INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on April 7 & 8, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Recovery Center of America at Devon 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:
|
Plan of Correction
|
704.12(a)(5) LICENSURE Partial Hosp Ratio
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.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that the partial hospitalization activity serving adult clients had one FTE counselor for every ten clients.
The facility FTE is determined by dividing the total number of hours devoted to the current number of clients by the facility's workweek. Then to obtain the facility's ratio, the total number of clients is divided by the FTE.
The facility was reported to have forty hours per week devoted to their 14 clients.
The facility FTE caseload calculation is as follows: 40/40=1 (FTE); 14/1=14, which equals to a client/counselor ratio of 14/1.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Effective 05/01/2026, Director of Outpatient and Quality Assurance have reviewed all applicable regulations pertaining to this citation. Director of Outpatient programming will review assigned caseloads daily to ensure ongoing compliance, making adjustments as needed and/or required. The mixed caseloads of all FTE staff in our OP programming will be discussed during monthly QAPI meetings to also ensure ongoing compliance. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in all group counseling rooms, as well as lounges that also host small group sessions.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
RCA intends to respectfully submit an exception request, no later than 6/1/26, as it relates to this regulation since all installed/mounted security cameras do not record or retain any audio footage, retention is video only in nature. The presence of the security cameras are strictly for the safety and security for all staff, visitors, and patients. Security Camera access and review is isolated to only (4) Senior Leadership members who are identified by Organizational Executive Leadership members in the event incident review is necessary.
Should the exception not be approved, RCA will work to have all cameras removed from facility group rooms and lounges within (30) days of the issued denial notification.
While the state is reviewing our request, RCA has disabled/deactivated all security cameras located within the facility's group rooms as well as those located in lounges which are utilized for our smaller groups, for both our IP and OP programming, effective 5/26/26. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of fire drill logs from March 2025 through March 2026, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation for a fire drill occurring during the month of July 2025.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 04/13/26, Director of Facilities has reviewed all completed fire drills and implemented a digital checklist which will prompt the department throughout the month with reminders to ensure the completion of the needed drills. Director of Facilities will audit fire drill binder monthly upon the completion of routine drill and this data will be reported during monthly Safety Committee meeting. |
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.
|
Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two out of twenty-two full records reviewed.
Client #4 was admitted to the detoxification level of care on February 2, 2026, and was discharged to the residential level of care on February 8, 2026. Client #4 was discharged to the outpatient level of care on February 11, 2026, and remains active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
Client # 25 was admitted to the partial hospitalization level of care on July 2, 2025, and discharged to the outpatient level of care on August 1, 2025, and then discharged on August 7, 2025. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 04/17/26, Director of Admissions has re-educated all Admission staff on the applicable elements and overall importance of obtaining informed and voluntary consent, inclusive of all verbiage found within RCA's internal Assignment of Benefits form, to ensure this is completed for all new admissions regarding their respective funding sources. Director of Admissions will audit the department's Admissions Process report daily to monitor completion and will report any ongoing non-compliance during monthly QAPI/Medical Records meeting. |
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:
|
Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within three visits of admission, per the facility ' s policy and procedures manual in four out of seven applicable records reviewed.
Client #26 was transferred to the partial hospitalization level of care from the residential level of care on January 6, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than January 7, 2026: however, it was completed on January 14, 2026.
Client #28 was admitted to the partial hospitalization level of care from the residential level of care on February 3, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 4, 2026; however, it was completed on February 12, 2026.
Client #29 was admitted to the partial hospitalization level of care from the residential level of care on March 2, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than March 3, 2026; however, it was completed on March 6, 2026.
Client #31 was admitted the partial hospitalization level of care from the residential level of care on January 7, 2026, and discharged on February 12, 2026. A comprehensive treatment plan was due no later than January 8, 2026; however, it was completed on January 12, 2026.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 04/16/26, Outpatient Director held a treatment plan review for all non-residential clinical staff which was inclusive of creating and updating treatment plans within required timeframe. Treatment plan creation will be audited monthly at 5 charts with goal of 90% compliance. Data compliance will be reported by QI during monthly Medical Record Committee meeting. |
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of six records reviewed.
Client #26 was admitted to the partial hospitalization level of care on January 6, 2026, and is still active at the time of the inspection. A treatment plan was completed on January 14, 2026, and the next update was due no later than February 13, 2026; however, there is no documentation that one was completed.
Client #27 was admitted to the partial hospitalization level of care on October 28, 2025, and discharged to the outpatient level of care on December 12, 2025. A treatment plan was completed on November 7, 2025, and the next update was due no later than December 7, 2025, however, there is no documentation that one was completed.
Client #28 was admitted to the partial hospitalization level of care from the residential level of care on February 3, 2026, and was still active at the time of the inspection. A treatment plan was completed on February 12, 2026, and the next update was due no later than March 14, 2026; however, there is no documentation that one was completed.
Client #29 was admitted to the partial hospitalization level of care from the residential level of care on March 2, 2026, and was still active at the time of the inspection. A treatment plan was completed on March 6, 2026, and the next update was due no later than April 5, 2026; however, it was not completed until April 8, 2026.
This is a repeat citation from the April 16-18, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 04/16/26, Outpatient Director held a treatment plan review for all non-residential clinical staff which was inclusive of creating and updating treatment plans within required timeframe. Treatment plan updates will be audited monthly, (5) charts, with goal of 90% compliance. Data compliance will be reported by QI during monthly Medical Record Committee meeting. |
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.
|
Observations
Based on a review of the client records, the facility failed to ensure that counseling was provided to a client on a regular and scheduled basis to include individual counseling, at least twice weekly in five out of seven records reviewed.
Client #26 was admitted to the partial hospitalization level of care on January 6, 2026, and is still active at the time of the inspection. The weeks of January 12, 19, February 9, 16, 23, March 23 and 30, 2026 did not have documentation of two individual counseling sessions.
Client #27 was admitted to the partial hospitalization level of care on October 28, 2025, and discharged to the outpatient level of care on December 12, 2025. The week of November 17, 2025, did not have documentation of two individual counseling sessions.
Client #28 was admitted to the partial hospitalization level of care from the residential level of care on February 3, 2026, and was still active at the time of the inspection. The weeks of March 16, 23 and 30, 2026 did not have documentation of two individual counseling sessions.
Client #29 was admitted to the partial hospitalization level of care from the residential level of care on March 2, 2026, and was still active at the time of the inspection. The weeks of March 9, 23 and 30, 2026 did not have documentation of two individual counseling sessions.
Client #31 was admitted to the partial hospitalization level from the residential level of care on January 7, 2026, and discharged on February 12, 2026. There was no documentation of any individual counseling sessions occurring.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Effective 04/16/26, Outpatient Director held a team meeting for all non-residential clinical staff pertaining to individual session scheduling and required frequency. Individual Session progress note compliance, based on (5) monthly chart audits, with goal of 90% compliance. This data will be reported by QI during monthly Medical Records Committee meeting. |
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.
|
Observations
Based on the review of client records, the facility failed to document case consultations every fourteen days, per the facility ' s policy and procedures manual in six out seven applicable records reviewed.
Client #25 was admitted to the partial hospitalization level of care on July 2, 2025 and discharged to the outpatient level of care on August 1, 2025. A case consultation was due no later than July 16, 2025; however, there is no documentation that one was completed until July 30, 2025.
Client #27 was admitted to the partial hospitalization level of care on October 28, 2025 and stepped down to the outpatient level of care on December 12, 2025. Case consultations were due no later than November 11, 25 and December 9, 2025; however, there is no documentation that they were completed.
Client #28 was admitted to the partial hospitalization level of care on February 3, 2026 and is still active at the time of the inspection. Case consultations were due February 17, March 3, 17 and 31, 2026; however, there is no documentation that they were completed.
Client #29 was admitted to the partial hospitalization level of care on March 2, 2026 and was still active at the time of the inspection. Case consultations were due no later than March 16 and 30, 2026; however, there is no documentation that they were completed.
Client #30 was admitted to the partial hospitalization level of care on February 23, 2026 and discharged on March 11, 2026. A case consultation was due no later than March 9, 2026; however, there is no documentation that it was completed.
Client #31 was admitted to the partial hospitalization level of care on January 7, 2026 and discharged on February 12, 2026. A case consultation was due no later than January 21, 2026; however, there is no documentation that they were completed.
This is a repeat citation from the April 16-18, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 04/16/26, Outpatient Director re-educated all non-residential clinical staff on documentation of case consultations for all levels of outpatient care. Outpatient Director will audit 5 charts per month with compliance goal of 90% to ensure case consultation is documented via Outpatient Case Management note. Case Consultations will be documented in the chart following weekly treatment team meetings. Case Consultation compliance will be reported by Outpatient Director during monthly Medical Records Committee meeting. |
709.83(a)(6) 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:
(6) Aftercare plans, if applicable.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which included aftercare information that was initiated at the time of admission, per the facility ' s policy, in three out four applicable records reviewed.
Client #25 was admitted to the partial hospitalization level of care on July 2, 2025, and discharged to the outpatient level of care on August 1, 2025. An aftercare plan was due to be initiated on July 2, 2025; however, there was no documentation that one was started.
Client #27 was admitted to the partial hospitalization level of care on October 28, 2025, and stepped down to the outpatient level of care on December 12, 2025. An aftercare plan was due to be initiated on October 28, 2025; however, there was no documentation that one was started.
Client #30 was admitted to the partial hospitalization level of care on February 23, 2026, and discharged on March 11, 2026. An aftercare plan was due to be initiated on February 3, 2026; however, there was no documentation that one was started.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 04/16/26, Outpatient Director re-educated non-residential clinical staff on Aftercare Plan completion. Aftercare plans are audited monthly as part of routine medical record audits, (5) charts audited monthly to obtain compliance data. This data will be reported by Outpatient Director or QI during monthly Medical Records Committee meeting. |
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.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which included follow-up information for clients within five days of discharge, per facility policy, in one out of one applicable record reviewed.
Client #31 was admitted to the partial hospitalization level of care on January 7, 2026, and discharged on February 12, 2026. A follow up contact was due no later than February 17, 2026; however, there was no documentation that it was completed.
This is a repeat citation from the April 16-18, 2025, licensing inspection.
.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 04/16/26, Outpatient Director re-educated non-residential clinical staff on follow up documentation completion. Follow Up contact is made per the policy timeframe and uploaded to the patient chart. Follow Up notes are audited monthly as part of routine medical record audits, (5) charts audited monthly to obtain compliance data. This data will be reported by Outpatient Director or QI during monthly Medical Records Committee meeting. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
|
Observations
Based on a review of patient records, the facility failed to ensure that verification of the individual's identity was obtained during the intake process in one of three applicable records
reviewed.
Patient #1 was admitted to the detoxification level of care on December 5, 2025, and was transferred to the outpatient level of care on December 13, 2025. The record did not contain documentation that the individual's identity was verified during intake.
This is a repeat citation from the April 16-18, 2025, annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 04/17/26, Director of Admissions has re-educated all Admission Coordinator staff on the importance of the Patient Identification Attestation form. Admissions staff will be responsible for uploading a patient's ID card, if applicable upon admission. For patients without photo ID or ID verification, admission staff will be responsible for outreach attempts to obtain a valid photo ID and document accordingly in the patient record. Director of Admissions will audit (10) charts monthly as part of routine record review for verification of identification and/or Attestation completion. Plan will discontinue after 90% compliance for consecutive 90 days. QI will report on Attestation completion during monthly Medical Records Committee meeting. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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.
|
Observations
Based on the review of client records, the facility failed to document case consultations every seven days from admission until discharge, per facility policy, in seven out ten applicable records reviewed.
Client #14 was admitted to the residential level of care on December 7, 2025, and discharged to the partial hospitalization level of care on January 6, 2026. Case consultations were due no later than December 14, 21, 28, 2025 and January 4, 2026; however, there was no documentation that a case consult occurred.
Client #17 was admitted to the residential level of care on March 16, 2026, and is still active at the time of the inspection. Case consultations were due no later than March 23 and 31, 2026; however, there was no documentation that they were completed.
Client #19 was admitted to the residential level of care on March 14, 2026, and still active at the time of the inspection. Case consultations were due no later than March 21, 28 and April 4, 2026; however, there was no documentation that they were completed.
Client #20 was admitted to the residential level of care on March 21, 2026, and is still active at the time of the inspection. Case consultations were due no later than March 28 and April 4, 2026; however, there was no documentation that they were completed.
Client #21 was admitted to the residential level of care on January 9, 2026, and stepped down to the partial hospitalization level of care on February 3, 2026. A case consultation occurred on January 19, 2026. The next one was due no later than January 26, 2026; however, there was no documentation that it was completed.
Client #22 was admitted to the residential level of care on February 2, 2026, and stepped down to the partial hospitalization level of care on March 2, 2026. A case consultation was due no later than February 9, 16, and March 2, 2026; however, there was one case consult that occurred on February 22, 2026.
Client #24 was admitted to the residential level of care on January 8, 2026, and stepped down to the outpatient level of care on February 2, 2026. Case consultations were due no later than January 15, 22 and 28, 2026; however, there was no documentation that they were completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 05/04/26, Clinical Supervisor and Clinical Director re-educated all inpatient residential clinical staff on documentation of case consultation notes for all levels of inpatient care during scheduled individual supervision sessions. QI will audit (5) charts per month with compliance goal of 90% to ensure case consultation is documented via stand-alone MDT Note and/or included within the body of an Individual Progress Note. Case Consultation compliance will be reported by QI during monthly Medical Records Committee meeting. |
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.
|
Observations
Based on a review of client records, the facility failed to follow the regulatory requirement to update treatment and rehabilitation plans every sixty days in three out of three applicable records reviewed.
Client #37 was admitted to the outpatient level of care on February 2, 2026, and is still active at the time of the inspection. A treatment plan was completed on February 2, 2026, and the next update was due no later than April 3, 2026; however, there was no documentation that one was completed.
Client #38 was admitted to the outpatient level of care on January 12, 2026, and is still active at the time of the inspection. A treatment plan was completed on January 26, 2026, and the next one was due on March 27, 2026; however, there was no documentation that one was completed.
Client #40 was admitted to the outpatient level of care on December 13, 2025, and discharged on April 7, 2025. A treatment plan was completed in the partial hospitalization level of care on December 12, 2025, and the next update was due no later than February 10, 2026; however, there was no documentation that one was completed.
This is a repeat citation from the April 16-18, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 04/16/26, Outpatient Director held a treatment plan re-education for all clinical staff pertaining to reviewing and updating treatment plans within required timeframe. Treatment plan updates for outpatient levels of care will be audited monthly as part of routine medical record review. Treatment plan update compliance based on (5) monthly chart audits with goal of 90% compliance. This data will be reported by QI during monthly Medical Records Committee meeting. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
|
Observations
Based on a review of outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in four out of five applicable records reviewed.
Client #33 was admitted to the outpatient level of care on May 2, 2025, and discharged on June 30, 2025. A treatment plan, dated May 13, 2025, indicated one individual counseling session a week. The weeks of May 19, 26, June 2, 9, 16 and 23, 2025 did not have documentation that individual counseling sessions occurred.
Client #35 was admitted to the outpatient level of care on January 26, 2026, and discharged on February 13, 2026. A treatment plan dated January 26, 2026, indicated one individual counseling session a week. The weeks of February 2 and 9, 2026 did not have documentation that individual counseling sessions occurred.
Client #37 was admitted to the outpatient level of care on February 2, 2026, and was still active at the time of the inspection. A treatment plan, dated February 2, 2026, indicated one individual counseling session a week. The weeks of February 9, 16, 23, March 2, 9, 16, 23 and 30, 2026 did not have documentation that individual counseling sessions occurred.
Client #38 was admitted to the outpatient level of care on January 12, 2026, and was still active at the time of the inspection. A treatment plan, dated January 26, 2026, indicated one individual counseling session a week. The weeks of February 9, 16, and March 23, 2026, did not have documentation that individual counseling sessions occurred.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 04/16/26, Outpatient Director held a team meeting for all clinical staff pertaining to individual session scheduling and required frequency. Individual Session progress note compliance based on (5) monthly chart audits with goal of 90% compliance. This data will be reported by QI during monthly Medical Records Committee meeting. |
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.
|
Observations
Based on the review of client records, the facility failed to provide a complete client record which included documentation of a case consultation every fourteen days, per the facility policy, in seven out of eight applicable records reviewed.
Client #33 was admitted to the outpatient level of care on May 2, 2025, and discharged on June 30, 2025. Case consultations were due no later than May 16, 30, June 13, and 27, 2025; however, there was no documentation that they were completed.
Client #35 was admitted to the outpatient level of care on January 26, 2026, and discharged on February 13, 2026. A case consultation was due no later than February 9, 2026; however, there was no documentation that one was completed.
Client #36 was admitted to the outpatient level of care on October 22, 2025, and discharged on December 3, 2025. Case consultations were due no later than November 5 and 19, 2025; however, there was no documentation that they were completed.
Client #37 was admitted to the outpatient level of care on February 2, 2026, and was still active at the time of the inspection. Case consultations were due no later than February 16 and March 2, 2026; however, only one was completed on March 12, 2026.
Client #38 was admitted to the outpatient level of care on January 12, 2026, and was still active at the time of the inspection. Case consultations were due no later than January 26, February 9. 23 and March 9, 2026; however, there was no documentation that they were completed.
Client #40 was admitted to the outpatient level of care on December 13, 2025, and discharged on April 7, 2026. Case consultations were due no later than December 27, January 10, 24, February 7, 21, March 7, 21 and April 4, 2026; however, there was no documentation that they were completed.
This is a repeat citation from the April 16-18, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 04/16/26, Outpatient Director re-educated all outpatient staff on documentation of case consultation for all levels of outpatient care. Outpatient Director will audit (5) charts per month with compliance goal of 90% to ensure case consultation is documented via Outpatient Case Management note. Case Consultations will be documented in the chart following treatment team meetings. Case Consultation compliance will be reported by Outpatient Director during monthly Medical Records Committee meeting. |
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.
|
Observations
Based on the review of client records, the facility failed to provide a complete client record, which included documentation of an aftercare plan initiated at admission, per the facility policy, in four out of seven records reviewed.
Client #33 was admitted to the outpatient level of care on May 2, 2025, and discharged on June 30, 2025. An aftercare plan was due to be initiated no later than May 2, 2025; however, there was no documentation that one was started.
Client #35 was admitted to the outpatient level of care on January 26, 2026, and discharged on February 13, 2026. An aftercare plan was due to be initiated no later than January 26, 2026; however, there was no documentation that one was started.
Client #36 was admitted to the outpatient level of care on October 22, 2025, and discharged on December 3, 2025. An aftercare plan was due to be initiated no later than October 22, 2025; however, there was no documentation that one was started.
Client #38 was admitted to the outpatient level of care on January 12, 2026, and was still active at the time of the inspection. An aftercare plan was due to be initiated no later than January 12, 2026; however, there was no documentation that one was started.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 04/16/26, Outpatient Director re-educated outpatient staff on Aftercare Plan completion. Aftercare plans are audited monthly as part of routine medical record audits, (5) charts audited monthly to obtain compliance data. This data will be reported by Outpatient Director or QI during monthly Medical Records Committee meeting. |
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary charge within thirty days of discharge per the facility policy, in four out of six applicable records reviewed.
Client #32 was admitted to the outpatient level of care on December 15, 2025, and discharged on January 8, 2026. A discharge summary was due no later than February 8, 2026; however, there was no documentation that one was completed.
Client #33 was admitted to the outpatient level of care on May 2, 2025, and discharged on June 30, 2025. A discharge summary was due no later than July 30, 2025; however, there was no documentation that one was completed.
Client #34 was admitted to the outpatient level of care on August 1, 2025, and discharged on August 7, 2025. A discharge summary was due no later than September 6, 2025; however, there was no documentation that one was completed.
Client #35 was admitted to the outpatient level of care on January 26, 2026, and discharged on February 13, 2026. A discharge summary was due no later than March 15, 2026; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 04/16/26, Outpatient Director re-educated outpatient staff on discharge summary completion. Discharge summaries are audited monthly as part of routine medical record audits, (5) charts audited monthly to obtain compliance data. This data will be reported by Outpatient Director or QI during monthly Medical Records Committee meeting. |