INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 15, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mid-Atlantic Rehabilitation Services, Inc., 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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709.92(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, the facility failed to document whether a client participated in the development of the individual treatment and rehabilitation plan in three of seven client records reviewed.Client #2 was admitted on August 12, 2025 and was active at the time of the inspection. A comprehensive treatment plan completed on August 21, 2025, did not have written documentation that the client participated in the development of the comprehensive treatment plan.Client #5 was admitted on August 26, 2025 and was discharged on November 3, 2025. A comprehensive treatment plan completed on October 9, 2025, did not have written documentation that the client participated in the development of the comprehensive treatment plan.Client #6 was admitted on May 2, 2025 and was discharged on November 4, 2025. A comprehensive treatment plan completed on June 6, 2025, did not have written documentation that the client participated in the development of the comprehensive treatment plan.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How to correct: Clinicians have been instructed to document in clinical notes when treatment plans are updated.
Clinical staff will submit treatment plans on or before date due.
Training supplied: A training has been held to overview correct protocol and processes.
Preventing reoccurrence: Auditing will be completed by quality assurance on a monthly basis. If ongoing issues are identified, quality assurance will inform clinical supervisor and additional trainings will be held with clinician on proper protocol.
Person responsible for overseeing change: Quality Assurance Director, Clinical Supervisor
CAP completed: 3/1/26 |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include an aftercare plan entered seven days prior to discharge, per the facility's policy, in two of two applicable records reviewed.Client #4 was admitted on February 18, 2025, and was discharged on April 22, 2025. Per the facility ' s policy, the client's aftercare plan was to be documented no later than April 15, 2025; however, the client ' s aftercare plan was not documented in the record until April 28, 2025.Client #6 was admitted on May 2, 2025 and was discharged on November 4, 2025. Per the facility ' s policy, the client's aftercare plan was to be documented no later than October 28, 2025; however, the client ' s aftercare plan was not documented in the record until November 24, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How to correct: While aftercare plans will be conducted during final sessions with client, plan submissions will be extended to 14 days after discharge.
This policy has been written, however, needs approval by the board of directors of our company. Anticipated date of implementation is March 31, 2026.
Training supplied: A training has been held to overview correct protocol and processes.
Preventing reoccurrence: Auditing will be completed by quality assurance and clinical supervisor monthly. Clinical supervisor will address any documentation challenges with clinician to remedy. Corrective action to clinicians will be conducted if repeated late submissions are found.
Person responsible for overseeing change: Quality Assurance Director, Program Director, Clinical Supervisor
CAP complete: 3/31/26 |