INITIAL COMMENTS
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This report is a result of on-site complaint investigations conducted on May 12-15, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigations, Auberle was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on a review of policy and procedures and personnel records, the facility failed to follow their own policy regarding educational and experiential qualifications for staff positions.
Facility policy states that all staff must have a bachelor ' s degree. A total of nine support staff did not have documentation of a bachelor ' s degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Family Healing Center will revise its staffing qualifications policy to align with current hiring practices and position-specific requirements. The revised policy will ensure that educational requirements are based on the duties and responsibilities of each position and will not unnecessarily restrict qualified applicants from consideration. All candidates will continue to be evaluated based on the qualifications, experience, and competencies required for the position. The revised policy will be submitted to the Governing Body for review and approval no later than July 01,2026 |
704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
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Observations
Based on a review of policies and procedures, the facility failed to develop a written policy to address relapse of recovering clinical personnel and the discipline of nonrecovering employees who abuse alcohol and other drugs.
The policy was written by facility staff while the inspectors were onsite and dated May 12, 2026; however, this policy was not yet reviewed and approved by the governing body.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Family Healing Center developed a written policy addressing relapse among recovering clinical personnel and the discipline of nonrecovering employees who abuse alcohol and other drugs. The policy was drafted and implemented on May 12, 2026. The policy will be presented to the Governing Body for formal review. |
704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
Based on a review of policies and procedures, the facility failed to develop a written policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served and that every effort shall be made to hire staff persons representative of that population.
The policy was written by facility staff while the inspectors were onsite and dated May 12, 2026; however, this policy was not yet reviewed and approved by the governing body.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Family Healing Center developed a written policy addressing the recruitment and hiring of staff who are appropriate to the population served and affirming the agency's commitment to making every effort to recruit and hire staff who are representative of the population served. The policy was developed on May 12, 2026, during the licensing review process. The policy will be presented to the Governing Body. |
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a comprehensive staff development program for agency personnel including policies and procedures for the program including the following components: An assessment of staff training needs, and overall plan for addressing these needs, a mechanism to collect feedback on completed training and an annual evaluation of the overall training plan.
The policy was written by facility staff while the inspectors were onsite and dated May 12, 2026; however, this policy was not yet reviewed and approved by the governing body.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Family Healing Center developed a comprehensive Staff Development and Training Plan policy that includes an assessment of staff training needs, an annual training plan, a mechanism for collecting staff feedback regarding completed trainings, and an annual evaluation of the effectiveness of the overall training program. The policy was developed on May 12, 2026, during the licensing review process. The policy will be presented to the Governing Body. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff schedules and CPR certification certificates, the facility failed to provide CPR certification so that at least one person trained is onsite during the project ' s hours of operation.
Staff #5 does not currently have documentation of CPR certification. Staff #5 was by themselves, at the facility on April 17, 2026 from 7:00 - 8:00 PM, April 18, 2026 from 5:30 - 6:45 PM, April 25, 2026 from 7:45 - 11:41 PM, May 2, 2026 from 5:30 - 7:00 PM, May 8, 2026 from 6:30 - 7:00 PM and May 9, 2026 from 5:00 - 8:00 PM.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #5 has been scheduled to complete CPR certification. Upon identification of this finding, the Family Healing Center immediately implemented a procedure to ensure that no staff member without current CPR certification is scheduled to work alone or be the sole staff member onsite during program operating hours. This practice has already been implemented and is being monitored by program leadership.
Additionally, a policy was developed outlining CPR certification requirements and staffing expectations to ensure that at least one CPR-certified staff member is onsite at all times. The policy will be presented to the Governing Body for formal review and approval no later than July 31, 2026, as part of the FY 2026?2027 policy review cycle. Ongoing schedule reviews will be conducted by management to ensure continued compliance. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times.
The following was observed by DDAP staff:
-Trash was found on the floor by the freezer and refrigerator and the storage room.
-The freezer had chicken that was not dated and freezer burned.
-The refrigerator contained food that was not covered.
-The dining room contained food that was not covered and not maintained at required temperatures.
-A large spider web was observed in the dining room.
-The refrigerator in the daycare room was found to have liquid at the bottom and needed to be cleaned.
-Apartment 305 was observed to have a broken recliner.
-Apartment 307 was observed to have peeling paint on the outside door of the appartment.
-Apartment 308 was observed to have peeling paint on the outside door of the appartment.
-A variety of mouse traps were found laying out in the open around the facility, making them accessible to the children residing at the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon notification of the findings, all identified concerns were immediately addressed. Expired, uncovered, improperly stored, and freezer-burned food items were discarded. Refrigerators, freezers, storage areas, and the daycare refrigerator were cleaned and sanitized. The spider web was removed, mouse traps were relocated to secure areas inaccessible to children, and maintenance requests were submitted for the recliner in Apartment 305 and peeling paint observed on Apartments 307 and 308.
To prevent recurrence, the Family Healing Center has implemented a Daily Environmental Safety and Sanitation Checklist to be completed by staff each day. The checklist includes inspection of food storage areas, refrigerators, freezers, common areas, apartments, housekeeping concerns, maintenance needs, and environmental safety hazards. In addition, program leadership will conduct and document weekly facility walk-through inspections to ensure continued compliance with physical plant requirements. Maintenance concerns identified during inspections will be documented and tracked through resolution.
These procedures have been implemented and will be incorporated into facility policy, which will be presented to the Governing Body for review and approval no later than July 31, 2026. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
A camera was observed in the group counseling room. There was no documentation of an approved regulatory exception for this camera.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon notification of the finding, the Family Healing Center disabled the camera located within the group counseling room to ensure the privacy and confidentiality of counseling services. The facility recognizes the importance of maintaining a therapeutic environment where counseling sessions cannot be seen or heard by unauthorized individuals.
Due to ongoing safety concerns within the facility and the presence of children residing onsite, the Family Healing Center intends to submit a waiver request seeking approval for the use of video monitoring in this area by June 21st 2026. While awaiting a determination regarding the waiver request, the camera will remain disabled and will not be utilized. Should the waiver request be denied, the camera will remain permanently disabled and will not be used in the group counseling room. Program leadership will monitor compliance to ensure the privacy and confidentiality of all counseling services. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to keep cold food at or below 40 , hot food at or above 140 and frozen food at or below 0 spaghetti, garlic bread and cookies were observed to be sitting out, uncovered, in the dining room, hours after lunch, with no means to keep them at required temperatures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon notification of the finding, all food items that were not being maintained at the required temperatures were discarded. The Family Healing Center is in the process of obtaining SafeServ certification for designated staff responsible for food service oversight. In addition, the facility has implemented designated meal service times for lunch and dinner to ensure food is consumed or properly stored within appropriate timeframes.
A staff member will be assigned to monitor the dining and food service areas during meal periods, and the Program Manager will be responsible for ensuring that all hot, cold, and frozen foods are maintained at required temperatures. All staff will be retrained on food handling, storage, temperature monitoring, and dining room expectations by July 31, 2026.
Additionally, the facility will develop and implement a formal food handling and temperature monitoring procedure by July 31, 2026. The procedure will include temperature requirements, food storage guidelines, monitoring expectations, and corrective actions for noncompliance. The procedure will be posted in the kitchen as an ongoing reminder and reference for staff. Program leadership will conduct routine monitoring to ensure continued compliance with food safety requirements. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential 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, the facility failed to ensure that there were no heaters that were not permanently mounted or installed in the facility. Specifically, a space heater was observed in the conference room where DDAP staff were working.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Family Healing Center intends to submit a waiver request by June 21st 2026 regarding the use of these heaters due to the unique needs of the facility and building layout.
While awaiting a determination on the waiver request, the heaters will remain out of service and stored in a secure location. If the waiver request is not approved, the facility will coordinate with the agency's maintenance department to install permanently mounted heating units in accordance with regulatory requirements. Any necessary installation work will be scheduled and completed as directed by the maintenance team to ensure ongoing compliance with physical plant regulations. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a physical plant inspection, the facility failed to keep the facility free of rodent and insect infestation. Numerous varieties of rodent traps were observed throughout the facility. The storage room by the refrigerator was observed to have black bugs flying around and on the floor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon notification of the finding, the affected areas were inspected and cleaned. The Family Healing Center maintains an active pest control contract with pest control company, which conducts routine monthly inspections and treatment services throughout the facility. The pest company is responsible for monitoring pest activity and placing rodent control devices as needed to prevent infestation.
Following the inspection, pest control company was notified of the concerns identified in the storage area and will continue to monitor and treat the facility as part of its ongoing service plan. Facility staff will conduct routine environmental inspections to identify and address any signs of pest activity between scheduled pest control visits. Documentation of pest control services and corrective actions will be maintained onsite for review. The Family Healing Center will continue to work with pest control company to ensure the facility remains clean, sanitary, and free from rodent and insect infestation. |
705.9 (4) (i) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of residents and staff to a safe location.
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Observations
Based on a review of policy and procedures, the facility failed to document written emergency procedures for staff and residents to follow in case of an emergency, which included the evacuation and transfer of residents and staff to a safe location, assignments of staff during emergencies and the evacuation and transfer of residents impaired by alcohol or other drugs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of May 15, 2026, the Family Healing Center, in collaboration with the agency's Director of Facilities and Maintenance, developed and implemented a comprehensive Emergency Preparedness and Evacuation Policy addressing emergency response procedures for staff and residents. The policy includes procedures for evacuation and transfer to a safe location, staff assignments during emergencies, communication protocols, and procedures for evacuating and transporting residents who may be impaired by alcohol or other drugs.
The policy was shared with all Family Healing Center staff to ensure a clear understanding of emergency procedures and expectations. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection, the facility failed to maintain protective caps over each electrical outlet.
Clients are permitted to bring their children to the facility. No electrical caps were observed in the shared dining room, youth room (next to the desk by the door), lobby, library, and apartments 201, 205, 206, 207, 301, 302, 303, 307 and 308.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon notification of the finding, the Family Healing Center immediately replaced all missing outlet caps identified during the inspection to ensure resident and child safety. The facility has researched available child safety products and is prepared to purchase and install self-closing electrical wall outlet covers throughout the facility to provide a more permanent safety solution.
Program leadership will continue to monitor compliance through routine environmental inspections to ensure the safety of all residents and children residing within the facility. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a written plan for the coordination of client treatment and rehabilitation services which includes: Definition of the target population toward whom facility services are directed, identification of the treatment models and practices utilized by the project, written procedures for the management of treatment/rehabilitation services for clients and written procedures for referral outlining cooperation with other services providers including, but not limited to, provisions for access to emergency services.
In addition, the policy and procedures regarding the documentation of a discharge summary state that the discharge summary is required to be completed seven days prior to discharge. The policy for the development of the preliminary treatment plan has conflicting timeframes. One policy stated they are developed twenty-four hours after admission, the other policy states they are developed seven days after admission. The policy for the development of the comprehensive treatment and rehabilitation plan has conflicting timeframes. One policy stated they are developed seventy-two hours after admission, the other policy states they are developed thirty days after admission.
The policy was written by facility staff while the inspectors were onsite and dated May 12, 2026; however, this policy was not yet reviewed and approved by the governing body.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Family Healing Center developed a comprehensive Treatment and Rehabilitation Services Plan on May 12, 2026, which addresses the target population served, treatment models and evidence-based practices utilized by the program, procedures for the management and coordination of treatment and rehabilitation services, and referral procedures outlining collaboration with community providers and access to emergency services.
In addition, the facility completed a comprehensive review of all clinical policies and procedures and identified inconsistencies related to discharge summaries, preliminary treatment plans, and comprehensive treatment plans. These policies have been revised to ensure consistent timeframes and alignment with regulatory requirements, agency practice, and documentation expectations.
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709.26 (a) LICENSURE Personnel Management
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
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Observations
Based on a review of the policy and procedure manual, the facility failed to document and have the governing body adopt written personnel policies which include: Utilization of volunteers, rules of conduct, supervision of staff and orientation of new employees.
The policy was written by facility staff while the inspectors were onsite and dated May 12, 2026; however, this policy was not yet reviewed and approved by the governing body.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Family Healing Center developed written personnel policies addressing the utilization of volunteers, rules of conduct, staff supervision, and the orientation of new employees. These policies were developed on May 12, 2026, during the licensing review process to ensure all required personnel practices are formally documented and consistently implemented.
The policy was developed on May 12, 2026, during the licensing review process. The policy will be presented to the Governing Body.
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709.26 (c) LICENSURE Personnel management.
§ 709.26. Personnel management.
(c) There shall be written job descriptions for project positions.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document written job descriptions for project positions.
Job descriptions were written by facility staff while the inspectors were onsite and dated May 12, 2026; however, this policy was not yet reviewed and approved by the governing body.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Family Healing Center developed written job descriptions for all program positions on May 12, 2026. The job descriptions clearly define the duties, responsibilities, qualifications, reporting structure, and expectations associated with each position to ensure consistency in hiring, supervision, performance management, and program operations.
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709.28 (a) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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Observations
Based on a review of policy and procedures, the facility failed to document policies and procedures which included the identification of project staff having access to records and the methods by which staff gain access.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Family Healing Center developed a policy addressing access to client records on May 15th 2026, including the identification of staff positions authorized to access records and the procedures by which access is granted, modified, and monitored. The policy outlines role-based access requirements, confidentiality expectations, and safeguards to ensure that client information is accessed only by authorized personnel for legitimate program purposes.
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709.30 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.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures on client rights including:
A client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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.
Clients have the right to appeal a decision limiting access to their records to the director.
Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Clients have the right to submit rebuttal data or memoranda to their own records.
The policy was written by facility staff while the inspectors were onsite and dated May 12, 2026; however, this policy was not yet reviewed and approved by the governing body.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Family Healing Center developed a comprehensive Client Rights Policy on May 12, 2026, which incorporates all applicable client rights requirements, including the preservation of civil rights and liberties, nondiscrimination in the provision of services, client access to records, the right to appeal decisions regarding access to records, the right to request correction of inaccurate or incomplete information, and the right to submit rebuttal statements or memoranda to their records.
The policy also outlines the limited circumstances under which portions of a record may be temporarily withheld if disclosure is determined to be detrimental to the client, as well as the required documentation and appeal process associated with such decisions.
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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 client records, policy and procedures, personnel records and administrative documentation, the facility failed to maintain a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
On April 9, 2026, documentation was requested to be sent to DDAP staff via email, with a due date of April 10, 2026 by 9:00 AM. This information was never received by DDAP staff. DDAP staff was onsite at the facility again May 12-15, 2026 and needed to re-request the documentation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 1, 2026, the Family Healing Center implemented a cloud-based data management and recordkeeping system designed to improve data collection, reporting capabilities, document retention, and the efficient retrieval of information necessary to monitor program performance and regulatory compliance. The system provides centralized storage of program documentation and has enhanced the program's ability to respond to regulatory and operational data requests in a timely and organized manner.
Written procedures governing data collection, record retention, reporting responsibilities, and document retrieval were developed and implemented in conjunction with the new system. Administrative staff and program leadership were trained on both the procedures and the use of the system to ensure consistency in documentation and compliance practices. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of policy and procedure, medication records and client and staff interviews, the facility failed to follow their medication administration policy.
It was reported during staff and client interviews that nursing staff were " pre-pouring " client medications prior to the client reporting to the medication administration area. In addition, it was reported that unqualified, non-medical staff, are administering medication to clients by opening medication packages, removing the medication and handing it to the clients, when facility policy states that client medications are self-administered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon notification of the finding, the Family Healing Center immediately revised its medication administration practices to ensure that all medications are self-administered by clients under staff observation, consistent with program policy and regulatory requirements. The practice of pre-pouring medications had already been discontinued, and staff are no longer permitted to remove medications from packaging or otherwise administer medications directly to clients.
All staff responsible for overseeing medication self-administration were informed of this change on May 15, 2026, and the associated staff training curriculum was updated to reflect the revised procedures and expectations. The medication administration procedure and policy have also been updated to clearly define staff responsibilities and client self-administration requirements. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document and implement written policy and procedures regarding all mediations used by clients which includes:
Methods for control and accountability of drugs, including, but not limited to:
Who is authorized to remove drug.
The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
The policy was written by facility staff while the inspectors were onsite and dated May 12, 2026; however, this policy was not yet reviewed and approved by the governing body.
These findings were reviewed with facility staff during the licensing process.
In addition:
Based on a review of client records, the facility failed to document that medications were provided as prescribed by a physician in nine of nine client records. In addition, the internal medication inventories were not matching the medication administration record.
Client #1 was admitted on February 11, 2026 and was active at the time of the inspection.
There was a discrepancy between the medication administration record and inventory of Buprenorphine on April 15, 2026.
Client #3 was admitted on February 17, 2026 and was active at the time of the inspection.
Polyethylene Glycol Powder 17gm was ordered to be taken daily. Client #3 refused to take the medication on May 1-7 and 11-13, with no documentation as to why the medication is not being taken or contact being made with medical staff.
Clonidine Hcl 0.1 mg was ordered to be taken every four hours for one week, then every six hours for one week and finally, every eight hours for one week, then twice per day, as needed. The 12:00 PM and 8:00 PM doses of the medication were missed on May 4, 2026.
Buprenorphine 8/2mg was ordered to be taken four times per day. The medication was missed on April 29, 2026.
Prazosin 1mg was ordered to be taken daily at bedtime. The 8:00 PM dose of this medication was missed on April 6 and 24, 2026.
Polyethylene Glycol 17gm was ordered to be taken by mouth daily. The medication was missed from April 21 - 30, 2026.
Gabapentin 600 mg was ordered to be taken three times daily. The 8:00 PM dose of this medication was missed on April 24, 2026.
The medication inventory and medication administration record for Buprenorphine for this client had a discrepancy on May 9, 2026.
Client #4 was admitted on January 24, 2026 and was active at the time of the inspection.
Gabapentin 300mg was ordered to be taken three times daily. The 4:00 PM dose of the medication was missed on April 30 and May 12, 2026.
Buprenorphine 8mg, was ordered to be taken twice daily. The 8:00 PM dose of the medication was missed on May 12, 2026. On May 13, 2026, client #4 was provided a dose at 5:00 AM and 8:00 AM. The 8:00 AM dose was missed on April 12, 27, 28, 29, and 30, 2026. The 12:00 PM dose was missed on April 11, 12, 26 and 30, 2026.
Mirtazapine 7.5 mg was ordered to be taken once daily at bedtime. The medication was missed on April 4, 2026.
Multivitamin was ordered to be taken daily. The medication was missed on April 18 and 25, 2026. The medication was marked as refused on April 11, 2026.
Vitamin B-1 100mg was ordered to be taken daily. The medication was missed on April 19 and 25, 2026 and was marked as refused on April 11, 2026.
Client #5 was admitted on January 23, 2026 and was discharged on April 24, 2026.
Bupropion Hcl xl 150mg was ordered to be taken daily in the morning. This medication was missed on April 17, 2026 and refused, with no explanation on April 1, 2026.
Cyproheptadine 4mg was ordered to be taken once daily at bedtime. This medication was missed on April 21, 2026. A circle, with no explanation, was documented on April 14 - 20 and 22-23, 2026.
Gabapentin 800mg was ordered to be taken three times daily. The 8:00 AM dose of the medication was refused on April 1, 2026. The 12:00 PM dose was missed on April 1 and 3, 2026.
Lithium Carbonate Er 300mg was ordered to be taken once daily at bedtime. The medication was missed on April 11 and 13, 2026.
Melatonin 3mg tablet was ordered to be taken once daily at bedtime. This medication was missed on April 13, 2026.
Mirtazapine 7.5mg was ordered to take once daily at bedtime. This medication was missed on April 9, 13, 19, 22 and 23, 2026. A circle, with no explanation, was documented for April 14 - 18 and 20 - 21, 2026.
Olanzapine 10mg was ordered to take twice daily. The medication was documented as refused on April 1, 2026 at 8:00 AM and was missed on April 13, 2026 at 8:00 PM.
Pantoprazole 40mg was ordered to take twice daily in the morning. This medication was marked as refused on April 1, 2026.
Prenatal Vitamin tablet was ordered to take daily. This medication was marked as refused on April 1, 2026.
Trazodone 200mg was ordered to take once daily at bedtime. This medication was missed on April 11 and 13, 2026.
There was a discrepancy between the medication administration record and inventory of Buprenorphine on March 2, 6, 14, 18, 22, 27 and 29 and April 2, 2026.
Client #8 was admitted on May 11, 2026 and was active at the time of the inspection.
Lurasidone 60 mg tablet was ordered to be taken once daily. Client #8 did not receive this medication on May 12, 2026.
Client #9 was admitted on March 31, 2026 and was active at the time of the inspection.
Docusate Sodium 100mg was ordered to be taken twice daily, at 08:00 and 20:00. Client #9 did not receive the medication for the 08:00 dose on May 4, 5, 6, 7, 8, 9, 11 and 12, 2026. Client #9 did not receive the medication for the 20:00 dose on May 9, 2026.
Nicotine, 21mg patch was ordered to be placed onto the skin daily, at 08:00. Client #9 did not receive the medication on May 4, 5, 6, 7, 8, 9, 10, 11 and 12, 2026.
Mirtazapine, 15mg was ordered to be taken daily, at bedtime. This medication was scheduled to be taken at 20:00. Client #9 did not receive the medication on April 30, May 4 and 5, 2026. N/A was documented for April 9 and 19, 2026.
Gabapentin 400 mg, was ordered to be taken twice daily at 08:00 and 20:00. Client #9 did not receive the 08:00 dose on May 1, 2026 and the 20:00 dose on May 4 and 5, 2026.
Nifedipine ER 30mg, was ordered to be taken daily. Client #9 did not receive the medication on May 1 and 3, 2026. N/A was marked for the period of April 5 - April 30, 2026, with no explanation documented.
Polyethylene Glycol 17mg was ordered to be taken by mouth at 8:00 AM daily. Client #9 refused the medication on May 1 - 12, 2026. There was no documentation as to why the client refused or that the refusal was discussed with the client or medical staff. Client #9 did not receive this medication for the month of April 2026.
Buspirone 15mg was ordered to be taken three times daily. Client #9 did not receive the 2:00 PM dose on April 1, 9, 10, 16, 17, 21, 24 and 30, 2026.
Fluoxetine 20mg was ordered to be taken daily in the morning. Client #9 did not receive the medication on April 19, 2026, as it was documented as N/A.
Oxcarbazepine 600mg was ordered to be taken daily at bedtime. Client #9 did not receive the medication on April 9 and 19, 2026, as it was documented as N/A. The medication was not documented as being taken on April 30, 2026.
Buprenorphine 4/1mg was ordered to be taken daily for two days. Client #9 did not receive the medication on April 17, 25, 28, 29 and 30, 2026.
Buprenorphine 8/2mg was ordered to be taken daily for two days. Client #9 did not receive the medication on April 30, 2026, as it was documented as N/A.
Quetiapine 400mg was ordered to be taken daily at bedtime. This medication was documented as being refused on April 23 and 24, 2026, N/A on April 9 and 28, 2026 and was missed on April 17, 19 and 30, 2026.
Clonidine .2mg was ordered to be taken twice daily. This medication was documented as being N/A for the 8:00 AM dose on April 7, 27, 28, 29 and 30, 2026 and the 8:00 PM dose on April 9, 27 and 28, 2026. The 8:00 AM dose was missed on April 12 and 18, 2026 and the 8:00 PM dose was missed on April 12, 19 and 30, 2026.
Emtricitabine 200mg was ordered to be taken daily at 8:00 PM. This medication was documented as being missed on April 16, 19, 29 and 30, 2026.
Sertraline 100mg was ordered to be taken daily at 8:00 am. Client #9 did not receive this medication on April 26, 2026.
Methocarbamol 500 mg was ordered to be taken four times daily for seven days, starting on April 23, 2026. The 12:00 PM dose was missed on April 24, the 4:00 PM dose was missed on April 25 and 29 and the 8:00 PM dose was missed on April 26 and 29, 2026.
There was a discrepancy between the medication administration record and inventory of Buprenorphine on May 3 and 11, 2026.
Client #10 was admitted on February 13, 2026 and was active at the time of the inspection.
Carvedilol 6.25 mg was ordered to be taken twice daily. Client #10 refused the medication on May 3, 2026. The medication was missed on May 3, 6, 7 and 8, 2026. The 8:00 AM dose was missed on April 23 and 25, 2026. The 8:00 PM dose was missed on April 9, 13, 22, 25 and 26, 2026.
Nifedipine 60mg was ordered to be taken twice daily. The medication was missed on May 3, 6, 7 and 8, 2026. The 8:00 AM dose was missed on April 23 and 26, 2026. The 8:00 PM dose was missed on April 9, 12, 22, 25 and 29, 2026.
Client #11 was admitted on April 24, 2026 and was active at the time of the inspection.
Valacyclovir HCl 500mg was ordered to be taken twice daily. Client #11did not take the 8:00 AM dose of the medication on April 30 and May 1, 2026. The medication was listed as N/A on May 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13, 2026. The 8:00 PM dose was missed on May 3, 4 and 5, 8 and 12, 2026. On May 9, 11 and 12, 2026 it was listed as N/A.
Methocarbamol 500mg was ordered to be taken twice daily.
The 8:00 AM dose was missed on May 1 and 2, 2026. On May 3, 2026 a circle was documented, but no explanation why. On April 27, 28, 29 and 30, 2026 and May 4, 5, 6, 7, 8 and 9, 2026, it was documented as N/A. The 8:00 PM dose on May 1, 2, 3, 5 and 6, 2026 has circle with no explanation why and on May 6 and 7, 2026 it has N/A. The 8:00 PM dose was missed on May 8 and 9, 2026.
Nifedipine ER 30mg was ordered to be taken once daily.
The 8:00 AM dose medication was missed May 1, 2026 and was marked N/A on May 13, 2026.
Complete Natal DHA (Prenatal Vitamin) was ordered to take daily.
The 8:00 AM dose on May 1 and 13, 2026 were missed. The May 12, 2026 was marked as N/A.
Methadone 75mg was ordered to be taken at bedtime. The client did not take the 8:00 PM dose on May 11, 2026.
Duloxetine HCL 30 mg was ordered to be taken daily at bedtime. The medication was missed on April 30, 2026.
The medication inventory and medication administration record for Methadone had a discrepancy on May 3, 2026.
Client #12 admitted on December 18, 2025 and was active at the time of the inspection.
Buprenorphine 8mg was ordered to take three times daily. The 2:00 PM dose was missed on May 12 and the 8:00 PM dose was missed on May 3, 2026.
Fluticasone 50 mg was ordered to be taken daily. The medication was missed on May 5-10 and 13, 2026 and was marked as refused on May 1-4, 2026.
Fluoxetine HCL 40 mg was ordered to be taken daily every morning. The medication was missed on May 11-13, 2026 and marked as refused on May 8-10, 2026.
Gabapentin 600 mg was ordered to take three times daily. The 2:00 PM dose of this medication was missed on April 4, 2026.
Quetiapine Fumarate 50 mg was ordered to be taken once daily at bedtime. The 8:00 PM dose was missed on April 4 and 10, 2026.
Buprenorphine 8mg was ordered to be taken three times daily. The 8:00 AM dose was missed on April 5 and marked as N/A on April 14, 2026. The 2:00 PM dose was missed on April 18, and marked as N/A on April 14, 2026. The 8:00 PM dose was missed on April 6 and 14 and marked as N/A on April 12, 2026. On May 3, 2026, client #12 received four doses of this medication, at 5:00 AM, 8:00 AM, 1:00 PM and 7:00 PM. On May 6, 2026, client #12 only received one dose at 8:00 AM. On May 9, 2026, client #12 received doses at 5:00 AM, 8:00 AM, 2:00 PM and 8:00 PM. On May 11, 2026, client #12 received doses at 2:00 PM and 7:00 PM. On May 12, 2026, client #12 received on dose at 8:00 AM.
The significant other of client #12, whom resides at the facility with the client, was ordered to take Buprenorphine. Inventories are taken as this is a controlled substance. There was a discrepancy between the medication administration record and the inventory for this medication on May 10, 2026.
The child of client #13, whom resides with the client at the facility, was ordered to take 250mg of Amoxicillin twice daily, at 8:00 AM and 8:00 PM. The medication was missed on May 6, 7, 8 and 9, 2026.
There was a discrepancy between the medication administration record and inventory of Buprenorphine on May 1, 3 and 12, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Family Healing Center acknowledges the medication management deficiencies identified during the licensing review and has taken immediate corrective action to strengthen medication oversight, accountability, documentation, and compliance. Upon identification of these findings, the facility revised its medication pass process and designated specific staff responsible for medication observation and documentation. Effective May 15, 2026, one designated staff member has been assigned to oversee medication passes Monday through Friday to promote consistency and accountability in medication practices.
All staff involved in medication observation and documentation were educated on the findings identified during the DDAP review and retrained on medication policies, documentation requirements, medication refusals, inventory management, medication error reporting, and self-administration procedures on May 15, 2026. The Facility Director receives and reviews Medication Administration Records (MARs) daily to identify discrepancies, missed doses, inventory concerns, and documentation errors requiring immediate follow-up.
The facility has updated its medication administration procedures to ensure medications are self-administered under staff observation, medication refusals are documented and communicated to medical providers when clinically indicated, inventory discrepancies are investigated, and medication errors are documented and addressed in accordance with policy. Additional medication management training for all staff involved in medication observation will be completed.
In addition, the Facility Director is working collaboratively with the program's Medical Director to review and strengthen medication management policies and procedures to ensure long-term sustainability and compliance. Revised medication policies and procedures, including medication accountability, inventory reconciliation, refusal documentation, medication error reporting, controlled substance management, and MAR documentation requirements.
To ensure ongoing compliance, daily MAR reviews by the Facility Director began on May 15, 2026, weekly medication audits will be conducted by program leadership.
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709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of policy and procedure, the facility failed to document policies and procedures to respond to unusual incidents involving the following:
Selling or use of illicit drugs on the premises.
Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when know by facility, for ambulatory services.
Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than one day.
Theft, burglary, break-in or similar incident at the facility.
Fire or structural damage to the facility.
Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of May 15, 2026, the Family Healing Center developed and implemented a comprehensive Unusual Incident Response Policy addressing the identification, reporting, documentation, and response procedures for unusual incidents occurring within the facility. The policy includes procedures related to the sale or use of illicit drugs on the premises, death or serious injury resulting from trauma, suicide, medication errors, or other unusual circumstances, significant disruptions of services due to disasters such as fire, storm, flood, or other events resulting in facility closure, theft, burglary, break-ins, fire or structural damage, and outbreaks of contagious diseases requiring notification to the Centers for Disease Control and Prevention (CDC) or other applicable authorities.
The policy clearly establishes staff responsibilities, notification requirements, reporting timelines, documentation standards, and procedures to ensure the safety of residents, children, visitors, and staff during emergency or unusual situations. |
709.51(a)(1) LICENSURE Criteria for Admission
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a written plan providing for intake and admission which includes the criteria for admission, treatment methodology and requirements for the completion of treatment.
These policies were written by facility staff while the inspectors were onsite and dated May 12, 2026; however, this policy was not yet reviewed and approved by the governing body.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Family Healing Center developed a comprehensive Intake and Admission Policy on May 12, 2026, outlining the program's admission criteria, target population, treatment methodology, and requirements for successful completion of treatment. The policy provides clear guidance regarding eligibility for admission, referral and screening procedures, admission decision-making processes, service expectations, and discharge planning requirements.
The policy also defines the evidence-based treatment approaches utilized by the program and establishes expectations for participation in treatment, recovery activities, case management, parenting services, and other program requirements necessary for successful completion of treatment.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of facility policy and procedures and client records, the facility failed to document a physical examination in four of four client records.
Facility policy states that referrals will be made for physical examinations within seven days of admission. There were no physical examinations documented in client records #1, 2, 3 and 4.
Client #1 was admitted on February 11, 2026.
Client #2 was admitted on April 18, 2026.
Client #3 was admitted on February 17, 2026.
Client #4 was admitted on January 24, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 1, 2026, the Family Healing Center implemented a formal procedure to ensure that completed physical examination documentation is obtained and maintained within each client's record. Because the Family Healing Center does not provide physical examinations onsite, clients continue to be referred to community primary care providers and partner medical clinics for completion of their required physical examinations.
To standardize the process, the Family Healing Center developed a Physical Examination Form that accompanies each client to their appointment. Primary care providers are asked to complete the form during the examination and return it to the Family Healing Center via secure fax, encrypted email, electronic transmission, or by providing the completed form to the client to return to the facility. Staff are responsible for tracking scheduled appointments, following up with medical providers when documentation has not been received, and ensuring the completed form is maintained in the client's medical record.
Written procedures outlining the scheduling process, use of the Physical Examination Form, documentation tracking, follow-up expectations, and record retention were implemented on June 1, 2026.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of policy and procedure, the facility failed to document a written policy that includes short and long-term goals for treatment as formulated by the staff and client, type and frequency of treatment and rehabilitation services and proposed type of support service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of May 15, 2026, the Family Healing Center developed and implemented a comprehensive Treatment Planning Policy that outlines the requirements for individualized treatment planning, including the development of short-term and long-term treatment goals in collaboration with the client. The policy also specifies the required type and frequency of treatment and rehabilitation services, support services, case management activities, recovery support services, and other interventions necessary to address each client's identified needs.
The policy emphasizes active client participation in the treatment planning process and ensures that treatment goals, objectives, interventions, and support services are individualized based on the client's strengths, needs, preferences, and stage of recovery.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every thirty days, as required by facility policy and regulation in two of six client records.
Client #1 was admitted on February 11, 2026 and was active at the time of the inspection. A treatment plan was documented with client #1 on February 11, 2026. A treatment plan update was due to be completed by March 11, 2026. The treatment plan was documented on March 25, 2026.
Client #4 was admitted on January 24, 2026 and was active at the time of the inspection. A treatment plan was documented with client #1 on March 26, 2026. A treatment plan update was due to be completed by April 26, 2026. The treatment plan was documented on May 4, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon identification of this finding, the Family Healing Center reviewed its treatment plan monitoring process and implemented additional oversight measures to ensure treatment plan updates are completed within required timeframes. The Clinical Supervisor currently maintains a treatment plan monitoring checklist that tracks due dates for treatment plans and treatment plan updates and provides ongoing oversight of clinical documentation requirements.
The monitoring checklist has been reinforced as part of the facility's quality assurance process and is reviewed regularly to identify upcoming deadlines and ensure timely completion of treatment plan updates. Clinical staff have been reminded of the requirement to complete treatment plan updates every 30 days in accordance with facility policy and regulatory requirements.
In addition, the Clinical Supervisor will continue to conduct routine chart audits and documentation reviews to verify compliance with treatment planning requirements and provide corrective action or additional supervision when deficiencies are identified. Program leadership will monitor compliance through ongoing quality assurance activities to ensure treatment plan updates are completed within required timeframes moving forward. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the client ' s individual treatment and rehabilitation plan in seven of seven client records.
Client #1 was admitted on February 11, 2026 and was active at the time of the inspection. Client #1 ' s treatment plan documented that individual sessions were to be offered once per week and group sessions daily.
Client #1 did not have documentation of individual sessions the weeks of February 15 - 21 and 22-28, March 8-14, 15-21, 22-28, March 20 - April 4, April 5-11 and 12-18, 2026.
Client #1 did not have documentation of group sessions daily every week for the entire treatment episode.
Client #2 was admitted on April 18, 2026 and was active at the time of the inspection. Client #1 ' s treatment plan documented that individual sessions were to be offered once per week and group sessions daily.
Client #2 did not have documentation of any individual sessions for the entire treatment episode.
Client #2 did not have documentation of group sessions daily every week for the entire treatment episode.
Client #3 was admitted on February 17, 2026 and was active at the time of the inspection. Client #3 ' s treatment plan documented that individual sessions were to be offered once per week and group sessions daily.
Client #3 did not have documentation of individual sessions the weeks of March 1-7, 15-21, April 5-11 and April 26 - May 2, 2026.
Client #3 did not have documentation of group sessions daily every week for the entire treatment episode.
Client #4 was admitted on January 24, 2026 and was active at the time of the inspection. Client #4 ' s treatment plan documented that individual sessions were to be offered once per week and group sessions daily.
Client #4 did not have documentation of any individual sessions for the weeks of January 25 - 31, February 8 - 14, and March 8 - 14, 2026.
Client #4 did not have documentation of group sessions daily every week for the entire treatment episode.
Client #5 was admitted on January 23, 2026 and was discharged on April 24, 2026. Client #5 ' s treatment plan documented that individual sessions were to be offered once per week and group sessions daily.
Client #5 did not have documentation of any individual sessions for the weeks of January 25 - 31, February 1 - 8, 8 - 14, 15-21 and April 5 -11, 2026.
Client #5 did not have documentation of group sessions daily every week for the entire treatment episode.
Client #6 was admitted on May 9, 2025 and discharged on April 6, 2026. The time period reviewed for Client #6 was January 1, 2026 - April 6, 2026. Client #6 ' s treatment plan documented that individual sessions were to be offered once per week and group sessions daily.
Client #6 did not have documentation of any individual sessions for the weeks of January 11 - 17, 18 - 24, 25 - 31, February 1 - 7, 15-21, March 8 - 14, 15 - 21, 22-28 and March 29 - April 4, 2026.
Client #6 did not have documentation of group sessions daily every week for the entire time period reviewed.
Client #7 was admitted on November 19, 2025 and was discharged on April 1, 2026. Client #7 ' s treatment plan documented that individual sessions were to be offered once per week and group sessions daily.
Client #7 did not have documentation of any individual sessions for the weeks of November 23 - 29, November 30 - December 6, December 7 - 13, 21-27, 2025 and January 4 - 10, 18 - 24, February 1 - 8, 8 - 14, 15-21, March 1 - 7, 8 - 14, 15- 21 and 22 - 28, 2026
Client #7 did not have documentation of group sessions daily every week for the entire treatment episode.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Family Healing Center acknowledges that deficiencies in clinical documentation occurred during the review period. During this time, multiple clinical staff members were terminated for failure to complete required documentation and clinical recordkeeping responsibilities. Documentation regarding these personnel actions is maintained within agency Human Resources records.
Effective June 10, 2026, the Family Healing Center implemented its initial corrective actions in response to these concerns. Since that time, the facility has hired new clinical staff and implemented enhanced clinical oversight procedures. The Clinical Supervisor now meets individually with each clinician on a weekly basis to review client progress, treatment needs, service delivery requirements, and documentation expectations. These supervision meetings are documented through weekly supervision records and are currently being conducted on an ongoing basis.
Additionally, the facility initiated a comprehensive review of all active client records beginning June 10, 2026, to ensure that counseling services provided are accurately reflected in the clinical record and that all documentation requirements are met. The Clinical Supervisor oversees this process and is responsible for ensuring all active client records are reviewed for compliance.
Moving forward, weekly supervision, ongoing chart audits, documentation monitoring, and clinical oversight will continue to ensure counseling services are delivered in accordance with individualized treatment plans and appropriately documented within the client record. Program leadership will continue to monitor compliance, provide ongoing coaching to clinical staff, and implement corrective action whenever documentation deficiencies are identified. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to document counseling sessions on a regular and scheduled basis in seven of seven client records.
Client #1 was admitted on February 11, 2026 and was active at the time of the inspection. Client #1 did not have documentation of weekly individual sessions and daily group sessions for the entire treatment episode. Client #1 had documentation of three individual sessions and twenty one group sessions total from February 11 - May 12, 2026.
Client #2 was admitted on April 18, 2026 and was active at the time of the inspection. Client #2 did not have documentation of weekly individual sessions and daily group sessions for the entire treatment episode. Client #2 did not have documentation of any individual sessions and four group sessions total from April 18 - May 12, 2026.
Client #3 was admitted on February 17, 2026 and was active at the time of the inspection. Client #3 did not have documentation of weekly individual sessions and daily group sessions for the entire treatment episode. Client #3 had documentation of eleven individual sessions and twenty two group sessions total from February 17 - May 12, 2026.
Client #4 was admitted on January 24, 2026 and was active at the time of the inspection. Client #4 did not have documentation of weekly individual sessions and daily group sessions for the entire treatment episode. Client #4 had documentation of thirteen individual sessions and twenty five group sessions total from January 24 - May 12, 2026.
Client #5 was admitted on January 23, 2026 and discharged on April 24, 2026. Client #5 did not have documentation of weekly individual sessions and daily group sessions for the entire treatment episode. Client #5 had documentation of eight individual sessions and sixteen group sessions total from January 23 - May 12, 2026.
Client #6 was admitted on May 9, 2025 and discharged on April 6, 2026. Client #6 did not have documentation of weekly individual sessions and daily group sessions for the entire treatment episode. Client #6 had documentation of sixteen individual sessions total from February 1 - April 6, 2026 and nineteen group sessions from February 1 - April 6, 2026.
Client #7 was admitted on November 19, 2025 and discharged on April 1, 2026. Client #7 did not have documentation of weekly individual sessions and daily group sessions for the entire treatment episode. Client #7 had documentation of six individual sessions total from November 19, 2025 - April 1, 2026 and nineteen group sessions from January 1 - April 1, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 10, 2026, the Family Healing Center corrected this deficiency through changes in clinical staffing and enhanced documentation oversight. During the review period, the facility experienced significant clinical staffing challenges, including the termination of multiple clinical staff members for failure to complete required documentation and recordkeeping responsibilities. Documentation regarding these personnel actions is maintained within agency Human Resources records. New clinical staff were hired and trained on the facility's documentation standards and regulatory requirements upon hire.
Since implementation of the staffing changes, counseling services are being documented consistently within the clinical record. The Program Manager is responsible for monitoring documentation completed by Certified Recovery Specialists and support staff, while the Clinical Supervisor reviews all clinical documentation completed by counselors and therapists. The Facility Director also conducts ongoing supervision with program leadership to review documentation compliance, identify deficiencies, and ensure timely completion of records.
All staff have been educated on the requirement that documentation be completed within 48 hours of service delivery in accordance with facility policy. Additionally, the Family Healing Center implemented a daily group attendance and documentation tracking process to verify that all services provided are accurately documented and entered into the electronic health record. Program leadership reviews documentation compliance daily and conducts routine chart audits to ensure records remain current. |
709.54(a)(1) LICENSURE Purchasing food/equipment
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(1) Purchasing of food and equipment.
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Observations
Based on a review of policies and procedures, the facility failed to develop written policies and procedures for its dietetic services which include:
Purchasing of food and equipment.
Receiving, storing and preserving of food stuff.
Proper preparation of food.
Safety and sanitation, including the preparation, handling, and storage of foods; the care and cleaning of dishes, utensils and work area.
Personal hygiene for those in food preparation areas.
Special dietary needs.
The policy was written by facility staff while the inspectors were onsite and dated May 12, 2026; however, this policy was not yet reviewed and approved by the governing body.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Family Healing Center developed a comprehensive Dietetic Services Policy on May 12, 2026, addressing all required components of food service operations, including the purchasing of food and equipment, receiving, storing, and preserving food items, food preparation procedures, safety and sanitation practices, food handling and storage requirements, cleaning and maintenance of dishes, utensils, and food preparation areas, personal hygiene expectations for staff working in food preparation areas, and procedures for addressing special dietary needs.
As part of the facility's corrective action efforts, staff responsible for food service oversight will receive SafeServ training, and all staff will be retrained on food safety, sanitation, food storage, and temperature monitoring. In addition, written food handling and temperature monitoring procedures will be implemented and posted within the kitchen area as an ongoing reference for staff.
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709.54(b) LICENSURE Aftercare policy
709.54. Project management services.
(b) The project shall develop a written client aftercare policy.
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Observations
Based on a review of policy and procedures, the facility failed to develop a written aftercare policy which includes what will be documented in the aftercare plan and what clients will receive one.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of May 15, 2026, the Family Healing Center developed and implemented a comprehensive Aftercare and Continuing Care Policy outlining the requirements for aftercare planning and the development of individualized aftercare plans for clients transitioning from treatment. The policy specifies when aftercare plans are to be completed and identifies the required components, including recovery goals, housing plans, medical and behavioral health follow-up appointments, medication and medication-assisted treatment (MAT) coordination, recovery support services, community resources, family support services, employment or educational resources, and other recommendations necessary to support ongoing recovery and stability.
The policy emphasizes the development of individualized aftercare plans in collaboration with each client and, when appropriate, family members, child welfare representatives, and other community supports to promote continuity of care and a successful transition from residential treatment.
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709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
Based on a review of policies and procedures, the facility failed to develop written policies and procedures for client follow up.
The policy was written by facility staff while the inspectors were onsite and dated May 12, 2026; however, this policy was not yet reviewed and approved by the governing body.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Family Healing Center developed a written Client Follow-Up Policy on May 12, 2026, outlining procedures for post-discharge follow-up and ongoing recovery support. The policy establishes expectations regarding the timing, method, and documentation of follow-up contacts with clients following discharge from the program and identifies staff responsibilities related to follow-up services.
The policy includes procedures for documenting follow-up attempts and successful contacts, assessing client progress and recovery status, identifying barriers to continued recovery, providing referrals or linkage to additional services when needed, and documenting outcomes of follow-up efforts within the client record.
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709.54(d)(1) LICENSURE Outreach Identifying Persons
709.54. Project management services.
(d) The project shall develop a written plan providing for outreach services which includes, but is not limited to:
(1) Identifying persons in need of project services.
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Observations
Based on a review of policies and procedures, the facility failed to develop written policies and procedures for its outreach services which include:
Identifying persons in need of project services.
Alerting persons and their families to the availability of project services.
Encouraging persons to utilize the service delivery system.
The policy was written by facility staff while the inspectors were onsite and dated May 12, 2026; however, this policy was not yet reviewed and approved by the governing body.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Family Healing Center developed a written Outreach Services Policy on May 12, 2026, outlining the program's approach to identifying individuals and families who may benefit from services, increasing awareness of available treatment and recovery supports, and encouraging engagement in the service delivery system.
The policy includes procedures for community outreach, collaboration with referral sources, communication with child welfare and community partners, dissemination of program information, and efforts to educate potential clients and families regarding available services and treatment opportunities. The policy also outlines strategies for promoting access to care and reducing barriers to treatment participation.
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