INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 25, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CJ Therapy Group 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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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical site inspection, it was determined that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
The fire extinguisher located on the first floor did not have a current inspection tag.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director will immediately ensure that all fire extinguishers are inspected, serviced, and tagged by a licensed fire extinguisher company.
The first-floor fire extinguisher will be inspected immediately.
Documentation of the inspection will be maintain
The project director will implement a Fire Safety Equipment Monitoring System that includes:
A master log of all fire extinguishers with A scheduled annual inspection with a licensed fire extinguisher company
A policy will be created or revised to include:
Requirement for annual inspection and tagging of all fire extinguishers on-site. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative documents and an interview with the facility director, the project failed to document an annual report for the year 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will immediately complete and document a comprehensive Annual Report for calendar year 2025.
The completed Annual Report will be dated, signed by the Program Director, and maintained on CJ Therapy Group website.
the project director will implement a standardized Annual Report process that includes:
Collection of required data throughout the year and Development of a formal written Annual Report each year
A policy will be created or revised to include:
Requirement for annual completion of a program Annual Report |
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 a consent to release information form prior to releasing information in two out of seven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #2 was admitted on November 24, 2025 and was discharged on November 24, 2025.
Client #3 was admitted on November 18, 2025 and was discharged on November 18, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project director immediately reviewed the identified records and will:
Document corrective action taken if clients are no longer active
A 100% audit of all current active client records will be conducted to ensure:
A valid ROI is on file for all apporpriate entities.
A policy will be created or revised by the project director to include:
Requirement for written consent prior to any disclosure |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the name of the person, agency or organization to whom disclosure is made in three out of six records reviewed.
Client #2 was admitted on November 24, 2025 and was discharged on November 24, 2025.
Client #3 was admitted on November 18, 2025 and was discharged on November 18, 2025.
Client #6 was admitted on January 29, 2026 and was discharged on January 29, 2026.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
project director will immediately review the identified records and ensure all future client records have
fully completed Consent to Release Information (ROI) forms that include:
Specific name of the person, agency, or organization receiving the information
Ensure all ROI forms are complete
All required elements will be fully completed (not blank or generalized)
project director will implement:
An intake checklist requiring verification of ROI completeness including specific information. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the specific information to be disclosed in three out of six records reviewed.
Client #2 was admitted on November 24, 2025 and was discharged on November 24, 2025. A release of information dated November 24, 2025 did not have the specific information to be disclosed.
Client #3 was admitted on November 18, 2025 and was discharged on November 18, 2025. A release of information dated November 18, 2025 did not have the specific information to be disclosed.
Client #6 was admitted on January 29, 2026 and was discharged on January 29, 2026. A release of information dated January 29, 2026 to a government agency did not have the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director will immediately review the identified records and ensure all future records contain:
The specific information to be disclosed clearly documented.
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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the purpose of the disclosure in three out of six records reviewed.
Client #3 was admitted on November 18, 2025 and was discharged on November 18, 2025. A release of information dated November 18, 2025 had "other" checked but did not specify any addtional purposes.
Client #4 was admitted on December 31, 2025 and was discharged on December 31, 2025. A release of information dated December 31, 2025 to a government agency had "other" checked but did not specify any addtional purposes.
Client #5 was admitted on January 28, 2026 and was discharged on January 28, 2026. A release of information to a government agency did not have the purpose of disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
project director will immediately review the identified records and ensure all future records contain:
correct and fully completed ROI forms ensuring:
A clearly defined purpose of disclosure is documented (e.g., "billing," "coordination of care," "legal," etc.) |
709.28 (c) (6) 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. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of the client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the clients that recorded the date, event, or condition upon which the consent will expire in six out of six records reviewed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director will ensure
All ROI forms include a clearly defined expiration date, event, or condition
For all active clients:
New, fully compliant ROI forms will be completed that include:
A specific expiration (e.g., "one year from signature," "upon discharge," or specific date). |
709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
Based on a review of client records, the facility failed to obtain a consent to treat in six out of six records reviewed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director will verify the presence of a signed Consent to Treat
For all active clients
A Consent to Treat form will be completed, signed, and dated before conducting LOCA assessment. |