INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 4, 2026 through August 5, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Silver Linings USA Limited Liability Company 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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704.8(a)(1) - (5) & (b) LICENSURE Qualification Level
704.8. Qualifications for the position of counselor assistant.
(1) A Master's Degree in a human service area.
(2) A Bachelor's Degree in a human service area.
(3) Licensure in this Commonwealth as a registered nurse.
(4) An Associate's Degree in a human service area.
(5) A high school diploma or General Education Development (GED) equivalent.
(b) A counselor assistant shall also complete the training requirements in 704.11 (relating to staff development program).
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure all individuals met the regulatory educational requirements for the position of counselor assistant in one of two applicable personnel records reviewed.
Employee # 6 was hired as a counselor assistant on May 1, 2026. There were no educational credentials documented in the personnel record at the time of the inspection; therefore, the Licensing Representative was unable to verify the employee met the regulatory educational requirements for the counselor assistant position.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An HR audit was undertaken by Administrator of facility with special instruction on verifying, updating, or correcting the educational backgrounds of clinical employees. Administrator instructed staff to provide them directly with all educational background including high school, undergraduate, graduate, and professional development paperwork. Many submitted updated curriculum vitae to rectify records. Administrator will be tasked with completing HR audits on September 1st, December 1st, March 1st, and June 1st (or thereabouts if date falls on a non-service day) so this will not happen again.
Employee #6 educational credentials was verified and put into his HR chart. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to document that a counselor assistant was appropriately supervised by trained counselor, lead counselor or clinical supervisor in one of one applicable personnel records reviewed.
Employee # 6 was hired as a counselor assistant on May 1, 2026. At the time of the inspection, there were no supervision notes documented in the personnel record to show if the employee was being appropriately supervised, as well as indicate which counselor assistant supervision period the employee was to follow.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All documentation and personnel charts were reviewed between Administration and Clinical Director. Charts were audited to ensure certain documentation was present in all clinical staffs' and therein included (identification of department, clinical supervisor, signed proposed plan of supervision, performance reviews, documentation related to both group and individual supervision sessions, educational background, etc.)
Those providing supervision, were instructed that all supervision sessions must be fully document and signed by both supervisor and supervisee before being filed in personnel charts.
Where personnel charts were found to be out of compliance related to the inclusion of relevant documentation (ie. signed supervision notes), the clinical supervisor was instructed to provide this documentation insofar as to make all charts current and accurate. Clinical Director and Clinical Lead reviewed the company policy regarding the appropriation and expectation of fully compliant supervision practices. |
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 ensure an individual training plan was developed annually for each employee, with the plan having input from both the employee and their supervisor and appropriate to that employee's skill level, in one of six applicable personnel records reviewed.
Employee # 5 was hired as a counselor assistant on December 12, 2021. There was no current individual training plan documented in the personnel record at the time of the inspection.
This is a repeat citation from the September 4, 2025 and February 12, 2026 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All documentation and personnel charts were reviewed between Administration and Clinical Director. Charts were audited to ensure certain documentation was present in all clinical staffs' and therein included (identification of department, clinical supervisor, signed proposed plan of supervision, performance reviews, documentation related to both group and individual supervision sessions, educational background, etc.)
Clinical Director and Clinical Lead met to review employee personnel records. As some charts were shown to lack appropriate individualized employee training plans, recourse was required-not only to bring charts into compliance, but to provide appropriate employee development for the clinical staff. For employees that lacked this discrete documentation, meetings were held between supervisors and staff to development aforementioned plans, create clear and concise documentation, provide dated signatures, and schedule follow-up to review and amend employee development plans. All appropriate documentation was then filed into personnel charts.
Administrator will be tasked with completing HR audits on September 1st, December 1st, March 1st, and June 1st (or thereabouts if date falls on a non-service day) so this will not happen again. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher 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 instruct all staff in the use of the fire extinguisher upon staff employment in two of two applicable personnel records reviewed.
Employee # 4 was hired as a counselor on April 1, 2026. There was no training in the use of fire extinguishers documented in the personnel record as of the date of the inspection.
Employee # 6 was hired as a counselor assistant on May 1, 2026. There was no training in the use of fire extinguishers documented in the personnel record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All documentation and personnel charts were reviewed by Administration. Charts were audited to ensure certain documentation was present in all clinical staffs' and therein included (identification of department, clinical supervisor, signed proposed plan of supervision, performance reviews, documentation related to both group and individual supervision sessions, educational background, etc.)
Charts were reviewed in order to verify all necessary and required documentation was included. The onboarding procedure was also reviewed and instruction was given to Administrator to ensure a document verifying completion of fire safety training was reviewed, signed, and included in all staffs' personnel charts. In any charts that lacked this particular paperwork, a training was provided to the staff and documentation was produced verifying such training was dispensed.
Administrator will be tasked with completing HR audits on September 1st, December 1st, March 1st, and June 1st (or thereabouts if date falls on a non-service day) so this will not happen again. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 all personnel on all shifts were trained to perform assigned tasks during emergencies in two of two applicable personnel record reviewed.
Employee # 4 was hired as a counselor on April 1, 2026. There was no documentation of staff emergency preparedness training in the personnel record as of the date of the inspection.
Employee # 6 was hired as a counselor assistant on May 1, 2026. There was no documentation of staff emergency preparedness training in the personnel record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All documentation and personnel charts were reviewed between Administration and Clinical Director. Charts were audited to ensure certain documentation was present in all clinical staffs' and therein included (identification of department, clinical supervisor, signed proposed plan of supervision, performance reviews, documentation related to both group and individual supervision sessions, educational background, etc.) All employee charts are required to contain verification of universal trianings across all divisions and departments of the company. Any employee working at the building must be trained on emergency preparedness and be in compliance with related local and state mandates. When charts were reviewed, any that did not contain verification of training related to emergency preparedness, employees were provided such training, signed verification paperwork, and included this in their personnel charts.
Administrator will be tasked with completing HR audits on September 1st, December 1st, March 1st, and June 1st (or thereabouts if date falls on a non-service day) so this will not happen again. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the March 2026 through July 2026 fire drill logs, the facility failed to ensure the preparation of alternate exit routes to be used during fire drills.
Every fire drill log completed during the reviewed period indicated only the side door was used as the fire drill exit route and there was no other documentation showing alternate routes were prepared.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Administrator was tasked with reviewing the emergency preparedness plan, devoting particular focus on remediating the identification and allocation of several exit routes from which to utilize for both agency led drills and for use in actual emergency situations. These were presented to all staff who verbalized understanding and comprehension of this correction. Administrator will ensure that during future occurrences of fire drills, varied exit routes will be utilized in order to reinforce understanding of these alternatives. |
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 an administrative review, the facility failed to develop, and make available to the public, an annual report, which is to include, but not be limited to, a statement disclosing the names of officers, directors and principal shareholders.
This finding was discussed with facility staff during the licensing process.
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Plan of Correction
Administrator met with ownership team to develop parameters and template for providing annual reports. A page was developed for the agency website wherein all relevant information will be provided for public access. The website was reviewed to include the aforementioned details. An information was created that provides contact details for the public requisition of these materials. Biographs were also included for the ownership team and are posted for public access. |
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 an administrative review, the project director failed to ensure the written manual delineating the project's policies and procedures was updated and signed annually.
At the time of the inspection, the project's policy and procedure manual was last updated and signed by the project director on October 13, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Administrator was tasked with reviewing and verifying that an updated and signed polices and procedures manual was signed by the CEO. A current policies and procedures manual was created and presented to CEO for review, possible revision, acceptance, and signature. CEO received the manual and submitted signed approval of the updated document. This document was then ascertained by administrator who, according the policy, identified the storage of this document and identification of a yearly date or date range for which the complete this identical procedure annually. |
709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
Based on a review of personnel records, the facility failed to ensure the written verification of qualifying professional credentials were included in the personnel record in one of three applicable personnel records reviewed.
Employee # 6 was hired as a counselor assistant on May 1, 2026. The facility reported on the Staffing Requirements Facility Summary Report that the employee had a high school diploma; however, there was no documentation or verification of their education in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All documentation and personnel charts were reviewed between Administration and Clinical Director. Charts were audited to ensure certain documentation was present in all clinical staffs' and therein included (identification of department, clinical supervisor, signed proposed plan of supervision, performance reviews, documentation related to both group and individual supervision sessions, educational background, etc.)
Administrator will be tasked with completing HR audits on September 1st, December 1st, March 1st, and June 1st (or thereabouts if date falls on a non-service day) so this will not happen again.
Employee #6 high school diploma was obtained and put in HR chart on 8/22/26. It was verified by Administrator. |
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 the review of personnel records, the facility failed to ensure annual written individual staff performance evaluations, with copies of which shall be reviewed and signed by the employee, were documented in the personnel records in one of three applicable personnel records reviewed.
Employee # 2 was hired as a lead counselor on April 27, 2021. The annual performance evaluation was completed by the supervisor on April 18, 2026; however, there was no documentation the evaluation was reviewed and signed by the employee at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All documentation and personnel charts were reviewed between Administration and Clinical Director. Charts were audited to ensure certain documentation was present in all clinical staffs' and therein included (identification of department, clinical supervisor, signed proposed plan of supervision, performance reviews, documentation related to both group and individual supervision sessions, educational background, etc.). The created document was delivered to staff to sign, thereby evidencing completion, comprehension, and acceptance of the aforementioned document. This was then filed into personnel chart.
Administrator will be tasked with completing HR audits on September 1st, December 1st, March 1st, and June 1st (or thereabouts if date falls on a non-service day) so this will not happen again.
Employee #2 signed annual evaluation the day of the audit and it was updated and put into HR chart. |
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 complete an informed and voluntary consent to release information form prior to the disclosure of client information in two of fourteen client records reviewed.
Client # 7 was admitted to the partial hospitalization activity on March 23, 2026 and was discharged on April 6, 2026. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 13 was admitted to the outpatient activity on April 6, 2026 and was discharged on July 2, 2026. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This is a repeat citation from the September 4, 2025 and February 12, 2026 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met with Clinical Staff to review forms and documentation that are integral to include in client charts. The Authorization for Release of Information form was presented and reviewed with staff. Clinical Director reviewed policies, laws, and mandates related to the release of any client information both during and surrounding treatment. Clinical Director also presented necessary sources to which these documents must be included in charts universally including emergency contacts, funding sources, managed care (when appropriate), legal resources, and means of collateral communications. Clinical Director also reviewed how to present this information to clients and instructed clinical staff to ensure that these forms are filled out completely, accurately, and verified by client signature.
The counselor or counselor assistant will hold the responsibility to check said releases of clients on their caseload and will fix it with client if any information is missing. It will also be checked by the lead therapist for review. As well as the Clinical Director during her weekly audit.
Lead therapist has been going into charts to make sure that all consents have the specific information in the consent form.
Client #7 has been discharged so unable to update ROI to include specific information to be disclosed.
Client #13 client has been discharged so unable to update ROI to include specific information to be disclosed |
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 document the name of the person, agency, or organization to whom the disclosure is made to on a consent to release information form in one of fourteen client records reviewed.
Client # 6 was admitted to the partial hospitalization activity on March 19, 2026 and was discharged on April 14, 2026. The release of information form to a referral source was signed by the client on March 19, 2026; however, the release form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met with Clinical Staff to review forms and documentation that are integral to include in client charts. The Authorization for Release of Information form was presented and reviewed with staff. Clinical Director reviewed policies, laws, and mandates related to the release of any client information both during and surrounding treatment. Clinical Director also presented necessary sources to which these documents must be included in charts universally including emergency contacts, funding sources, managed care (when appropriate), legal resources, and means of collateral communications. Clinical Director also reviewed how to present this information to clients and instructed clinical staff to ensure that these forms are filled out completely, accurately, and verified by client signature.
The counselor or counselor assistant will hold the responsibility to check said releases of clients on their caseload and will fix it with client if any information is missing. It will also be checked by the lead therapist for review. As well as the Clinical Director during her weekly audit.
Lead therapist has been going into charts to make sure that all consents have the specific information in the consent form.
Client #6 has been discharged so unable to update ROI to include specific information to be disclosed. |
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 document the specific information to be disclosed on consent to release information forms in six of fourteen client records reviewed.
Client # 2 was admitted to the partial hospitalization activity on March 23, 2026 and was still active at the time of the inspection. The release of information form to a referral source was signed by the client on March 23, 2026; however, the release form did not include the specific information to be disclosed.
Client # 3 was admitted to the partial hospitalization activity on July 9, 2026 and was still active at the time of the inspection. The release of information form to a referral source was signed by the client on July 9, 2026; however, the release form did not include the specific information to be disclosed.
Client # 5 was admitted to the partial hospitalization activity on April 7, 2026 and was discharged on May 21, 2026. The release of information form to a referral source was signed by the client on April 7, 2026; however, the release form did not include the specific information to be disclosed.
Client # 9 was admitted to the outpatient activity on May 21, 2026 and was still active at the time of the inspection. The release of information form to a referral source was signed by the client on April 7, 2026; however, the release form did not include the specific information to be disclosed.
Client # 12 was admitted to the outpatient activity on March 11, 2026 and was discharged on July 31, 2026. The release of information form to a correctional facility was signed by the client on March 11, 2026; however, the release form did not include the specific information to be disclosed.
Client # 14 was admitted to the outpatient activity on April 23, 2026 and was discharged on July 2, 2026. The release of information form to a referral source was signed by the client on April 23, 2026; however, the release form did not include the specific information to be disclosed.
This was a repeat citation from the July 26, 2024, September 4, 2025, and February 12, 2026 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met with Clinical Staff to review forms and documentation that are integral to include in client charts. The Authorization for Release of Information form was presented and reviewed with staff. Clinical Director reviewed policies, laws, and mandates related to the release of any client information both during and surrounding treatment. Clinical Director also presented necessary sources to which these documents must be included in charts universally including emergency contacts, funding sources, managed care (when appropriate), legal resources, and means of collateral communications. Clinical Director also reviewed how to present this information to clients and instructed clinical staff to ensure that these forms are filled out completely, accurately, and verified by client signature.
The counselor or counselor assistant will hold the responsibility to check said releases of clients on their caseload and will fix it with client if any information is missing. It will also be checked by the lead therapist for review. As well as the Clinical Director during her weekly audit.
Lead therapist has been going into charts to make sure that all consents have the specific information in the consent form.
Client #2 release of information has been updated for the referral source to include all specific information to be disclosed.
Client #3 release of information has been updated for the referral source to include all specific information to be disclosed.
Client #5 has been discharged so unable to update ROI to include specific information to be disclosed.
Client #9 release of information has been updated for the referral source to include all specific information to be disclosed. |
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 document the purpose of the disclosure on a release of information form in one of fourteen client records reviewed.
Client # 3 was admitted to the partial hospitalization activity on July 9, 2026 and was still active at the time of the inspection. The release of information form to a pharmacy was signed by the client on July 9, 2026; however, the release form did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met with Clinical Staff to review forms and documentation that are integral to include in client charts. The Authorization for Release of Information form was presented and reviewed with staff. Clinical Director reviewed policies, laws, and mandates related to the release of any client information both during and surrounding treatment. Clinical Director also presented necessary sources to which these documents must be included in charts universally including emergency contacts, funding sources, managed care (when appropriate), legal resources, and means of collateral communications. Clinical Director also reviewed how to present this information to clients and instructed clinical staff to ensure that these forms are filled out completely, accurately, and verified by client signature.
The counselor or counselor assistant will hold the responsibility to check said releases of clients on their caseload and will fix it with client if any information is missing. It will also be checked by the lead therapist for review. As well as the Clinical Director during her weekly audit.
Lead therapist has been going into charts to make sure that all consents have the specific information in the consent form.
Client #3 release of information to pharmacy was updated to include the purpose of the disclosure.
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client record reviewed.
Client # 6 was admitted to the partial hospitalization activity on March 19, 2026 and was administratively discharged on April 14, 2026. There was no documentation in the client record indicating that the client was given the opportunity to request reconsideration of the decision to terminate treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director was tasked with reviewing procedures related to all forms and documentation pertaining to discharge. The Clinical Director reviewed the documentation and ensured that a check box was included that prompts the staff completing the form to verbally offer the client being administratively discharged the contact information for submitting a reconsideration. This was then reviewed with all clinical staff in order to educate them of this new addition and the methods by which to present this to clients. |
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.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in three of three applicable client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on May 19, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 20, 2026 and the first update was due no later than June 20, 2026; however, the update was completed on August 2, 2026.
Client # 2 was admitted to the partial hospitalization activity on March 23, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 24, 2026 and the first update was due no later than April 24, 2026; however, the update was completed on June 23, 2026. Additionally, the next treatment plan update was due no later than July 23, 2026; however, the update was completed on July 29, 2026.
Client # 5 was admitted to the partial hospitalization activity on April 7, 2026 and was discharged on May 21, 2026. The individual treatment and rehabilitation plan was completed on April 13, 2026 and the first update was due no later than May 13, 2026; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met with clinical staff in order to review the entirety of the treatment planning process including, but not limited to initial treatment plans, goals and objectives, treatment plan reviews, documenting treatment plan progress, etc. Staff was informed that treatment plans must be reviewed and updated every thirty days at minimum for partial hospitalization programs and every sixty days for intensive outpatient and outpatient levels of care. Clinical Director then informed staff that notice of these upcoming treatment plan reviews will be communicated to staff by Clinical Director in advance of discrete date in order for clinicians to meet with staff and perform these reviews. |
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.
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Observations
Based on review of client records, the facility failed to ensure counseling was provided to a client on a regular and scheduled basis, specifically individual counseling at least twice weekly for clients in the partial hospitalization activity, in three of seven applicable client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on May 19, 2026 and was still active at the time of the inspection. There was only one individual session documented in the client record during the week of June 7, 2026.
Client # 6 was admitted to the partial hospitalization activity on March 19, 2026 and was discharged on April 14, 2026. There was only one individual session documented in the client record during the week of March 22, 2026.
Client # 7 was admitted to the partial hospitalization activity on March 23, 2026 and was discharged on April 6, 2026. There were no individual sessions documented in the client record during the week of March 22, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met with clinical staff to provide guidance on the requirements related to the provision of services for each level of care including the frequency of both group and individual counseling sessions. Clinical Director maintained that partial hospitalization clients are required to be seen twice weekly for individual counseling sessions. These sessions must be documented in client charts. Clinical Director informed clinical staff that during weekly audits, Clinical Director will review client charts to verify that this frequency of individual sessions is being completed. |
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.
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to maintain a complete client record, which is to include documentation of case consultation notes, in one of one applicable client record reviewed.
The policy and procedure manual stated that case consultation notes are to be completed quarterly for each client in their first year of treatment and annually thereafter.
Client # 2 was admitted on March 23, 2026 and was still active at the time of the inspection. There were no case consultation notes documented in the client record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met with staff to better familiarize them with the form related to ongoing case consultation notes. Clinical Director explained how, in concert with treatment planning, case consultation notes are used as a barometer by which to measure clients' responses to treatments, interventions, and modalities. Clinical Director informed staff that these must occur quarterly for all clients during their first year of treatment, then annually from thereon. Clinical Director informed staff that reminder of completing these forms will be communicated in weekly audits performed on client charts.
Client #2 chart has been updated to include the case consultation for the quarterly mark of the treatment episode.
Clinical Director will complete audit for case consultations every week to make sure the clients who are the quarterly mark or annual mark have their case consultations in the chart. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client in four of seven applicable client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within 10 days of admission.
Client # 8 was admitted to the outpatient activity on May 14, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 14, 2026; however, there was no documentation indicating the treatment plan was developed with the client.
Client # 9 was admitted to the outpatient activity on May 21, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than May 31, 2026; however, the treatment plan was completed on June 30, 2026. Additionally, there was no documentation indicating the treatment plan was developed with the client.
Client # 11 was admitted to the outpatient activity on April 1, 2026 and was discharged on July 20, 2026. The individual treatment and rehabilitation plan was due to be completed no later than April 11, 2026; however, the treatment plan was completed on June 30, 2026.
Client # 13 was admitted to the outpatient activity on April 6, 2026 and was discharged on July 2, 2026. The individual treatment and rehabilitation plan was due to be completed no later than April 16, 2026; however, the treatment plan was completed on June 26, 2026.
This is a repeat citation from the July 26, 2024, September 4, 2025, and February 12, 2026 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met with clinicians in order to review treatment planning process, procedures, and documentation. Clinical Director identified time frames by which particular treatment plans must be drafted and included in client charts. Clinical Director informed staff on collaborative nature of treatment planning, goal and objective creation, and reviews. Clinical Director informed staff that individualized treatment plans must be completed within 10 days of admission by primary therapists. Clinical Director also reviewed treatment plan review process (as indicated in separate corrective action plan).
The Clinical Director will audit charts and send out a report and let clinical staff know if treatment plans need to be completed. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in two of three applicable client records reviewed.
Client # 12 was admitted to the outpatient activity on March 11, 2026 and was discharged on July 31, 2026. The individual treatment and rehabilitation plan was completed on March 20, 2026 and the first update was due no later than May 20, 2026; however, the update was completed on June 23, 2026.
Client # 14 was admitted to the outpatient activity on April 23, 2026 and was discharged on July 16, 2026. The individual treatment and rehabilitation plan was completed on April 30, 2026 and the first update was due no later than June 30, 2026; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met with clinical staff in order to review the entirety of the treatment planning process including, but not limited to initial treatment plans, goals and objectives, treatment plan reviews, documenting treatment plan progress, etc. Staff was informed that treatment plans must be reviewed and updated every thirty days at minimum for partial hospitalization programs and every sixty days for intensive outpatient and outpatient levels of care. Clinical Director then informed staff that notice of these upcoming treatment plan reviews will be communicated to staff by Clinical Director in advance of discrete date in order for clinicians to meet with staff and perform these reviews. |
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.
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to maintain a complete client record, which is to include documentation of case consultation notes, in two of two applicable client records reviewed.
The policy and procedure manual stated that case consultation notes are to be completed quarterly for each client in their first year of treatment and annually thereafter.
Client # 11 was admitted to the outpatient activity on April 1, 2026 and was discharged on July 20, 2026. There were no case consultation notes documented in the client record at the time of the inspection.
Client # 12 was admitted to the outpatient activity on March 11, 2026 and was discharged on July 31, 2026. There were no case consultation notes documented in the client record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met with staff to better familiarize them with the form related to ongoing case consultation notes. Clinical Director explained how, in concert with treatment planning, case consultation notes are used as a barometer by which to measure clients' responses to treatments, interventions, and modalities. Clinical Director informed staff that these must occur quarterly for all clients during their first year of treatment, then annually from thereon. Clinical Director informed staff that reminder of completing these forms will be communicated in weekly audits performed on client charts. |
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 an administrative review, the facility failed to comply with plans of correction that were previously approved by the Department.
Plans of correction for not documenting an annual individual training plan for each employee, with the plan being developed with input from both the employee and their supervisor and appropriate to that employee's skill level were submitted and approved by the Department for the September 4, 2025 and February 12, 2026 licensing inspections. Failing to document an annual individual training plan for each employee, with the plan being developed with input from both the employee and their supervisor and appropriate to that employee's skill level was again found to be a deficiency during the August 4, 2026 through August 5, 2026 annual licensing renewal inspection.
Plans of correction for not completing an informed and voluntary consent to release information form prior to the disclosure of information were submitted and approved by the Department for the September 4, 2025 and February 12, 2026 licensing inspections. Failing to complete an informed and voluntary consent to release information form prior to the disclosure of information was again found to be a deficiency during the August 4, 2026 through August 5, 2026 annual licensing renewal inspection.
Plans of correction for not documenting the specific information to be disclosed on consent to release information forms were submitted and approved by the Department for the July 26, 2024, September 4, 2025, and February 12, 2026 licensing inspections. Failing to document the specific information to be disclosed on consent to release information forms was again found to be a deficiency during the August 4, 2026 through August 5, 2026 annual licensing renewal inspection.
Plans of correction for not developing an individual treatment and rehabilitation plan with clients in the outpatient activity were submitted and approved by the Department for the July 26, 2024, September 4, 2025, and February 12, 2026 licensing inspections. Failing to develop an individual treatment and rehabilitation plan with clients in the outpatient activity was again found to be a deficiency during the August 4, 2026 through August 5, 2026 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The plan of corrections were not all followed up on from previous audits. This has been addressed with the CEO, Clinical Director, lead Counselor and Operations manager. This was also addressed in clinical meeting on 8/24/2026.
There will be consequences moving forward if clinical staff is not able to comply with having their charts stay in compliance.
Clinical Director will be going over trainings during staff meetings once a month on issues that occurred during this and previous corrective action plans to ensure this does not reoccur.
Clinical Director also sends out a weekly chart audit. |