INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 13, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. Vantage House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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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 five personnel records, the facility failed to document that the clinical supervisor participated in documented monthly meetings with their supervisor to discuss their duties and performances for the first six months of employment in that position.
Employee #3, who was hired as a clinical supervisor on August 27, 2024 and was still employed in that position at the time of the inspection did not have documented monthly supervision for the months of November and December 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction: The Program Director met with the Clinical Supervisor on June 5, 2025, and set a monthly calendar reminder to extend supervision to July 31, 2025, in order to make up for November and December 2024 missed supervision sessions.
The Program Director will be responsible for ensuring that the Clinical Supervisor participates in documented monthly meetings to discuss duties and performance over the next two months. Date of completion: 7/31/25.
The Program Director will be responsible for ensuring that supervision is provided for any newly hired Clinical Supervisors.
The Division Director will meet with the Program Director on a monthly basis to ensure supervisions are being documented for the current Clinical Supervisor, as well as for any new Clinical Supervisor upon their hire, to prevent deficiencies and ensure timely corrective action is being implemented.
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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 the personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level per the facility ' s policy and procedures manual in two out of three applicable employee records reviewed. The facility ' s policy and procedures manual states that the individual training plan is due by the end of January.
Employee #2 was hired on January 15, 2025 as the facility director and was still in the position as of the date of the inspection. The individual training plan was not dated until March 17, 2025.
Employee #3 was hired on August 27, 2024 as a clinical supervisor and was still in the position as of the date of the inspection. The individual training plan was not dated until March 17, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All staff members will have an Individual Training Plan generated on their start date and then updated annually in January. This is reviewed with the staff member and signed to indicate that they understand the training requirements.
The Program Director will ensure that Supervisors are completing this process as required with staff. Each plan will then be reviewed and updated annually by the end of January. Training Plans will be maintained in the staff file.
The Supervisor or Program Director will review the Individual Training Plans weekly for new hires, and at least quarterly for all staff.
If any issues are noted with Supervisors failing to complete individual training plans, the Program Director will address with the Supervisor in a documented supervision session with a clear plan to have the training plans completed.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to ensure one employee received the required training in the use of the fire extinguishers upon employment.
Employee #4 was hired on February 18, 2025 for the position of counselor and was still employed at the time of the inspection. Employee #3 did not have the training until May 12, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that all new employees will have fire safety training during the first 3 days of unit Orientation.
The Program Director or Recovery Support Professional Supervisor will provide new employees with the Fire Safety tour of facility identifying all extinguishers, fire exits, and AED unit and document in Orientation Supervision and place in employee file.
The Program Director will work with the Supervisor to make sure that new staff are scheduled for the fire extinguishers and the safety surrounding a fire prior to the due dates and will monitor to ensure full and timely completion.
Certificates of completion as well as Evaluations will be maintained in the staff file.
If any issues are noted with staff failing to complete scheduled fire extinguishers and the safety surrounding a fire training the Program Director will address with the Supervisor, the need to meet with the staff in a documented supervision session with a clear plan to have the fire extinguishers and the safety surrounding a fire training completed.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure one employee received the required training for assignments of staff during emergencies upon employment in one out of three applicable employees.
Employee #4 was hired on February 18, 2025 for the position of counselor and was still employed at the time of the inspection. Employee #3 did not have the training until May 12, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director or RSP Supervisor will ensure that all staff receive emergency procedures training, including evacuations and shelter-in-place protocols to ensure that they know how to perform the assigned task during an emergency.
Each new employee will participate in an emergency procedure during their shift and will be supported by a trained staff that can guide them through the emergency procedure.
The Supervisor or the Program Director will work with the staff member to schedule the emergency procedure prior to the due dates and will monitor to ensure full and timely completion.
Certificates of completion as well as Evaluations will be maintained in the staff file.
If any issues are noted with staff failing to complete scheduled emergency procedure training the Program director will address with the Supervisor, the need to meet with the staff in a documented supervision session with a clear plan to have the emergency procedure training completed.
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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 the review of client records, the facility failed to follow their policy to contact a client ' s emergency contact within twelve hours of leaving against medical advice in one out of two applicable records reviewed.
Client #7 was admitted on December 9, 2024 and discharged against facility advice on January 23, 2025 at 1 PM. The facility did not notify the emergency contact until January 24, 2025 at 9:55 AM.
This is a repeat citation from the May 4, 2023 and April 23, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
"Plan of Correction: All clients' Emergency Contact persons will be notified within 12 hours of an ASA discharge of a client.
This will be completed by the client's assigned counselor, or in their absence, but Administrative personnel.
The Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time."
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation per the facility ' s policy and procedures manual in five out of seven records reviewed. The facility ' s policy states a psychosocial evaluation is completed within three days of admission.
Client #1 was admitted on February 10, 2025 and was still active at the time of the inspection. A psychosocial evaluation was due no later than February 13, 2025; however, there was no documentation that a psychosocial evaluation was completed.
Client #2 was admitted on March 11, 2025 and was still active at the time of the inspection. A psychosocial evaluation was due no later than March 14, 2025; however, one was completed on April 3, 2025.
Client #4 was admitted on November 19, 2024 and discharged on December 1, 2024. A psychosocial evaluation was due no later than November 22, 2024; however, there was no documentation that a psychosocial evaluation was completed.
Client #5 was admitted on August 10, 2024 and discharged on October 31, 2024. A psychosocial evaluation was due no later than August 13, 2024; however, there was no documentation that a psychosocial evaluation was completed.
Client #7 was admitted on December 9, 2024 and discharged on January 23, 2025. A psychosocial evaluation was due no later than December 12, 2024; however, there was no documentation that a psychosocial evaluation was completed.
This is a repeat citation from the May 4, 2023 and April 23, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"All documentation will be completed correctly and in a timely manner.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 6/30/25. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
Any missing or incorrect documentation for any active client will be updated within 2 week and reviewed by the Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 6/30/25.
The Clinical Supervisor will complete at least weekly reviews, the Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time."
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan completed with the client within guidelines established by the facility's policy and procedures manual in four out of seven records reviewed. The facility's policy and procedures manual states that the individual treatment and rehabilitation plan is developed within seven days of admission.
Client #2 was admitted on March 11, 2025 and was still active at the time of the inspection. An individual treatment and rehabilitation plan was completed on March 17, 2025; however, there was no documentation that it was completed with the client.
Client #4 was admitted on November 19, 2024 and discharged on December 1, 2024. An individual treatment and rehabilitation plan was due no later than November 26, 2024; however, there is no documentation that one was completed.
Client #5 was admitted on August 10, 2024 and discharged on October 31, 2024. An individual treatment and rehabilitation plan was due no later than August 17, 2024; however, it was not completed until August 30, 2024.
Client #7 was admitted on December 9, 2024 and discharged on January 23, 2025. An individual treatment and rehabilitation plan was completed on December 16, 202; however, there is no documentation that it was completed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"All documentation will be completed correctly and in a timely manner.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 6/30/25. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and how to request assistance when needed.
Any missing or incorrect documentation for any active client will be updated within 2 week and reviewed by the Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 6/30/25.
The Clinical Supervisor will complete at least weekly reviews, the Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time."
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709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 ensure that the clients received counseling services according to their individual treatment and rehabilitation plan in four out of six applicable records reviewed.
Client #1 was admitted on February 10, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plans dated March 6 and April 7, 2025 indicated one individual session a week. There was no documentation of the client receiving individual therapy the weeks of March 10, 31 and April 14, 2025.
Client #2 was admitted on March 11, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plans dated March 17, April 11 and April 29, 2025 indicated weekly individual sessions. There was no documentation that the client received individual sessions the weeks of March 31, April 7, 14, 21 and May 5, 2025.
Client #3 was admitted on March 19, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan dated April 14, 2025, indicated one individual session a week. There was no documentation that the client received individual therapy the week of April 28, 2025.
Client #7 was admitted on December 9, 2024 and discharged on January 23, 2025. The individual treatment and rehabilitation plan dated December 16, 2024, indicated one individual session a week. There was no documentation that the client received individual therapy the weeks of December 23 and 30, 2025.
This is a repeat citation from the May 4, 2023 and April 23, 2024 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"All documentation will be completed correctly and in a timely manner.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 6/30/25. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
Any missing or incorrect documentation for any active client will be updated within 2 week and reviewed by the Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 6/30/25.
The Clinical Supervisor will complete at least weekly reviews, the Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time."
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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.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include case consultation in six out of six applicable records reviewed. The facility ' s policy and procedures manual states that a case consult occurs within fifteen days and then every ninety days thereafter.
Client #1 was admitted on February 10, 2025 and was still active at the time of the inspection. A case consultation was due no later than February 25, 2025; however, it was completed on February 27, 2025.
Client #2 was admitted on March 11, 2025 and was still active at the time of the inspection. A case consultation was due no later than March 26, 2025; however, it was completed on March 31, 2025.
Client #3 was admitted on March 19, 2025 and was still active at the time of the inspection. A case consultation was due no later than April 3, 2025; however, it was completed on May 8, 2025.
Client #5 was admitted on August 10, 2024 and discharged on October 31, 2024. A case consultation was due no later than August 25, 2024; however, it was completed on September 3, 2024.
Client #6 was admitted on November 6, 2024 and discharged on February 13, 2025. A case consultation was due no later than November 21, 2024; however, it was completed on December 2, 2024.
Client #7 was admitted on December 9, 2024 and discharged on January 23, 2025. A case consultation was due no later than December 24, 2024; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"All documentation will be completed correctly and in a timely manner.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 6/30/25. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
Any missing or incorrect documentation for any active client will be updated within 2 weeks and reviewed by the Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 6/30/25.
The Clinical Supervisor will complete at least weekly reviews, the Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time."
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709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include aftercare information in five out of seven records reviewed. The facility ' s policy and procedures manual states that aftercare documentation starts within twenty-four hours of admission and finalized at discharge.
Client #1 was admitted on February 10, 2025 and was still active at the time of the inspection. An aftercare form was due to be started by February 11, 2025; however, there is no documentation that one was started.
Client #2 was admitted on March 11, 2025 and was still active at the time of the inspection. An aftercare form was due to be started by March 12, 2025; however, there is no documentation that one was started.
Client #3 was admitted on March 19, 2025 and was still active at the time of the inspection. An aftercare plan was due to be started by March 20, 2025: however, there was no documentation that one was started.
Client # 4 was admitted on November 19, 2024 and discharged on December 1, 2024. An aftercare form was due to be started by November 20, 2024, and completed by December 1, 2024; however, there is no documentation that one was completed.
Client #7 was admitted on December 9, 2024 and discharged on January 23, 2025. An aftercare form was due to be started by December 10, 2024, and completed by January 23, 2025; however, there is no documentation that that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"All documentation will be completed correctly and in a timely manner.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 6/30/25. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
Any missing or incorrect documentation for any active client will be updated within 2 weeks and reviewed by the Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 6/30/25.
The Clinical Supervisor will complete at least weekly reviews, the Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time."
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709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in three out of four applicable discharged records reviewed. The facility ' s policy and procedures manual states that discharge summaries are completed within seven days of discharge.
Client #4 was admitted on November 19, 2024 and discharged on December 1, 2024. A discharge summary was due no later than December 8, 2024; however, there is no documentation that one was completed.
Client #5 was admitted on August 10, 2024 and discharged on October 31, 2024. A discharge summary was due no later than November 7, 2024; however, there is no documentation that one was completed.
Client #7 was admitted on December 9, 2024 and discharged on January 23, 2025. A discharge summary was due no later than January 30, 2025; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"All documentation will be completed correctly and in a timely manner.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 6/30/25. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
Any missing or incorrect documentation for any active client will be updated within 2 weeks and reviewed by the Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 6/30/25.
The Clinical Supervisor will complete at least weekly reviews, the Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time."
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in four out of four applicable discharged records reviewed. The facility ' s policy and procedures manual states that follow up contacts occur within seven days of discharge.
Client #4 was admitted on November 19, 2024 and discharged on December 1, 2024. A follow up contact was due no later than December 8, 2024; however, there is no documentation that a follow up contact was made.
Client #5 was admitted on August 10, 2024 and discharged on October 31, 2024. A follow up contact was due no later than November 7, 2024; however, it was completed on November 19, 2024.
Client #6 was admitted on November 6, 2024 and discharged on February 13, 2025. A follow up contact was due no later than February 20, 2025; however, there is no documentation that one was completed.
Client #7 was admitted on December 9, 2024 and discharged on January 23, 2025. A follow up contact was due no later than January 30, 2025; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"All documentation will be completed correctly and in a timely manner.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 6/30/25. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
Any missing or incorrect documentation for any active client will be updated within 2 weeks and reviewed by the Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 6/30/25.
The Clinical Supervisor will complete at least weekly reviews, the Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time."
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failure to follow their policy to contact a client ' s emergency contact within twelve hours of leaving against medical advice was submitted and approved by the Department for the May 4, 2023, and April 23, 2024, annual licensing inspections. Failure to follow their policy to contact a client ' s emergency contact within twelve hours of leaving against medical advice was again found to be a deficiency in the May 13, 2025, licensing inspection.
A plan of correction for completing a psychosocial evaluation was submitted and approved by the Department for the May 4, 2023, and April 23, 2024, annual licensing inspections. Completing a psychosocial evaluation was again found to be a deficiency in the May 13, 2025, licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
"The Program Director will be ultimately responsible for ensuring full implementation of this Plan of Correction as noted in each area above.
Implementation will be monitored through at least monthly reviews of the Plan of Correction and documented follow up with any staff member found to be deviating from the action items listed.
The Division Director will meet with the Program Director at least monthly in documented supervision sessions to review and identify barriers on implementation of each action item. Any barriers noted will be addressed as appropriate.
The Division Director will report at least monthly to the Deputy Director regarding any outstanding items, identified barriers, or other areas requiring improvement.
Any areas noted as not meeting the requirements listed above will be addressed with the Program Director in a documented supervision session note detailing any additional required actions to be taken to bring the program into full compliance."
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