INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 12, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Synergy Treatment LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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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 and the facility policy and procedures manual, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client, per facility policy, in four of seven applicable records reviewed. The facility policy and procedure manual stated that the individual treatment and rehabilitation plan will be developed with the client within five days of admission.Client # 2 was admitted into the partial hospitalization activity on July 20, 2026 and was active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed by July 25, 2026; however, the plan was not completed until July 28, 2026.Client # 4 was admitted into the partial hospitalization activity on September 25, 2025 and discharged on October 13, 2025. The individual treatment and rehabilitation plan was due to be completed by September 30, 2025; however, the plan was not completed until October 6, 2025. Client # 5 was admitted into the partial hospitalization activity on November 7, 2025 and discharged on January 5, 2026. The individual treatment and rehabilitation plan was due to be completed by November 12, 2025; however, the plan was not completed until November 14, 2025. Client # 7 was admitted into the partial hospitalization activity on March 1, 2026 and discharged on April 9, 2026. The individual treatment and rehabilitation plan was due to be completed by March 6, 2026; however, the plan was not completed until March 12, 2026. This is a repeat citation from the August 27, 2025 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations will conduct an audit of all new PHP admissions in the next three months to ensure individual treatment plans are developed within 5 days.
On September 16, 2026, the Director of Clinical Operations will provide a treatment plan training to all staff reinforcing documentation timelines. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records and the facility policy and procedures manual, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client, per facility policy, in two of six applicable records reviewed. Client # 10 was admitted into the outpatient activity on June 11, 2026 and was active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed by June 16, 2026; however, the plan was not completed until June 18, 2026.Client # 12 was admitted into the outpatient activity on September 8, 2025 and discharged on January 8, 2026. The individual treatment and rehabilitation plan was due to be completed by September 13, 2025; however, the plan was not completed until September 19, 2025. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations will conduct an audit of all new admissions in the next three months to ensure individual treatment plans are developed in compliance with policy and procedures.
On September 16, 2026, the Director of Clinical Operations will provide a treatment plan training to all staff reinforcing documentation timelines. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in two of four applicable records reviewed. Client # 11 was admitted into the outpatient activity on October 10, 2025 and was discharged on February 27, 2026. There was no follow-up information documented in the record at the time of the inspection.Client # 12 was admitted into the outpatient activity on September 8, 2025 and discharged on January 8, 2026. There was no follow-up information documented in the record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations will conduct an audit of one discharged chart per therapist monthly.
On September 14, 2026, the Director of Clinical Operations will provide a discharge documentation training to all staff. |