INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted May 12-13, 2026, 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 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure one clinical supervisor who had not functioned for 2 years as a supervisor in the provision of clinical services completed a core curriculum in clinical supervision.
Employee #2 was hired as the clinical supervisor on July 29, 2025, and was current in that position. Employee #2 did not complete a Department approved core curriculum in clinical supervision until March 24, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor has obtained her clincial supervisor training on 3/24/26,the CEO and compliance department will perform quarterly personnel reviews to ensure all trainings and required documentation are compliant for regulation 704.6(c). |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure one clinical supervisor participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in that position.
Employee #2 was hired as the clinical supervisor on July 29, 2025, and was current in that position. Employee #2 ' s supervision for the first 6 months of employment was not conducted with their supervisor according to the facility ' s organization chart; it was instead conducted with the chief financial officer.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The organizational chart has been updated which accurately reflects the organizational changes from July 7, 2025. These changes include the CFO being hired with the intention of utilizing his significant clinical experience to assist the CEO with oversight of clinical operations which included supervising employee #2. The CFO has a master's in science of clinical mental health counseling and is a certified clinical supervisor as well as CADC which makes the CFO qualified for the clinical oversight and duties. The HR director and CEO individualized the job description for the CFO which reflect the forementioned job responsibilities. The HR director will ensure that job descriptions are individualized to reflect accurate job duties to avoid further discrepancies. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of administrative documents, the facility failed to 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 a mechanism to collect feedback on all forms of completed training.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The HR-Compliance director has implemented a training feedback survey which is issued to all staff to submit for feedback after each training is completed. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to annually develop an individual training plan for each employee appropriate to that employee's skill level that included input from both the employee and the supervisor, at hire and annually thereafter, per facility policy in one of
Employee #2 was hired as the clinical supervisor on July 29, 2025, and is current in that position. Employee #2 ' s individual treatment plan was digitally signed and dated on February 3, 2026, however, the electronic date stamp of the document indicated that it was actually completed on February 5, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
HR Director contacted the digital platform. The solution applied, will be the only date and timestamp will be that of the digital signature to avoid further date discrepancies on the document. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employees received at least 4 hours of TB/STD and other health related topics within the regulatory timeframe for the position in one out of one applicable record reviewed.
Employee #1 was hired as the project director on May 1, 2024 and is current in that position. There was no documentation in the personnel file verifying the completion of the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director has requested DDAP to generate his previous login for the DDAP training site, in effort to gain access to the TB certificate obtained. Should this not produce a certificate of completion, the project director is registered to take the DDAP training on June 29, 2026.
The HR/Compliance director will ensure the training certificate is uploaded to his HR file by July 1, 2026.
HR/Compliance Director will monitor all staff training hours quarterly to ensure compliance with required training hours for all staff. |
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 personnel records, the facility failed to demonstrate that CPR certification and first aid training were provided to a sufficient number of project staff persons so that at least one person trained in these skills was onsite during all project hours of operation. The staff schedules documented no CPR and First Aid certified coverage at the facility on Sundays from 1:00 pm - 3:00 pm and Saturdays between 10:00 am and 3:00 pm from April 4, 2026, to May 3, 2026.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The HR Director had all staff complete in-person CPR/First Aid training on 5.5.26. All certificates have been recorded in personnel files. The HR Director will ensure that in-person CPR/First trainings will be conducted annually for compliance. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that each counselor's caseload remained at or below 35 active clients.
Based on the total number of hours per week devoted to each client and the facility's standard work week of 35 hours as documented on the Staffing Requirements Facility Summary Report dated March 15, 2026, employee # 2 exceeded the allowable maximum 35/1 caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
Employee # 2 was hired as a clinical supervisor on July 29, 2025, and remains current in that position. The FTE counselor ' s caseload calculation is as follows: 12 hours a week devoted to clients/35 hour work week=0.34 (FTE); Employee #2 has 15 clients on their caseload which equals 15/.34, which equals to a client/counselor ratio of 44/1.
This finding was reviewed by facility staff during the licensing process.
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Plan of Correction
The clinical supervisor currently does not have any assigned clients at this time, as she is out on maternity leave. When the clinical supervisor returns, they will not exceed (5) active clients on their caseload.
The CEO and HR/compliance director will monitor client assignments each week to ensure that the entire clinical team does not exceed 35/1 ratio.
The CEO and HR/Compliance director will hire additional counseling staff if the client volume exceeds counselor: staff ratios
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705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on May 12, 2026, the facility failed to provide a wall mirror in each bathroom.
The was not a wall mirror in the staff bathroom at 10:00 am on May 12, 2026, during the onsite inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A wall mirror was installed above the sink in the staff bathroom on 5/12/2026. CEO will be responsible to ensure that the mirror remains in place for compliance. |
705.27 (3) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
On May 12, 2026, it was observed that the facility failed to limit smoking to designated smoking areas.
While Department staff were at the facility there were individuals smoking near the rear door rather than within the designated smoking area on the edge of the rear parking lot.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and clients have been informed of the smoking policies which include smoking/vaping are limited to outside designated area only. The CEO will be responsible to ensure that this policy is followed daily during breaks in the program schedule. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility were unobstructed.
On May 13, 2026, at approximately 10:00am, the exit on the front, road-facing side of the building was locked. It was reported the door is kept locked to ensure people from the street don ' t walk into the building. After discussion, a facility staff member utilized their keys to unlock the door.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A sign has been placed on the front door to alert any mail/deliveries to use the rear entrance. All staff are responsible to ensure upon daily arrival that the front door is unlocked to allow use as a fire exit. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative documents, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.
The policy and procedure manual signature page included a signature of the project director; however, there was not a date to indicate that it had been annually updated.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The project director will review the policy manual annually and will execute a policy review statement confirming the current year review in January of every year. HR-Compliance director will ensure the project director reviews the policy manual every January and that the document has the signature date included. |
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 facility ' s written plan for the coordination of client treatment and rehabilitation services which includes but is not limited to the written procedures for the management of treatment/rehabilitation services for clients, the facility failed to document procedures for the completion of case consultations.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The written treatment rehabilitation plan has been updated to reflect that case consultation is completed every 30 days. The clinical supervisor will conduct weekly chart audits which will include that all case consultations are completed every 30 days. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document annual written individual staff performance evaluations in two out of five applicable records reviewed.
Employee #1 was hired as the project director on May 1, 2024, and is still current in that position. There was no documentation of an annual performance evaluation in the employee record.
Employee #4 was hired as a counselor on June 3, 2024, and is still current in that position. There was no documentation of an annual performance evaluation in the employee record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The CFO/CCO and HR director will collaboratively complete the project director's performance review annually. All staff will have an annual performance review started one month prior to their anniversary date and completed by their anniversary date. The HR director utilizes a tracking spreadsheet and reminder alerts in the HRIS for employee review dates to ensure the reviews are completed annually.
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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 client records, the facility failed to follow their confidentiality policy (policy 5.16) to allow access to client records " on a need-to-know basis and/or when they are members of the treatment team. " An additional policy on confidentiality of client records (policy 2.03), states " only those staff members who require access to records to perform job duties will be granted access. Staff access will be monitored periodically to ensure that they are only accessing information necessary for their job role. "
Client #3 was admitted on September 1, 2025, and discharged on February 12, 2026. There was a level of care change dated September 3, 2025, that was completed by the chief financial officer. The chief financial officer is not defined as a member of the clinical team, nor is completing level of care changes listed as a duty of that position.
Client #7 was admitted on January 7, 2026, and was an active client at the time of the inspection. Client #7 had a group progress note completed by the billing assistant in the client record. The billing assistant is not defined as a member of the clinical team, nor is facilitating groups or completing group progress notes listed as a duty of that position.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Confidentiality policy has been updated to reflect that access to records will be limited to staff who need the information to complete duties within their role, including treatment team members and staff in recovery who facilitate non-clinical groups that need to document those sessions. The HR director and CEO individualized the job descriptions for the CFO and the billing specialist which reflect access to client record(s) to document duties within the scope of their role and responsibilities. HR director will ensure that job descriptions are individualized to reflect accurate job duties to avoid further discrepancies. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on 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 one of fourteen records reviewed.
Client #5 was admitted on December 12, 2025 and was current at the time of the inspection. Client #5 did not have an informed and voluntary consent for the funder signed until November 6, 2025. The facility acknowledged billing had occurred previous to the consent being obtained.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Admission/Intake coordinator is responsible to ensure that all releases are obtained and signed at the time of admission. The counselor will be responsible for adding addition releases of information at the client's discretion. Clinical supervisor will complete weekly chart audits to monitor that consents for all individuals/organizations/funding sources are fully executed.
The admission/intake coordinator will notify the clinical supervisor if a client refuses to sign releases of information at the time of their intake.
The billing specialist will not submit any information to any funding source without first verifying the release of information for the funding source is fully executed.
The counselors will not disclose any information to any source without verifying the appropriate release of information is fully executed.
All active clients have fully executed releases of information. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that they were notified of their right to appeal a decision limiting access to their records to the director in fourteen out of fourteen records reviewed.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The client's rights form has been updated in the EMR record to reflect notification of the right to appeal a decision limiting access to their records to the director. The clinical supervisor will conduct weekly chart audits to ensure that this form is completed by admitting clients. All active clients have been informed of the right to appeal a decision limiting access to their records to the director and signed the updated form in their record. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that they were notified of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in fourteen out of fourteen records reviewed.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The client's rights form has been updated in the EMR record to reflect notification of the right to request the correction of inaccurate information in their records. The clinical supervisor will conduct weekly chart audits to ensure that this form is completed by admitting clients.
All active clients have been informed of the right to appeal a decision limiting access to their records to the director and signed the updated form in their record. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that they were notified of their right to submit rebuttal data or memoranda to their own records in fourteen out of fourteen records reviewed.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The client's rights form has been updated in the EMR record to reflect notification of the right to submit rebuttal data or memoranda information in their records. The clinical supervisor will conduct weekly chart audits to ensure that this form is completed by admitting clients.
All active clients have been informed of the right to appeal a decision limiting access to their records to the director and signed the updated form in their record. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on a review of client records, the facility failed to develop a data collection and recordkeeping system that allowed for the identification of clients ' admissions and discharges within a specific time period.
The facility was unable to provide separate lists of client admission and discharge dates for each level of care offered. Lists provided had inaccurate dates and were unable to distinguish between levels of care. Client lists that identified outpatient level of care clients included episodes of partial hospitalization level of care.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR-Compliance Director contacted the EMR platform and they informed that the report can be filtered to include the components needed for record keeping which includes admission and discharge for current level of care, step down level and last level of care.
The HR-Compliance director was trained by EMR and will train the Clinical Supervisor on how to run the report.
The HR Director has created a step-by-step guide that includes instructions on how to run the report accurately to include the components needed for site inspection. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two out of two applicable client records.
Client #9 was admitted to the partial hospitalization program on February 23, 2026, and was administratively discharged on April 7, 2026. There was no documentation in the client record indicating that the facility provided the client with a written termination notice.
Client #10 was admitted to the partial hospitalization program on April 20, 2026, and was administratively discharged on May 7, 2026. There was no documentation in the client record indicating that the facility provided the client with a written termination notice.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The administrative discharge form has been implemented in the EMR system, the treatment team have been informed of this implementation and will use this form which includes the notification to the client of decision to involuntarily terminate the client's treatment. The clinical supervisor will conduct weekly chart audits to ensure this form is completed accurately and appropriately for this discharge type. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of administrative documents, the facility failed to develop and implement policies and procedures to respond to unusual incidents which included the ongoing monitoring of corrective action plans for incidents of theft, burglary, break-in, or similar incident at the facility and for the outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The unusual incident reporting policy has been updated with detailed responses to these incidents as well as the monitoring of a corrective action plan, if one is implemented. The staff have been re-educated on the policy updates, and the facility/project director will be responsible to monitor the CAPs on a monthly basis, if a CAP is implemented as part of the incident response. |
709.81(b)(1) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of partial hospitalization client records, the facility failed to include documentation that the intake procedures included the disclosure to the client of criteria for admission, treatment, completion and discharge in seven out of seven records reviewed.
The client records did not include documentation of the criteria for admission, treatment, completion and discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client orientation handbook has been updated to include criteria for admission, treatment, and completion and discharge. The Admission/Intake coordinator will ensure that clients are provided with this information upon admission and a copy of the handbook is available on-site for clients to review at their preference. |
709.81(b)(2)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of partial hospitalization client records, the facility failed to include documentation that the client orientation to the project included a familiarization with the fee schedule in seven out of seven records reviewed.
There was no documentation of a fee schedule included as part of the client orientation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client orientation handbook has been updated to include the fee schedule. The Admission/Intake coordinator will ensure that clients are provided with this information upon admission and a copy of the handbook is available on-site for clients to review at their preference. |
709.82(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to develop an individual treatment plan with the client that included the proposed type of support service in three out of six applicable records reviewed.
Client #10 was admitted to the partial hospitalization level of care on April 20, 2026, and was discharged on May 7, 2026. Client #10 ' s treatment plan dated April 23, 2026, did not include documentation of any proposed type of support service.
Client #11 was admitted to the partial hospitalization level of care on April 18, 2026, and was discharged on April 27, 2026. Client #11 ' s treatment plan dated April 23, 2026, did not include documentation of any proposed type of support service.
Client #14 was admitted to the partial hospitalization level of care on February 26, 2026, and was still current at the time of the inspection. Client #14 ' s treatment plans dated February 27, 2026, and April 1, 2026 did not include documentation of any proposed type of support service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The master treatment plan has been updated in the EMR system to include documentation of support services. The treatment team have been informed of this change and requirement for this documentation. The clinical supervisor will conduct weekly chart audits to ensure that the support services are documented in the client's treatment plan. |
709.83(a)(9) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(9) Progress notes.
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Observations
Based on a review of partial hospitalization client records, the facility failed to have a complete client record on an individual which includes information relative to the client ' s involvement with the project including progress notes, in seven out of seven records reviewed. The facility ' s procedures require the progress notes/multiday notes to be documented in the record weekly with a dated signature.
Client #8 was admitted to the partial hospitalization program on March 13, 2026, and was discharged on March 15, 2026. A progress note for a group session held on March 14, 2026, was not signed.
Client #9 was admitted to the partial hospitalization program on February 23, 2026, and was discharged on April 7, 2026. Multi-day progress notes dated March 5, 2026, March 10, 2026, and April 1, 2026, documenting individual counseling sessions were not signed until March 25, 2026, March 25, 2026, and April 17, 2026, respectively. Progress notes for group sessions held on March 12, 2026, March 13, 2026, March 17, 2026, March 18, 2026, March 19, 2026, March 20, 2026, March 23, 2026, March 24, 2026, March 26, 2026, March 27, 2026, March 31, 2026, April 1, 2026, April 2, 2026, and April 3, 2026, were not signed. Progress notes for group sessions held on March 10, 2026, March 16, 2026, March 23, 2026, March 31, 2026, and April 6, 2026, were signed on May 8, 2026, April 9, 2026, May 12, 2026, April 16, 2026, and May 12, 2026, respectively.
Client #10 was admitted to the partial hospitalization program on April 20, 2026, and was discharged on May 7, 2026. Progress notes for group sessions held on April 22, 2026, and May 4, 2026, were not signed. Progress notes for group sessions held on April 20, 2026, April 21, 2026, April 22, 2026, and April 23, 2026, were not signed until April 30, 2026, May 8, 2026, May 5, 2026, and May 8, 2026, respectively.
Client #11 was admitted to the partial hospitalization program on April 18, 2026, and was discharged on April 27, 2026. Progress notes for group sessions held on April 18, 2026, April 20, 2026, April 21, 2026, and April 24, 2026, were not signed until May 8, 2026, April 30, 2026, May 8, 2026, May 5, 2026, and respectively.
Client #12 was admitted to the partial hospitalization program on March 30, 2026, and remained active at the time of inspection. Multi-day progress notes for individual counseling sessions held on March 31 & April 2, 2026, April 6 and April 10, 2026, April 14 and April 17, 2026, and April 21 and April 24, 2026, were not signed until May 7, 2026. Progress notes for group sessions held on April 4, 2026, April 9, 2026, April 10, 2026, April 11, 2026, April; 15, 2026, April 16, 2026, April 17, 2026, April 21, 2026, April 22, 2026, April 23, 2026, April 24, 2026, and April 30, 2026, were not signed. Progress notes for group sessions held on March 31, 2026, April 6, 2026, April 14, 2026, and April 17, 2026, were not signed until May 7, 2026, May 12, 2026, May 8, 2026, and May 5, 2026, respectively.
Client #13 was admitted to the partial hospitalization program on March 11, 2026, and remained active at the time of inspection. Multi-day progress notes for individual counseling sessions held on March 12 and 13, 2026, March 16 and March 19, 2026, and March 24 and 26, 2026 were not signed until April 6, 2026. Progress notes for group sessions held on March 20, 2026, March 21, 2026, March 23, 2026, March 24, 2026, March 26, 2026, March 31, 2026, April 4, 2026, April 7, 2026, April 8, 2026, April 9, 2026, April 10, 2026, April 11, 2026, April 15, 2026, April 16, 2026, April 17, 2026, April 21, 2026, April 23, 2026, April 24, 2026, and April 29, 2026 were not signed. Progress notes for group sessions held on March 13, 2026, March 17, 2026, March 19, 2026, March 23, 2026, and March 31, 2026, were not signed until April 9, 2026, May 8, 2026, April 12, 2026, May 12, 2026, and May 7, 2026, respectively.
Client #14 was admitted to the partial hospitalization program on February 26, 2026, and remained active at the time of inspection. Multi-day progress notes for individual counseling sessions held on March 9 and March 12, 2026, and March 16 and March 18, 2026, were not signed until March 31, 2026, and sessions held on April 3 and April 16, 2026, and April 20 and April 23, 2026, were not signed until May 5, 2026. Progress notes for group counseling sessions held on March 27, 2026, March 28, 2026, April 1, 2026, April 3, 2026, April 4, 2026, April 9, 2026, April 11, 2026, April 17, 2026, April 23, 2026, April 30, 2026, and May 1, 2026, were not signed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will complete weekly chart audits to ensure that all weekly notes (progress notes, group notes and multiday notes) are signed weekly. HR-compliance director will implement reminder alerts within the EMR system to alert users to sign notes timely. |
709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
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Observations
Based on a review of partial hospitalization client records, the facility failed to provide a complete client record, which is to include follow-up information completed at seven days and thirty days from discharge, per facility policy, in four out of four applicable discharged records reviewed.
Client #8 was admitted to the partial hospitalization program on March 13, 2026, and discharged on March 15, 2026. There was no documentation in the record indicating that follow-up information was completed seven days after discharge or thirty days after discharge.
Client #9 was admitted to the partial hospitalization program on February 23, 2026, and discharged on April 7, 2026. There was no documentation in the record indicating that follow-up information was completed seven days after discharge.
Client #10 was admitted to the partial hospitalization program on April 20, 2026, and discharged May 7, 2026. There was no documentation in the record indicating that follow-up information was completed seven days after discharge.
Client #11 was admitted to the partial hospitalization program on April 18, 2026, and discharged April 27, 2026. There was no documentation in the record indicating that follow-up information was completed seven days after discharge.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the February 6, 2026, on-site complaint investigation.
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Plan of Correction
Staff have been re-educated on the client follow-up policy. The clinical supervisor will complete chart audits weekly to ensure the client f/u is completed for all client discharge types. |
709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to display conspicuously to the general public the hours of project operation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A sign has been placed on the main entrance with hours of project operation and emergency contact information on 5/13/26. The project director is responsible to ensure the sign is up-to-date and remains in place daily. |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display a telephone number to the general public for emergency purposes.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A sign has been placed on the main entrance with hours of project operation and emergency contact information on 5/13/26. The project director is responsible to ensure the sign is up-to-date and remains in place daily. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of outpatient client records, the facility failed to include documentation that the intake procedures included the disclosure to the client of criteria for admission, treatment, completion and discharge in seven out of seven records reviewed.
The client records did not include documentation of the criteria for admission, treatment, completion and discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client orientation handbook has been updated to include criteria for admission, treatment, and completion and discharge. The Admission/Intake coordinator will ensure that clients are provided with this information upon admission and a copy of the handbook is available on-site for clients to review at their preference. The Admission/Intake Coordinator provided updated copies of the client handbook to all active clients. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of outpatient client records, the facility failed to include documentation that the client orientation to the project included a familiarization with the fee schedule in seven out of seven records reviewed.
There was no documentation of a fee schedule included as part of the client orientation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client orientation handbook has been updated to include the fee schedule. The Admission/Intake coordinator will ensure that clients are provided with this information upon admission and a copy of the handbook is available on-site for clients to review at their preference. The Admissions/Intake Coordinator has provided all active clients with updated copies of the client handbook. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of outpatient client records, the facility failed to ensure psychosocial evaluations were completed within seven days of admission, per facility policy, in three out of seven records reviewed.
Client #1 was admitted to the outpatient level of care on September 18, 2025, and was still current at the time of the inspection. Client #1 ' s psychosocial evaluation was not documented as completed until September 26, 2025.
Client #2 was admitted to the outpatient level of care on January 12, 2026, and was discharged on April 3, 2026. Client #2 ' s psychosocial evaluation was not documented as completed until January 22, 2026.
Client #7 was admitted to the outpatient level of care on January 7, 2026, and was current at the time of the inspection. Client #7 ' s psychosocial evaluation was not documented as completed until March 31, 2026.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will complete weekly chart audits to ensure that the treatment team are documenting the Biopsychosocial evaluation within 7 days of admission. HR-compliance director has implemented reminder alerts within the EMR system to alert users to complete within that timeframe. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to develop an individual treatment plan with the client that included the proposed type of support service in seven out of seven records reviewed.
Client #1 was admitted to the outpatient level of care on September 18, 2025, and was still current at the time of the inspection. Client #1 ' s treatment plans dated September 22, 2025, and March 16, 2026, did not include documentation of any proposed type of support service.
Client #2 was admitted to the outpatient level of care on January 12, 2026, and discharged on April 3, 2026. Client #2 ' s treatment plans dated January 14, 2026, and March 12, 2026, did not include documentation of any proposed type of support service.
Client #3 was admitted to the outpatient level of care on September 1, 2025, and discharged on February 12, 2026. Client #3 ' s treatment plan dated August 28, 2025, did not include documentation of any proposed type of support service.
Client #4 was admitted to the outpatient level of care on July 23, 2025, and was still current at the time of the inspection. Client #4 ' s treatment plans dated October 27, 2025, and March 3, 2026, did not include documentation of any proposed type of support service.
Client #5 was admitted to the outpatient level of care on December 12, 2025, and was still current at the time of the inspection. Client #5 ' s treatment plans dated January 13, 2026, and March 23, 2026, did not include documentation of any proposed type of support service.
Client #6 was admitted to the outpatient level of care on December 1, 2025, and was still current at the time of the inspection. Client #6 ' s treatment plan dated March 5, 2026 and signed off on March 11, 2026, did not include documentation of any proposed type of support service.
Client #7 was admitted to the outpatient level of care on January 7, 2026, and was still current at the time of the inspection. Client #7 ' s treatment plans dated February 20, 2026, and April 8, 2026, did not include documentation of any proposed type of support service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The master treatment plan has been updated in the EMR system to include documentation of support services. The treatment team have been informed of this change and requirement for this documentation. The clinical supervisor will conduct weekly chart audits to ensure that the support services are documented in the client's treatment plan. |
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 client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in three out of six applicable records reviewed.
Client #1 was admitted to the outpatient level of care on September 18, 2025, and was still current at the time of the inspection. Client #1 had a treatment and rehabilitation plan dated September 22, 2025, and the update was due no later than November 21, 2025; however, the next one was not documented and signed until March 16, 2026.
Client #4 was admitted to the outpatient level of care on October 24, 2025, and was still current at the time of the inspection. Client #4 had a treatment and rehabilitation plan dated October 27, 2025, and the update was due no later than December 26, 2025; however, the next one was not documented and signed until March 3, 2026.
Client #6 was admitted to the outpatient level of care on December 1, 2025, and was still current at the time of the inspection. Client #6 had a treatment and rehabilitation plan dated November 12, 2025, from a higher level of care and the next update was due no later than January 11, 2026; however, the next one was not documented and signed until March 11, 2026.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 22-23, 2025, and April 23, 2024, licensing inspections.
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Plan of Correction
Clinical supervisor will complete weekly chart audits to ensure that the treatment team are completing and updating the treatment plan according to policy timeframes of every 60 days. HR-compliance director has implemented reminder alerts within the EMR system to alert users to complete within that timeframe. |
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 client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in four out of seven records reviewed.
Client #1 was admitted to the outpatient level of care on September 18, 2025, and was still current at the time of the inspection. Client #1 ' s treatment plan dated March 16, 2026, identified group sessions weekly; however, the client did not receive any groups for the weeks of March 22 - 28, 2026, March 29, 2026 - April 4, 2026, April 12-18, 2026, April 19-25, 2026, April 26, 2026 - May 2, 2026.
Client #4 was admitted to the outpatient level of care on October 24, 2025, and was still current at the time of the inspection. Client #4 ' s treatment plans dated October 27, 2025, and March 3, 2026, identified groups sessions weekly; however, the client did not receive any groups for the weeks of March 15-21, 2026, March 22 - 28, 2026, March 29, 2026 - April 4, 2026, and April 12-18, 2026.
Client #6 was admitted to the outpatient level of care on December 1, 2025, and was still current at the time of the inspection. Client #6 ' s treatment plan was documented and signed on March 11, 2026, and signed off on March 11, 2026, indicated the client should receive groups three times a week. There was no documentation of any groups documented in the client record for the weeks of March 22-28, 2026, March 29, 2026 - April 4, 2026, April 5-11, 2026, and April 19-25, 2026. For the weeks of March 15-21, 2026, April 12-18, 2026, and April 26, 2026- May 2, 2026, only one group session was documented in the client record.
Client #7 was admitted to the outpatient level of care on January 7, 2026, and was still current at the time of the inspection. Client #7 ' s treatment plans documented and signed February 20, 2026, and April 8, 2026, identified group sessions weekly; however, the client did not receive any groups for the week of April 12-18, 2026.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 22-23, 2025, licensing inspection.
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Plan of Correction
All clinical staff received re-education regarding 709.92(c) requirements, emphasizing the need for documentation to demonstrate a clear connection between services provided and the individualized Master Treatment Plan.
Clinical supervisor will complete weekly chart audits to ensure that all weekly notes (progress notes, group notes and multiday notes) are signed weekly. HR-compliance director implemented reminder alerts within the EMR system to alert users to sign notes timely. |
709.93(a)(4) 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:
(4) Referral contact.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual that included information relative to the client ' s involvement with the project including documentation of contacting a referral in one out of one applicable record reviewed.
Client #7 was admitted on January 7, 2026, and was current at the time of the inspection. Documentation in the client record indicated a referral was to be made to a mental health provider; however, there was no documentation in the record that the referral was made.
Thise finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff have been re-educated on clinical documentation policy. The clinical supervisor will complete weekly chart audits to ensure that referral contact information is documented and includes the details of referral confirmation.
The clinical supervisor will utilize the morning clinical meeting to identify any outside referral needs. This will serve as the mechanism for the clinical supervisor to ensure necessary documentation is executed for all outgoing referrals. The morning meeting happens Monday - Friday at 9AM. |
709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client ' s involvement with the project including progress notes for services, documented and signed in the record weekly, per facility policy, in five out of seven records reviewed.
Client #1 was admitted to the outpatient level of care on September 18, 2025, and was still current at the time of the inspection. Progress notes located in the client record for December 9, 2025 and February 24, 2026, did not include a signature.
Client #2 was admitted to the outpatient level of care on January 12, 2026, and discharged on April 3, 2026. Progress notes in the client record for January 14, 2026, January 22, 2026, January 29, 2026, February 2, 2026, February 19, 2026, and March 12, 2026, contained no content.
Client #4 was admitted to the outpatient level of care on October 24, 2025, and was still current at the time of the inspection. A progress note in the client record for March 11, 2026, was not signed until March 26, 2026.
Client #6 was admitted to the outpatient level of care on December 1, 2025, and was still current at the time of the inspection. Progress notes in the client record for December 30, 2025, and January 22, 2026, were not signed until January 8, 2026, and February 10, 2026, respectively.
Client #7 was admitted to the outpatient level of care on January 7, 2026, and was still current at the time of the inspection. A progress note in the client record for January 9, 2026, was not signed until March 26, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will complete weekly chart audits to ensure that all weekly notes (progress notes, group notes and multiday notes) are signed weekly. HR-compliance director will implement reminder alerts within the EMR system to alert users to sign notes timely. |
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 have a complete client record on an individual which includes information relative to the client ' s involvement with the project including follow-up information in two of three applicable records reviewed.
Client #2 was admitted to the outpatient level of care on January 12, 2026, and discharged on April 3, 2026. There was no follow-up information documented in the record at the time of the inspection.
Client #3 was admitted to the outpatient level of care on September 1, 2025, and discharged on February 12, 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
Staff have been re-educated on the client follow-up policy. The Certified Recovery Specialist(s) will complete the client follow-ups and document according to the client follow-up policy. The clinical supervisor will complete chart audits weekly to ensure the client f/u is completed for all client discharge types.
The HR-compliance Director will monitor the weekly chart audits to ensure the POC is followed for client follow-up. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to display conspicuously to the general public the hours of project operation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A sign has been placed on the main entrance with hours of project operation and emergency contact information on 5/13/26. The project director is responsible to ensure the sign is up-to-date and remains in place daily. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display a telephone number to the general public for emergency purposes.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A sign has been placed on the main entrance with hours of project operation and emergency contact information on 5/13/26. The project director is responsible to ensure the sign is up-to-date and remains in place daily. |
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 a plan of correction approved by the Department.
A plan of correction for updating treatment and rehabilitation plans within 60 days was submitted and approved by the Department for the April 22-23, 2025, and April 23, 2024, annual licensing inspections. Failure to update treatment and rehabilitation plans was again found to be a deficiency in the April 12-13, 2026, licensing inspection.
A plan of correction for documenting written acknowledgement by clients that they were notified of their right to appeal a decision limiting access to their records to the director was submitted and approved by the Department for the April 23, 2025, licensing inspection. Failure to document written acknowledgement by clients that they were notified of their right to appeal a decision limiting access to their records to the director was again found to be a deficiency in the April 12-13, 2026, licensing inspection.
A plan of correction for documenting written acknowledgement by clients that they were notified of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records was submitted and approved by the Department for the April 23, 2025, licensing inspection. Failure to document written acknowledgement by clients that they were notified of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records was again found to be a deficiency in the April 12-13, 2026, licensing inspection.
A plan of correction for documenting written acknowledgement by clients that they were notified of their right to submit rebuttal data or memoranda to their own records was submitted and approved by the Department for the April 23, 2025, licensing inspection. Failure to document written acknowledgement by clients that they were notified of their right to submit rebuttal data or memoranda to their own records was again found to be a deficiency in the April 12-13, 2026, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 23, 2025 licensing inspection.
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Plan of Correction
Fellowship House takes this finding seriously and appreciates the opportunity to improve our processes. While we believe the quality of care provided to our clients remains strong and that client safety and treatment outcomes were not adversely affected, we acknowledge that the identified deficiency represents a failure to fully meet documentation and/or regulatory requirements.
Upon identification of the issue, corrective action was initiated as the timeframes previously submitted for each citation. The affected records and processes were reviewed, staff were educated regarding the applicable requirement, and supervisory oversight measures were implemented to ensure compliance moving forward.
Fellowship House remains committed to providing high-quality, person-centered treatment services while maintaining full compliance with DDAP regulations. We view this finding as a correctable process issue and have implemented safeguards designed to prevent recurrence through ongoing training, quality assurance reviews, and supervisory monitoring.
The agency will continue to evaluate compliance through routine chart audits and clinical supervision to ensure that regulatory standards are consistently met and maintained.
The clinical supervisor will conduct weekly chart audits to ensure that treatment and rehabilitation plans are updated within 60 days, and that clients are provided with the written acknowledgement of their right to appeal a decision limiting access to their records to the director as well as the right to request the correction of inaccurate, irrelevant, outdated or incomplete information and their right to submit rebuttal data or memoranda to their record. |