INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 22-23, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Fellowship House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.28 (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 a review of fire drill logs from May 2024 through March 2025, the facility failed to ensure that fire drill logs included the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative in all months reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward a new Fire Drill Log Checklist has been implemented to ensure all required elements are reviewed and completed monthly.
The Facility Safety Officer (or designated staff) will review each monthly fire drill log for completeness and accuracy.
The Program Director will conduct a quarterly audit of fire drill logs to ensure sustained compliance.
This new plan was implemented on April 30, 2025.
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709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the name of the person, agency or organization in six out of fourteen records reviewed.
Client #2 was admitted on October 29, 2024, and was discharged on February 3, 2025. A consent to release information form was signed and dated by the client, on October 29, 2024; however, it did not indicate the name of the person, agency or organization to whom disclosure may be made.
Client #3 was admitted on April 9, 2024, and discharged on August 12, 2024. A consent to release information form was signed and dated by the client on April 9, 2024; however, it did not indicate the name of the person, agency or organization to whom disclosure may be made.
Client #5 was admitted on August 29, 2024, and was discharged on October 13, 2024. A consent to release information form was signed and dated by the client on August 29, 2024; however, it did not indicate the name of the person, agency or organization to whom disclosure may be made.
Client #6 was admitted on October 24, 2024 and discharged on January 27, 2025. A consent to release information form was signed and dated by the client on October 24, 2024; however, it did not indicate the name of the person, agency or organization to whom disclosure may be made.
Client #7 was admitted on September 5, 2024 and discharged on February 10, 2025. A consent to release information form was signed and dated by the client on September 5, 2024; however, it did not indicate the name of the person, agency or organization to whom disclosure may be made.
Client #12 was admitted on October 03, 2024 and discharged on March 26, 2025. A consent to release information form was signed and dated by the client on October 03, 2024; however, it did not indicate the name of the person, agency or organization to whom disclosure may be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Going foward, the facility reviewed and updated its Consent to Release Information form to ensure it includes a clearly designated field for the name of the person, agency, or organization to whom information will be disclosed.
This form is now included in the EMR under the intake tab in which admissions department completes and is also part of the intake checklist in which will be reviewed by clinical director weekly.
The admission coordinator of Fellowship Houses is responsible for reviewing and obtaining signature in EMR, after last year 2024 inspection the admission coordinator had this consent signed in the clients paper chart in which the compliance department was not aware of until the day after 2025 inspection. Since 2025 inspection this consent is now performed by the admissions coordinator upon admission to Fellowship Houses and is a release in the EMR under the intake tab, this was corrected on 4/30/2025 |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the purpose of the disclosure in ten out of fourteen records reviewed.
Client #1 was admitted on June 24, 2024, and was discharged on September 4, 2024. An informed and voluntary consent from the client for the disclosure of information to a county probation, emergency contact and another provider, signed and dated June 25, 2024, did not include the purpose of disclosure.
Client #3 was admitted on April 09, 2024, and was discharged on August 12, 2024. An informed and voluntary consent from the client for the disclosure of information to an attorney, therapist, and county probation, signed and dated May 03, 2024, did not include the purpose of disclosure.
Client #5 was admitted on August 29, 2024, and was discharged on October 13, 2024. An informed and voluntary consent from the client for the disclosure of information to the housing authority, and emergency contact, signed and dated August 29, 2024, did not include the purpose of disclosure.
Client #6 was admitted on October 24, 2024, and was discharged on January 27, 2025. An informed and voluntary consent from the client for the disclosure of information to emergency contacts, and a previous facility, signed and dated October 24, 2024, did not include the purpose of disclosure.
Client #7 was admitted on September 5, 2024, and was discharged on February 10, 2025. An informed and voluntary consent from the client for the disclosure of information to a county assistance office and emergency contact signed and dated September 5, 2024, did not include the purpose of disclosure.
Client #10 was admitted on May 30, 2024, and discharged on February 7, 2025. An informed and voluntary consent from the client for the disclosure of information to two emergency contacts, signed and dated May 30, 2024 and February 7, 2025, respectively, did not include the purpose of disclosure.
Client #11 was admitted on July 19, 2024, and discharged on September 1, 2024. An informed and voluntary consent from the client for the disclosure of information to an emergency contact, and treatment court, signed and dated July 19, 2024, did not include the purpose of disclosure.
Client #12 was admitted on October 3, 2024, and discharged on March 26, 2025. An informed and voluntary consent from the client for the disclosure of information to an emergency contact, signed and dated October 03, 2024, did not include the purpose of disclosure.
Client #13 was admitted on June 15, 2024 and discharged December 02, 2024. An informed and voluntary consent from the client for the disclosure of information to an emergency contact, signed and dated May 21, 2024, did not include the purpose of disclosure.
Client #14 was admitted on August 16, 2024, and discharged on January 9, 2025. An informed and voluntary consent from the client for the disclosure of information to an emergency contact, signed and dated August 16, 2024, did not include the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 23, 2024 licensing inspection.
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Plan of Correction
Going forward the facility has redesigned its "Consent to Release Information" form to ensure the "Purpose of Disclosure" field is clearly marked and required the admissions department is responsible for obtaining signature upon admission.
The clinical director will review these forms weekly to ensure proper documentation is appropriate and signed.
As of April 30 2025 this consent was added to the EMR and the admissions coordinator is responsible upon admission of reviewing and obtaining signature from client. |
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 client records, the facility failed to document the written acknowledgement by clients that they had been notified of all of their regulatory client rights in fourteen of fourteen client records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward the facility has updated its intake form in Sunwave EMR to ensure that a dedicated Client Rights Acknowledgment Form is included and must be signed and dated by the client at intake.
The admissions department is responsible for disclosing the right to the client obtaining signature and the clinical director will review the charts weekly to ensure all documentation is present and signed.
As of April 30, 2025 the client rights have been updated and added the EMR, the admissions coordinator is responsible for reviewing and obtaining signature of client upon admission. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within seven days following admission.
Client #1 was admitted on June 24, 2024, and discharged on September 4, 2024. A comprehensive treatment plan was due no later than July 1, 2024; however, it was not completed until July 11, 2024.
Client #2 was admitted on October 29, 2024, and discharged on February 3, 2025. A comprehensive treatment plan was due no later than November 5, 2024; however, it was not completed until November 15, 2024.
Client #4 was admitted on September 26, 2024, and discharged on January 10, 2025. A comprehensive treatment plan was due no later than October 3, 2024; however, it was not completed until October 11, 2024.
Client #5 was admitted on August 29, 2024, and discharged on October 13, 2024. A comprehensive treatment plan was due no later than September 5, 2024; however, it was not completed until September 6, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/21/2025, the facility conducted a review of all currently open client charts to ensure that comprehensive treatment plans were completed within the required 7-day timeframe. Any late or missing treatment plans were immediately completed and documented.
The four cited client records have been reviewed and logged internally. Although the clients may be discharged, these files will be used for staff retraining and compliance reinforcement.
Staff retraining of facility policies and procedures for treatment plan will occur with 30 days.
The clinical director will hold a in service training within 30 days for the proper procedure and policies of the manual and train clinical staff on how this will be completed.
The clinical director will check all charts in EMR to ensure proper documentation is present in timely manner according to policies and procedures, This will be completed 6/21/2025. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document treatment plan updates within the regulatory timeframe in seven out of seven records reviewed.
Client #1 was admitted on June 24, 2024 and was discharged on September 4, 2024. A comprehensive treatment plan was completed on July 11, 2024, and an update was due no later than August 11, 2024; however, none was completed.
Client #2 was admitted on October 29, 2024 and was discharged on February 3, 2025. A comprehensive treatment plan was completed on November 15, 2024, and an update was due no later than December 15, 2024; however, none was completed.
Client #3 was admitted on April 09, 2024 and was discharged August 12, 2024. A comprehensive treatment plan was completed on April 15, 2024, and an update was due no later than May 15, 2024; however, none was completed.
Client #4 was admitted on September 26, 2024 and was discharged on January 10, 2024. A comprehensive treatment plan was completed on October 11, 2024, and an update was due no later than November 11, 2024; however, none was completed.
Client #5 was admitted on August 29, 2024 and was discharged on October 13, 2024. A comprehensive treatment plan was completed on September 06, 2024 and an update was due no later than October 06, 2024; however, none was completed.
Client #6 was admitted on October 24, 2024, and was discharged on January 27, 2025. A comprehensive treatment plan was completed on October 30, 2024, and an update was due no later than November 30, 2024; however, none was completed.
Client #7 was admitted on September 5, 2024, and was discharged on February 10, 2025. A comprehensive treatment plan was completed on September 12, 2024, and an update was due no later than October 12, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/21/2025, the facility completed a full audit of all active PHP client records to identify and complete any overdue treatment plan updates.
The seven cited client records were reviewed and documented as part of internal compliance logs. These files will be used for training and quality improvement, even if the clients are now discharged.
On 6/21/2025, the facility reviewed and reinforced its policy requiring that treatment plan updates for PHP clients occur every 30 calendar days from the date of the last update or the original treatment plan.
Policy language was clarified to include:
A 30-day deadline tracking system,
Mandatory use of an update form or documented progress note summarizing progress, changes in goals or interventions, and updated objectives.
The clinical director will hold in service training within 30 days to train clinical staff on proper policies and procedures.
The clinical director will inspect charts in EMR weekly to check for missing documentation and signatures, this will be completed 6/21/2025 |
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 the review of partial hospitalization client records, the project failed to document individual counseling sessions, at least twice weekly in seven of seven client records reviewed.
Client #1 was admitted on June 24, 2024 and was discharged on September 4, 2024. The project only documented one individual counseling session for each week the client was admitted.
Client #2 was admitted on October 29, 2024 and was discharged on February 3, 2025. The project only documented one individual counseling session for each week the client was admitted.
Client #3 was admitted on April 09, 2024 and was discharged on August 12, 2024. The project only documented one individual counseling session for each week the client was admitted.
Client #4 was admitted on September 26, 2024 and was discharged on January 10, 2025. The project only documented one individual counseling session for each week the client was admitted.
Client #5 was admitted on August 29, 2024, and was discharged on October 13, 2024. The project only documented one individual counseling session for each week the client was admitted.
Client #6 was admitted on October 24, 2024, and was discharged on January 27, 2025. The project only documented one individual counseling session for each week the client was admitted.
Client #7 was admitted on September 05, 2024 and was discharged on February 10, 2025. The project only documented one individual counseling session for each week the client was admitted.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 5.22.2025, the facility performed a full audit of all active PHP client records to verify that each client is receiving and being documented for at least two individual counseling sessions per week.
Any missed or undocumented sessions were addressed with clinical staff, and documentation was brought up to date where applicable.
Clients with irregular session frequencies were prioritized for clinical supervision review and scheduling adjustments.
On 5/22/2025, the facility updated its Clinical Services Policy to clearly state that all PHP clients must receive a minimum of two individual counseling sessions per week, in addition to any group therapy requirements.
The policy now mandates that each individual session must be documented in the client's record with:
Date and time of session,
Duration,
Counselor name,
Summary of therapeutic content, and
Progress toward treatment goals.
3. Staff Training and Compliance Reinforcement:
On 6.15.2025, all clinical staff (including counselors and clinical supervisors) were required to attend a mandatory training focused on:
PHP service delivery expectations,
Required session frequency,
Proper documentation standards, and
Clinical scheduling to ensure clients are seen twice weekly.
Each staff member signed an acknowledgment of training and compliance responsibilities.
A "PHP Counseling Session Tracker" was implemented effective 6.15.2025. This tool tracks each client's weekly session count and flags any clients who fall below the minimum requirement.
Weekly reports are generated and reviewed by the Clinical Supervisor, who addresses any deficiencies immediately with the assigned counselor.
The Clinical director will hold in service training on policies and procedures with 30 days to train clinical staff on all documentation and timeframes of documentation, and the clinical director will perform weekly chart audits to ensure the documentation is complete. |
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 client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 30 days following admission.
Client #1 was admitted on June 24, 2024 and was discharged on September 4, 2024. There was no documentation of case consultations in the client record.
Client #2 was admitted on October 29, 2024 and was discharged on February 3, 2025. There was no documentation of case consultations in the client record.
Client #3 was admitted on April 9, 2024 and discharged on August 12, 2024. There was no documentation of case consultations in the client record.
Client #4 was admitted on September 26, 2024 and discharged on January 10, 2025. There was no documentation of case consultations in the client record.
Client #5 was admitted on August 29, 2024 and discharged on October 13, 2024. There was no documentation of case consultations in the client record.
Client #6 was admitted on October 24, 2024 and discharged on January 27, 2025. There was no documentation of case consultations in the client record.
Client #7 was admitted on September 5, 2024 and was discharged on February 10, 2025. There was no documentation of case consultations in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 5.22.2025, the facility conducted an audit of all current client records to identify missing or overdue case consultations.
All identified overdue case consultations were completed immediately and documented in the electronic medical record (EMR) or client chart.
The seven cited files have been flagged and reviewed internally for documentation training purposes
The Case Consultation Policy was reviewed on [insert date] to reaffirm that case consultations must be completed every 30 calendar days from the date of admission and then monthly thereafter.
The policy was revised to include:
Exact due dates for each client's required consultations,
Guidelines for multi-disciplinary participation,
Acceptable documentation format and minimum content.
The Clinical Director will hold in service training with 30 days for clinical staff to train on proper policies and procedures and hold weekly chart audits to ensure proper documentation is complete.
The in service is scheduled for 6.15.2025 for all clinical staff. |
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 the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client and include written documentation of the type and frequency of treatment and rehabilitation services in three out of seven client records reviewed.
Client #10 was admitted on May 30, 2024, and discharged on February 7, 2025. A comprehensive treatment plan was developed on June 05, 2025, that did not include the type or frequency of treatment and rehabilitation services.
Client #11 was admitted on July 19, 2024, and was discharged on September 1, 2024. A comprehensive treatment plan was developed on July 26, 2024, that did not include the type or frequency of treatment and rehabilitation services.
Client #12 was admitted on October 03, 2024, and discharged on March 26, 2025. A comprehensive treatment plan was developed on November 04, 2024. that did not include the type or frequency of treatment and rehabilitation services.
Client #13 was admitted on June 15, 2024 and discharged on December 02, 2024. A comprehensive treatment plan was developed on June 15, 2024, that did not include the type or frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5.22.2025, the facility reviewed and corrected the three cited treatment plans to clearly specify both the type (e.g., individual counseling, group therapy, case management) and frequency (e.g., 2x/week, 3x/week) of services.
A full chart audit was conducted for all active clients to identify any other treatment plans missing required information; all non-compliant plans were updated immediately.
The facility's treatment planning policy was revised on 5.22.2025 to explicitly require that:
All treatment plans include the specific type(s) of services being provided,
The frequency for each service is clearly written (e.g., "Individual therapy: 2x/week").
A new treatment plan template was adopted to include mandatory fields for type and frequency. These fields must be completed before the plan can be finalized in the EMR.
The clinical director will hold in service training on 6.15.2025 for clinical staff to train on proper documentation and hold weekly audits of charts in EMR to ensure documentation is complete. |
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 document treatment plan updates within the regulatory timeframe in seven out of seven records reviewed.
Client #8 was admitted on September 5, 2024 and was discharged on November 8, 2024. A comprehensive treatment plan was completed on September 5, 2024, and an update was due no later than November 5, 2024; however, there was no documentation of an update being completed.
Client #9 was admitted on June 24, 2024 and was discharged on December 27, 2024. A comprehensive treatment plan was completed on July 12, 2024, and an update was due no later than September 12, 2024; however, there was no documentation of an update being completed.
Client #10 was admitted on May 30, 2024 and was discharged on February 7, 2025. A comprehensive treatment plan was completed on June 05, 2024, and an update was due no later than August 05, 2025; however, there was no documentation of an update being completed.
Client #11 was admitted on July 19, 2024 and was discharged on September 1, 2024. A comprehensive treatment plan was completed on July 26, 2024, and an update was due no later than September 26, 2024; however, there was no documentation of an update being completed.
Client #12 was admitted on October 03, 2024 and was discharged on March 26, 2025. A comprehensive treatment plan was completed on November 04, 2024, and an update was due no later than January 04, 2024; however, there was no documentation of an update being completed.
Client #13 was admitted on June 15, 2024 and was discharged on December 02, 2024. A comprehensive treatment plan was completed on June 15, 2024, and an update was due no later than August 15, 2024; however, there was no documentation of an update being completed.
Client #14 was admitted on August 16, 2024 and was discharged on January 09, 2025. A treatment comprehensive plan was completed on August 27, 2024, and an update was due no later than October 27, 2024; however, there was no documentation of an update being completed.
These findings were reviewed with facility staff during licensing process.
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Plan of Correction
On 5.22.2025, the facility conducted a full chart review of all active outpatient clients.
All overdue or missing treatment plan updates were immediately completed and documented.
The 7 cited records were corrected to include updated treatment plan reviews with client input.
The facility's Treatment Plan Review Policy was reviewed and updated on 5.22.2025 to clearly state:
Outpatient treatment plans must be updated at least every 60 calendar days from the date of the initial plan and each subsequent update.
Updates must reflect progress on goals, modifications to services, and current clinical status.
The clinical director will hold in service training with clinical staff on 6.15.2025 proper policies and procedures, the clinical director will also perform weekly audits to ensure documentation is complete. |
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 facility failed to ensure that the clients received counseling services according to their individual treatment plan in seven out of seven applicable records reviewed.
Client #8 was admitted on September 05, 2024 and discharged on November 08, 2024. The treatment plan dated September 5, 2024, indicated one individual treatment session weekly and groups two times a week. There was no documentation of the client receiving any individual or group therapy sessions between intake and discharge.
Client #9 was admitted on June 24, 2024 and discharged on December 27, 2024. The treatment plan dated July 12, 2024, indicated one individual treatment session weekly and one group session weekly. There was no documentation of the client receiving any individual or group therapy sessions between intake and discharge.
Client #10 was admitted on May 30, 2024 and discharged on February 7, 2025. The treatment plan dated June 05, 2024, indicated one individual treatment session weekly and groups three times a week. There was no documentation of the client receiving any individual or group therapy sessions between intake and discharge.
Client #11 was admitted on July 19, 2024 and discharged on September 01, 2024. The treatment plan dated July 26, 2024 indicated one individual treatment session weekly and groups three times a week. There was no documentation of the client receiving any individual or group therapy sessions between intake and discharge.
Client #12 was admitted on October 03, 2024 and discharged on March 26, 2025. The treatment plan dated November 04, 2024, indicated one individual treatment session weekly and groups three times a week. There was no documentation of the client receiving any individual or group therapy sessions between intake and discharge.
Client #13 was admitted on June 15, 2024 and discharged on December 02, 2024. The treatment plan dated June 15, 2024, indicated one individual treatment session weekly and groups three times a week. There was no documentation of the client receiving any individual or group therapy sessions between intake and discharge.
Client #14 was admitted on August 16, 2024 and discharged on January 09, 2025. The treatment plan dated August 27, 2024, indicated one individual treatment session weekly and groups five times a week. There was no documentation of the client receiving any individual treatment sessions between intake and discharge. In addition, there is no documentation that the client received group five times a week for the weeks of August 18-24, 2024, August 25-31, 2024, September 1-7, 2024, September 15-21, 2024, September 29-October 5, 2024, October 6-12, 2024, October 13-19, 2024, October 20-26, 2024, October 27- November 02, 2024, November 10-16, 2024, November 17-23, 2024, November 24-30, 2024, December 1-7, 2024, December 8-14, 2024, December 15-21, 2024, December 22-28, 2024, December 29, 2024-January 4, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5.22.2025, all current outpatient client records were audited to compare scheduled services with what was documented in their treatment plans.
For any client not receiving services as scheduled in their plan, an updated treatment plan review was completed in collaboration with the client to realign services or adjust goals/frequency appropriately.
The 7 cited records were corrected with updated documentation, and services were aligned with active treatment goals.
The Treatment Delivery and Adherence Policy was reviewed and updated on 5.22.2025 to include:
Mandatory alignment between the documented frequency/type of counseling services and actual service delivery.
Documentation of justification when planned services are missed, canceled, or rescheduled (e.g., client no-show, emergency, clinical judgment).
The clinical director will hold in service training on 6.15.2025 for policies and procedures with the clinical staff and retrain on documentation and timeframe documentation is required and perform weekly chart audits of the EMR to ensure all documentation. |
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 document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every thirty days following admission.
Client #8 was admitted on September 05, 2024 and was discharged on November 8, 2024. There was no documentation of case consultations in the client record.
Client #9 was admitted on admitted on June 24, 2024 and discharged on December 27, 2024. There was no documentation of case consultations in the client record.
Client #10 was admitted on May 30, 2024 and was discharged on February 07, 2025. There was no documentation of case consultations in the client record.
Client #11 was admitted on July 19, 2024 and was discharged on September 1, 2024. There was no documentation of case consultations in the client record.
Client #12 was admitted on October 03, 2024 and was discharged on March 26, 2025. There was no documentation of case consultations in the client record.
Client #13 was admitted on June 15, 2024 and was discharged on December 02, 2024. There was no documentation of case consultations in the client record.
Client #14 was admitted on August 16, 2024 and was discharged on January 09, 2025. There was no documentation of case consultations in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5.22.2025, the facility conducted a full audit of all active outpatient records.
Any case consultations that were overdue or missing were immediately completed and documented in accordance with policy.
The 7 cited client records were corrected to include the required 30-day case consultations.
On 5.22.2025, the facility's policy regarding case consultations was re-reviewed with all clinical staff to ensure clarity on:
Case consultations must be completed every 30 days following admission,
Consultations must involve input from at least two members of the multidisciplinary team and be documented in the client's record.
The Clinical Director will hold in service training on 6.15.2025 to train clinical staff on proper procedures and policies for case consultation, the clinical director will hold weekly chart audits to ensure the documentation is complete.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for documentation of client's rights in the outpatient records was submitted and approved by the Department for the June 09, 2023, and April 23, 2024, annual licensing inspections. Documentation of client's rights was again found to be a deficiency in the April 22-23, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5.22.2025, the intake packet was revised to include a mandatory client rights acknowledgment form as a required field before clinical services can begin.
The intake checklist now includes a verification step for client rights documentation.
Client rights is now a form under the intake tab in which is signed upon admission in the EMR.
On 5.22.2025, all intake and admissions staff were retrained on:
The regulatory requirement for documenting client rights,
The importance of compliance with prior approved plans of correction,
Proper use of the revised intake packet and checklist.
Staff were required to sign a corrective action acknowledgment form, confirming understanding of updated intake procedures and accountability.
The clinical director perform weekly chart audits to ensure the documentation is done correctly and in the time appropriate manner according to policies and procedures. |