiarization with project fee schedule in one out of two records reviewed.
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024. There was no documentation of orientation to the project that included familiarization with fee schedule in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Operation will create a " Client Fee Schedule" and " Projection of Client Bill" In the EMR system. Clients will sign off on their Client Rates and Projected Fees. This will be done by 12/1/2025 |
709.81(b)(2)(iv) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(iv) Services provided.
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Observations
Based on review of partial hospitalization client records the facility failed to provide, a client orientation to the project that included familiarization with project services provided in one out of two records reviewed.
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024. There was no documentation of orientation to the project that included familiarization with project services provided in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Client Handbook will be created outlining the scoop of services. The Director of Operations will create this and will be implemented on 11/1/2025 |
709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on review of partial hospitalization client records the facility falied to provide intake procedures that included documentation of medical history within the first three sessions, per facility policy, in one out of one applicable records reviewed.
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024.There was no documentation of medical history in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
With in the EMR system, DOO will work to add a Medical History questionnaire that is already accessible and available in the EMR systems. This will be added within the Intake and Admission paperwork. Clinical Supervisor will train Intake Coordinator. This will be done by 10/31/2025. Staff will be trained on upload medical paperwork and discharge paper work from referral sources into the record. Discharge paperwork from HLOC and referrals will be uploaded from the BDO team. Clinical Supervisor will review all documentation after admission for compliance. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on review of partial hospitalization client records the facility falied to provide intake procedures that included documentation of personal history within the first three sessions, per facility policy, in one out of one applicable records reviewed.
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024.There was no documentation of personal history in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Operations will work with EMR system to re-create the Intake Admission / Biopsychosocial Assessment. With in the intake personal history will be included in the contents amongst the in the bio psychosocial and history and physical information. This will be done by 12/1/2025 |
709.81(b)(4) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on review of partial hospitalization client records the facility failed to provide intake procedures that included documentation of a consent to treatment in one of two records reviewed.
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024.There was no documentation for consent to treatment in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Operations will work to create and add the " consent to treatment" to the EMR system. This will be done by 11/1/2025 |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on review of partial hospitalization client records the facility failed to provide a psychosocial evaluation within the first three sessions, per facility policy, in one out of one applicable records reviewed.
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024.There was no documentation of a a psychosocial evaluation in client record .
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will review the policy and compliance with staff. Clinical Director will create documentation policy that biopsychosocial will be completed within 24 to 48 hours. Clinical Director will pull a report and check note completion daily and review with staff. This will be conducted immediately. |
709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on review of partial hospitalization client records the facility failed to complete a preliminary treatment and rehabilitation plan within the first three sessions, per facility policy, in one out of one applicable records reviewed..
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024. There was no documentation of a preliminary treatment and rehabilitation plan in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Operations will create a preliminary treatment plan with in the EMR system. This will be implemented for the first week of treatment. Psychiatrist and Clinical Director will sign off for compliance. |
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 review of partial hospitalization client records the facility failed to complete an individual treatment and rehabilitation plan with a client in one out of one applicable record reviewed.
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024. There was no documentation of an individual treatment plan in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Operations will review and completion a Master Treatment Plan policy. This will be created and reviewed with staff. Clinical Director will sign off on master treatment plans with psychiatry. Clinical Director will train on regulations and timelines. This will be done by 11/1/2025 |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on review of partial hospitalization client records the facility failed to provide counseling to clients on a regular and scheduled basis, at least twice weekly, in two of two clients reviewed.
Client #8 was admitted on November 26, 2024, and discharged on December 3, 2024. There was no documentation of individual counseling, at least twice weekly in the client record for the week the client was in care.
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024. There was no documentation of individual counseling, at least twice weekly in the client record for the span of the clients care.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Operations will create a scope of services and Explanation of Services. Staff will be receiving a training on compliance regard PHP expectations and attendance and services rendered verses IOP schedule and treatment regimen. Clinical Director will pull the census and review weekly to ensure individual sessions are in compliance. This will be done 11/1/2025 |
709.82(d)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(2) Group counseling, at least twice weekly.
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Observations
Based on review of partial hospitalization client records the facility failed to complete group counseling, at least twice weekly in two of two clients reviewed.
Client #8 was admitted on November 26, 2024, and discharged on December 3, 2024. There was no documentation of any group counseling in client record.
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024. There was no documentation of any group counseling in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Operations will be pulling weekly census to ensure group compliance and attendance. Clinical Director will be reviewing note compliance for 24-48 hours daily. This will occur immediately |
709.83(a)(2) 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:
(2) Treatment and rehabilitation plan.
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Observations
Based on a review of partial hospitalization client records, the facility failed to have a complete client record on an individual which included information relative to the client ' s involvement with the project that included a treatment and rehabilitation plan in one of two records reviewed.
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024. There was no documentation of a treatment and rehabilitation plan in client record
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will pull reporting daily to ensure treatment plan compliance. This will be reviewed in weekly supervision.
A training will be created and conducted by Operations Director and reviewed on 11/1 to demonstrated evidence based, measurable treatment plan construction.
Willey TP will be created with in the EMR system to aid with creation of TP for the team. |
709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on a review of partial hospitailization client records the facility failed to follow their written procedure to complete case consultations upon admission in two of two records reviewed.
Client #8 was admitted on November 26, 2024, and discharged on December 3, 2024. There was no documentation of a case consultation in client record
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024. There were no documentation of a case consultation in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
DOO will update the policy. There will be weekly clinical supervision. Case consultations will occur every 90 days and at step down as of 11/1/25. Clinical supervisor will monitor. Staff will be notified before 11/1/ 25 of the new policy and expectations on case consultations. |
709.83(a)(8) 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:
(8) Record of services provided.
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Observations
Based on a review of partial hospitalization client records, the facility failed to have a complete client record on an individual which included information relative to the client ' s involvement with the project that included a record of service in one out of two records reviewed.
Client #8 was admitted on November 26, 2024, and discharged on December 3, 2024. The client record of service listed the client attending services on November 26, 2024; however, there was no corresponding documentation to reflect services were provided on that date.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will review notes daily to ensure the 24-48 hour time line and completion. |
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 hospitailization client records the facility failed to follow their written procedures to complete progress notes on the same day of session in two out of two records.
Client #8 was admitted on November 26, 2024, and discharged on December 3, 2024. There were no progress notes for any services provided in client record reviewed.
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024. There were no progress notes for any services provided in client record reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will monitor notes and compliance with in 24-48 hour time frame. Clinical Supervisor will monitor notes daily. |
709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of partial hospitailization client records the facility failed to have a completed discharge summary in one of two applicable records reviewed.
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024. The discharge summary was incomplete, there was no summary of the client's involvement in treatment, the only item included was the reason for discharged.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 29, 2024 licensing inspection.
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Plan of Correction
Director will create Discharge policy and add the Discharge Summary to the EMR. This will be done within a week of the client being disengaged in services. The policy will reflect expectations around discharge. Discharge summaries will be signed by therapist and Clinical Director for compliance and review.
Staff will be notified in supervisor before 11/1 of the new expectations and policies on discharge summary completion. |
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 partial hospitailization client records the facility failed to follow their written procedure to complete follow up calls within seven days if a referral is made and within 30 days and if no referral was made in two out of two records reviewed.
Client #8 was admitted on November 26, 2024, and discharged on December 3, 2024. There was no documentation of a follow up in the client record.
Client #9 was admitted on Steptember 3, 2024 and discharged on October 3, 2024. There was no documentation of a follow up in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 29, 2024 licensing inspection.
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Plan of Correction
Director of operations will be adjusting the policy to reflect follow up with in 7 days of discharge and aftercare. Clinical Director will be responsible for ensuring compliance.
Staff will be trained and notified of the new policy for follow up and aftercare before 11/1 with in clinical supervisor meetings. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of outpatient client records the facility failed to include documentation of disclosure to the client of criteria for admission, treatment, completion and discharge in five out of seven records reviewed.
Client #1 was admitted on October 17, 2024 and discharged on March 13, 2025. There was no documentation of disclosure to the client of criteria for admission, treatment, completion and discharge in the record.
Client #2 was admitted on September 20, 2024 and discharged on November 1, 2024. There was no documentation of disclosure to the client of criteria for admission, treatment, completion and discharge in the record.
Client #3 was admitted on January 30, 2025 and discharged on March 20, 2025. There was no documentation of disclosure to the client of criteria for admission, treatment, completion and discharge in the record.
Client #5 was admitted on January 7, 2025 and discharged on June 6, 2025. There was no documentation of disclosure to the client of criteria for admission, treatment, completion and discharge in the record.
Client #7 was admitted on October 17, 2024 and discharged on December 4, 2024. There was no documentation of disclosure to the client of criteria for admission, treatment, completion and discharge in the record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 29, 2024 licensing inspection.
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Plan of Correction
DOO will create Service outline policy and documenting Admission and discharge criteria. This will also be notated in the client handbook. This will be done by 11/1/2025 |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of outpatient client records the facility failed to provide, a client orientation to the project that included familiarization with project policies in five out of seven records reviewed.
Client #1 was admitted on October 17, 2024 and discharged on March 13, 2025. There was no documentation of orientation to the project that included familiarization with project policies in in client record.
Client #2 was admitted on September 20, 2024 and discharged on November 1, 2024. There was no documentation of orientation to the project that included familiarization with project policies in client record.
Client #3 was admitted on January 30, 2025 and discharged on March 20, 2025. There was no documentation of orientation to the project that included familiarization with project policies in client record.
Client #5 was admitted on January 7, 2025 and discharged on June 6, 2025. There was no documentation of orientation to the project that included familiarization with project policies in client record.
Client #7 was admitted on October 17, 2024 and discharged on December 4, 2024. There was no documentation of orientation to the project that included familiarization with project policies in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients will be issued a Client Handbook at admission into the program outlining policies. DOO will work to complete the policies and procedures. This will be review annually for compliance and updates. Will be completed by 12/30/25 |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of outpatient client records the facility failed to provide, a client orientation to the project that included familiarization with project hours of operation in five out of seven records reviewed.
Client #1 was admitted on October 17, 2024 and discharged on March 13, 2025. There was no documentation of orientation to the project that included familiarization with project hours of operation in client record.
Client #2 was admitted on September 20, 2024 and discharged on November 1, 2024. There was no documentation of orientation to the project that included familiarization with project hours of operation in client record.
Client #3 was admitted on January 30, 2025 and discharged on March 20, 2025. There was no documentation of orientation to the project that included familiarization with project hours of operation in client record.
Client #5 was admitted on January 7, 2025 and discharged on June 6, 2025. There was no documentation of orientation to the project that included familiarization with project hours of operation in client record.
Client #7 was admitted on October 17, 2024 and discharged on December 4, 2024. There was no documentation of orientation to the project that included familiarization with project hours of operation in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client handbook will be created and outlining the project hours of operations. Clients will sign the " orientation checklist" at admission. This will be implemented on 11/1/25. DOO will create Client Handbook and Oreintation check list. Intake Coordinator will administer. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of outpatient client records the facility failed to provide, a client orientation to the project that included familiarization with project fee schedule in five out of seven records reviewed.
Client #1 was admitted on October 17, 2024 and discharged on March 13, 2025. There was no documentation of orientation to the project that included familiarization with fee schedule in client record.
Client #2 was admitted on September 20, 2024 and discharged on November 1, 2024. There was no documentation of orientation to the project that included familiarization with fee schedule in client record.
Client #3 was admitted on January 30, 2025 and discharged on March 20, 2025. There was no documentation of orientation to the project that included familiarization with fee schedule in client record.
Client #5 was admitted on January 7, 2025 and discharged on June 6, 2025. There was no documentation of orientation to the project that included familiarization with fee schedule in client record.
Client #7 was admitted on October 17, 2024 and discharged on December 4, 2024. There was no documentation of orientation to the project that included familiarization with fee schedule in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Oreintation check list will notate the fee and pay schedule. Every client will be given a payment plan and schedule of expected financial dues starting 11/1/25.Intake Coordinator will implement and issue the fee schedule. DOO will determine the pay rates. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of outpatient client records the facility failed to provide, a client orientation to the project that included familiarization with project services provided in five out of seven records reviewed.
Client #1 was admitted on October 17, 2024 and discharged on March 13, 2025. There was no documentation of orientation to the project that included familiarization with project services provided in client record.
Client #2 was admitted on September 20, 2024 and discharged on November 1, 2024. There was no documentation of orientation to the project that included familiarization with project services provided in client record.
Client #3 was admitted on January 30, 2025 and discharged on March 20, 2025. There was no documentation of orientation to the project that included familiarization with project services provided in client record.
Client #5 was admitted on January 7, 2025 and discharged on June 6, 2025. There was no documentation of orientation to the project that included familiarization with project services provided in client record.
Client #7 was admitted on October 17, 2024 and discharged on December 4, 2024. There was no documentation of orientation to the project that included familiarization with project services provided in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project services will be outlined in a Client HandBook that will be given at admission. DOO will crate the CLIENT HANDBOOK. Intake Coordinator will distribute the client handbook at admission. Starting on 11/1/2025 |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of outpatient client records the facility falied to provide intake procedures that included documentation of medical history in three out of seven records reviewed.
Client #5 was admitted on January, 7, 2025 and discharged on June 6, 2025. There was no documentation of medical history in client record.
Client #6 was admitted on August 21, 2024 and discharged on September 10, 2024. There was no documentation of medical history in client record.
Client #7 was admitted on October 17, 2024 and discharged on December 4, 2024. There was no documentation of medical history in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
DOO will update Biopsychosocial to include Medical History. Clients will meet with CRNP upon admission with in 24-48 hours to review medical hx. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of outpatient client records the facility failed to provide intake procedures that included documentation of a consent to treatment in four of seven records.
Client #1 was admitted on October 17, 2024 and discharged on March 13, 2025. There was no documentation of a consent to treatment in client record.
Client #2 was admitted on September 20, 2024 and discharged on November 1, 2024. There was no documentation of a consent to treatment in client record.
Client #3 was admitted on January, 30, 2025 and discharged on March 20, 2025. There was no documentation of a consent to treatment in client record.
Client #5 was admitted on January, 7, 2025 and discharged on June 6, 2025. There was no documentation of a consent to treatment in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake coordinator will first complete the consent to treatment at the beginning of intake.
Clinical Supervisor will review all admissions upon completion to ensure consents and releases as of 11.1.25.
Clinical Supervisor will ensure and confirm that consent to treat is completed upon admission.
Clinical Supervisor will review every intake to ensure contents are completed.
Staff will be notified and trained on this being the first consent to be done.
THI REVIEW will happen before 11/1. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of outpatient client records the facility failed to complete intake procedures that include documentation of a preliminary treatment and rehabilitation plan in three of seven records.
Client #2 was admitted on September 20, 2024 and discharged on November 1, 2024. There was no documentation of a preliminary treatment and rehabilitation plan in client record.
Client #5 was admitted on January, 7, 2025 and discharged on June 6, 2025. There was no documentation of a preliminary treatment and rehabilitation plan in client record.
Client #7 was admitted on October 17, 2024 and discharged on December 4, 2024. There was no documentation of a preliminary treatment and rehabilitation plan in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Initial Treatment Plan will be added into the EMR system and form will be created by 11/1/25 by DOO. Staff will be trained by DOO on the initial TP. Clinical Supervisor will follow up to ensure compliance. |
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 a review of outpatient client records the facility failed to develop an individual treatment and rehabilatation plan with the client to include written documentation of short and long-term goals for treatment as formulated by both staff and client in two out of five records.
Client #2 was admitted on September 20, 2024 and discharged on November 1, 2024. The individual treatment plan dated September 27, 2024 did not include written documentation of short and long-term goals for treatment as formulated by both staff and client.
Client #5 was admitted on January, 7, 2025 and discharged on June 6, 2025. The individual treatment plan dateed January 29, 2025 did not include written documentation of short and long-term goals for treatment as formulated by both staff and client.
Client #6 was admitted on August 21, 2024 and discharged on September 10, 2024. The individual treatment plan dateed August 22, 2024 did not include written documentation of short and long-term goals for treatment as formulated by both staff and client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan training will be conducted by 12/1/2025. The SNAP will be included in the MTP update. Staff will be educated on SMART GOALS by 12/1/25. Compliance will be monitored by Clinical Supervisor |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of outpatient client records the facility failed to develop an individual treatment and rehabilatation plan with the client to include written documentation of type and frequency of treatment and rehabilitation services in three out of five records reviewed.
Client #2 was admitted on September 20, 2024 and discharged on November 1, 2024. The individual treatment plan dated September 27, 2024 did not include written documentation of type and frequency of treatment and rehabilitation services.
Client #5 was admitted on January, 7, 2025 and discharged on June 6, 2025. The individual treatment plan dateed January 29, 2025 did not include written documentation of type and frequency of treatment and rehabilitation services.
Client #6 was admitted on August 21, 2024 and discharged on September 10, 2024. The individual treatment plan dateed August 22, 2024 did not include written documentation type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 29, 2024 licensing inspection.
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Plan of Correction
Type, frequency, LOC, and regiment will be notated in the MTP.DOO will edit the form in the EMR prior to 11/1/25 |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of outpatient client records the facility failed to develop an individual treatment and rehabilatation plan with the client to include written documentation of the proposed type of support service in three out of five records reviewed.
Client #2 was admitted on September 20, 2024 and discharged on November 1, 2024. The individual treatment plan dateed September 27, 2024 did not include written documentation of the proposed type of support service.
Client #5 was admitted on January, 7, 2025 and discharged on June 6, 2025. The individual treatment plan dateed January 29, 2025 did not include written documentation of the proposed type of support service.
Client #6 was admitted on August 21, 2024 and discharged on September 10, 2024. The individual treatment plan dateed August 22, 2024 did not include written documentation of the proposed type of support service.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 29, 2024 licensing inspection.
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Plan of Correction
DOO will work with clinical director to outline the notated recommendation as well as the referred level of care and treatment regiment on the MTP. This will be done by 11/1/25.
Wiley Treatment PLan builders will be purchased and utilized. This tool will include interventions and support offered from the therapist to accomplish the outlined goals.
Clinical Director will train staff before 11/1. |
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 outpatient client records the facility failed to review and update treatment and rehabilitation plans least every 60 days in one of two records reviewed.
Client #5 was admitted on January, 7, 2025 and discharged on June 6, 2025. A treatment rehabiliation plan was developed on March 13,2025 the next was due on May 13, 2025; however there was no documentation one was updated.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will sign all Master Treatment plans and treatment plan updates. Clinical Supervisor will monitor daily and pull a report weekly to review and observe what treatment plans are coming due. This will be reviewed in Clinical Supervision weekly starting 11/1/2025 |
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 outpatient client records the project failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in two out of two applicable records reviewed.
Client #1 was admitted on October 17, 2024 and discharged on March 13, 2025. The individual treatment plan developed on October 17, 2024 documents individual sessions once a week. There was no documentation of individual sesions the weeks of October 20, 2024 - October 26, 2024; October 27, 2024 - November 2, 2024; November 10, 2024-November 16, 2024; November 24, 2024-November 30, 2024; December 8, 2024-December 14, 2024; December 15, 2024 - December 21, 2024; December 22, 2024-December 28, 2024; December 29, 2024-January 4, 2025; January 5, 2025-January 11, 2025; January 19, 2025-January 25, 2025; and February 2, 2025-February 8, 2025.
Client #4 was admitted on November 25, 2024 and discharged on June 5, 2025. The individual treatment plan developed on November 27, 2024 documents individual sessions three times a week. Therecord was missing one session for week of December 1, 2024 to December 7, 2024, missing one session for week of December 22, 2024 to December 28, 2024, missing one session for week of December 29, 2024 to January 4, 2025, missing one session for week of January 5, 2025 to January 11, 2025, missing one session for week of January 12, 2025 to January 18, 2025, missing one session for week of January 19, 2025 to January 25, 2025, missing two sessions for week of February 9, 2025 to February 15, 2025, and missing three sessions for the week of February 16,2025 to February 22,2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
DOO will review documentation and regulatory policy. All IOP client will engage in weekly individual sessions for 60 mins. PHP will engage in two sessions weekly for at minimum 30 mins. OP will engage minimum monthly in individual sessions. weekly census will check for completed documentation and check for individual compliance. This will be managed by Clinical supervisor.
A training will be conducted in clinical supervision before 11/1 notifying the team of the required regulatory. Clincial Supervisor will follow up in individual sueprviaor to ensure compliance. OPs director will review compliance weekly. |
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 a review of outpatient client records the facility failed to follow their written procedures to complete progress notes on the same day of the session in six out of seven records.
Client #1 was admitted on October 17, 2024 and discharged on March 13, 2025. The record contained individual sessions that occured on Octobet 17, 2024 and November 5,2024 that were not documented until November 12, 2024.
Client #2 was admitted on September 20, 2024 and discharged on November 1, 2024. The record contained individual sessions that occured on September 24, 2024, September 25, 2024, September 26, 2024, October 1, 2024, October 2, 2024, October 3, 2024, October 8, 2024, October 9, 2024, October 10, 2024, and October 15, 2024, were not documented until October 17, 2025, October 18, 2025, and October 21, 2025.
Client #3 was admitted on January, 30, 2025 and discharged on March 20, 2025. The record contained individual sessions that occurred on February 20, 2025, February 27, 2025, March 3, 2025 and March 7, 2025. There was no corresponding progress note documented in chart for the individual sessions.
Client #4 was admitted on November 25, 2024 and discharged on June 5, 2025. The record contained individual sessions that occurred on December 10, 2024, December 11, 2024 December 12, 2024, December 30, 2024, January 3, 2025, January 6, 2025, January 7, 2025, and January 15, 2025, that were not completed until December 13, 2024, January 10, 2025, and January 29, 2025.
Client #5 was admitted on January, 7, 2025 and discharged on June 6, 2025. There was no documentation of progress notes in client record.
Client #6 was admitted on August 21, 2024 and discharged on September 10, 2024. There was no documentation of progress notes in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will conduct monthly chart audits. They will equally monitor weekly census completion and ensure sessions billed match documentation completed. Clinical supervisor will run a daily incomplete note report. |
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 outpatient client records the facility failed to follow their written procedures to complete case consultations upon admission in seven of seven records reviewed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 29, 2024 licensing inspection.
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Plan of Correction
Future policy will be created and implemented that case consults will occur every 90 days and prior to step down and discharge. The staff will be trained accordingly, and case consults will be signed by Clinical Supervisor for accountability |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of outpatient client records the facility failed to follow their written procedures to complete an aftercare plan prior to discharge in two out of five applicable records reviewed.
Client #5 was admitted on January, 7, 2025 and discharged on June 6, 2025. There was no documentation of an aftercare plan in client record.
Client #7 was admitted on October 17, 2024 and discharged on December 4, 2024. There was no documentation of an aftercare plan in client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This director will review the policy and implement discharge and aftercare training for the staff by 12/31/2025. Discharge summaries and aftercare plans will be signed and routed to the clinical supervisor for completion and signature to provide accountability and checks and balances. |
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 follow their written procedures to follow up within seven days if a referral is made and within 30 days if no referral was made in seven out of seven records reviewed.
There was no documentation of a follow up in seven of seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This director will review the current discharge and aftercare policy and train and educate future staff. The policy will be updated if necessary. A discharge and aftercare training will be conducted for future staff by 12/31/2025 |