INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on May 6, 2026 through May 7, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Consortium was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
|
Observations
Based on a review of personnel records, the facility failed to ensure the project director met the educational and experiential qualifications for the position in one of one applicable personnel records reviewed.
Employee # 1 was hired as the project director on April 6, 2026. The personnel record included documentation that the project director has a foreign degree equivalent to a Bachelor of Arts in liberal arts and sciences, which is not a qualifying major. Additionally, there was no direct service experience documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 6/30/2026
The Consortium, Inc. Board of Directors will assign the role of Project Director to the Division Director of the program.
The Division Director's credentials and experience meet the requirements in the regulations.
Moving forward, The Humans Resource Manager will discuss the potential new hire with the Division Director.
The Division Director and Human Resource Manager will review the staffing regulations prior to hiring an employee who will be in any way attached to the substance use treatment services to determine if the candidate meets requirements and, if that candidate is essential, what needs to be addressed before the candidate can be hired.
Responsible Party:
Human Resource Manager
Division Director
Board President
Monitoring:
Human Resource Director
Division Director
Board President
|
704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
|
Observations
Based on a review of personnel records, the facility failed to document an individual training plan, which was developed with input from both the employee and the supervisor, in four of thirteen applicable personnel records reviewed.
Employee # 1 was hired as the project director on April 6, 2026. There was no individual training plan documented in the personnel record at the time of the inspection.
Employee # 3 was hired as a clinical supervisor on November 10, 2021. There was documentation of a 2026 individual training plan; however, there was no documentation indicating the training plan was developed with both the employee and the supervisor.
Employee # 9 was hired as a counselor on September 13, 2021. There was documentation of a 2026 individual training plan; however, there was no documentation indicating the training plan was developed with the supervisor.
Employee # 12 was hired as a counselor on March 20, 2023. There was documentation of a 2026 individual training plan; however, there was no documentation indicating the training plan was developed with both the employee and the supervisor.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 7/30/2026:
Employee #1 Will complete and submit a Training Plan to the Human Resources Director.
Employees #3, #9, and #12 will the signature page of the Training Plans that were completed with their supervisors and submit the updated form to the Human Resources Department.
The Human Resource Manager will revise the Training Plan form to ensure that the signature page is included in the packet moving forward.
Responsible Party:
Division Director
Human Resource Manager
Monitoring:
Division Director
Human Resource Director
|
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of personnel records, the facility failed to ensure each clinical supervisor completed at least 12 clock hours of training annually during the facility's January 1, 2025 through December 31, 2025 training year in one of three applicable personnel records reviewed.
Employee # 3 was hired as a clinical supervisor on November 10, 2021. The personnel record documented 6.5 hours of training received during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The agency's Training Calendar ended in October 2025 because the Board of Directors announced that the agency was ceasing operations. Many staff had not accumulated all of their required training hours by that time. It was near the end of February 2026 when the Board of Directors announced that the agency will continue operations and the training tear ended in December 2025, too late for remediation.
Effective 7/31/2026 the program staff will utilize the recently developed a new Training Platform to assist with obtaining their requisite training hours. A new training tracker and process was developed to ensure monitoring and support occurs monthly.
Additionally, other free training platforms are identified and will be made available to the staff to ensure that all required trainings can be completed. If the agency should experience another shift in expectations, staff will be required to complete their trainings hours regardless of the agency's status.
The Division Director will monitor the training needs notification emails, support staff with connecting to available free training platforms, and document corrective actions for negligent staff.
Responsible Party:
Program Staff
Division Director
Human Resources Manager
Monitoring:
Clinical Supervisor
Division Director
Quality Assurance Director/Team
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2025 through December 31, 2025 training year in six of seven applicable personnel records reviewed.
Employee # 6 was hired as a counselor on June 10, 2024. The personnel record documented 21 hours of training received during the reviewed training year.
Employee # 7 was hired as a counselor on June 10, 2024. The personnel record documented 14.5 hours of training received during the reviewed training year.
Employee # 8 was hired as a counselor on May 13, 2019. The personnel record documented 12 hours of training received during the reviewed training year.
Employee # 9 was hired as a counselor on September 13, 2021. The personnel record documented 0 hours of training received during the reviewed training year.
Employee # 12 was hired as a counselor on March 20, 2023. The personnel record documented 10 hours, and 27 minutes of training received during the reviewed training year.
Employee # 13 was hired as a counselor on April 3, 2023. The personnel record documented 12 hours of training received during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The agency's Training Calendar ended in October 2025 because the Board of Directors announced that the agency was ceasing operations. Many staff had not accumulated all of their required training hours by that time. It was near the end of February 2026 when the Board of Directors announced that the agency will continue operations and the training tear ended in December 2025, too late for remediation.
Effective 7/31/2026 the program staff will utilize the recently developed Training Platform to assist with obtaining their requisite training hours.
All managers will review the trainings status for each of their direct reports monthly during individual supervision meetings. Staff will submit copies of their completed trainings to their direct supervisor. The managers will submit the copies to the program manager who monitors training and quality items. Th program manager will document the individual tracings for each employee on the new training tracker, scan the documents onto the HR shared folder, and once a month, inform staff via email of deadlines and trainings needed.
Responsible Party:
Employees #6, #7, #8, #9, #12, and #13
All other Program Staff
Division Director
Human Resources Manager
Monitoring:
Division Director will monitor notification emails
Human Resources Manager will acknowledge receipt of training documents from the shared folder
Quality Assurance Director/Team will review the new training tracker during quarterly program audit
|
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
At the time of the inspection, conducted on May 6, 2026, in the hallway outside room #238 and in the closet outside room #232, there was water leaking and dripping from the second-floor ceiling into large trash cans. Also, the walls and ceiling surrounding the leaks were discolored and damaged.
Additionally, there was evidence of water damage, which included discolored carpeting and stained and missing ceiling tiles, in room #225, room #228, room #235, and room #237.
This is a repeat citation from the June 11, 2025 annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Effective 7/31/2026:
Rooms #,238,232,225,228,235,237, and both hallways where the rooms are located are currently involved in remediation activities by facilities and other contractors.
The plan is to fix the leaks, replace tiles where needed, ensure that there is no presence of mold and mildew, and place air purifiers in strategic areas. There is no patient or staff activity in those areas. Moving forward, there will be no patient or staff activities in those areas. The bathrooms and Fire Exits remain accessible to the staff who are located in the opposite hallway.
The Recovery Program was just acquired by another company and will transition in approximately 9 months to a facility owned and operated by the acquiring company.
For the remaining months, The Quality Team will perform and document monthly walk through activities and report their findings to the CEO and Facilities Manager. The facilities department will prioritize the remediation of all concerns.
Responsible Party:
Consortium Facilities Staff
Division Director
Monitoring:
Consortium President/CEO
Quality Assurance Director/Team
|
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.
|
Observations
Based on the review of personnel and staff training records, the facility failed to ensure all staff were instructed in the use of the fire extinguisher upon employment in one of two applicable personnel records reviewed.
Employee # 1 was hired as the project director on April 6, 2026. The training in the use of the fire extinguisher was not completed until May 5, 2026.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Effective 6/30/2026:
Employee #1 will complete the required Fire Safety Training. The documentation will be submitted to the employee's staff files
Additionally, all new hires who are not site based will complete the required Fire Safety Training with the Human Resources Manager on their first day of employment.
The Human Resource Director will review the new hire files to ensure the Human Resource Manager and/or Division Director completed this task.
The Quality Assurance Director/Team will review the new HR files for compliance and report findings during the monthly CQI meetings.
Responsible Party:
Human Resource Manager
Division Director
Monitoring:
Human Resource Director
Quality Assurance Director |
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.
|
Observations
Based on the review of personnel and staff training records, the facility failed to ensure that all personnel on all shifts were trained to perform tasks during emergencies in one of two applicable personnel records reviewed.
Employee # 1 was hired as the project director on April 6, 2026. The training in performing tasks during emergencies was not completed until May 5, 2026.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Effective 6/15/2026:
The program will ensure that all personnel on all shifts are trained to perform tasks during emergencies.
The Safety Committee member on site will provide training for staff to perform tasks during emergencies.
The Quality Assurance Department and Safety Committee will receive a copy of the POCs. This activity will be monitored by both during monthly audits.
The Division Director will ensure that documentation of the the Fire Safety Training for Employee #1 is submitted to the employee's folder.
Additionally, all new hires who are not site based will complete the required tasks training and Fire Safety Training with the Human Resources Manager on their first day of employment.
Responsible Party:
Division Director
Human Resource Manager
Security Supervisor
Monitoring:
Safety Committee reviews
Quality Assurance audits
|
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
Based on a review of the facility's June 2025 through April 2026 fire drill logs, the facility failed to ensure their written fire drill log included documentation of the time of the drill.
At the time of the inspection, the February 2026 fire drill log did not include documentation of the time of the conducted drill.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 7/31/2026:
The February 2026 Fire Drill Log will be updated with the time of the drill.
The Fire Drill Logs will be subject to a two person review to ensure accuracy and completion prior to submission to the binder.
The Division Director will review each Fire Drill Log submitted to ensure accuracy and completion.
Responsible Party:
Lead Security Officer
Security Supervisor
Monitoring:
Division Director
Quality Assurance Director |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
|
Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for the completion of an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 8/31/2026:
The current audit will be completed by 8/31/2026.
The President/CEO will engage with an independent certified public accountant firm for the development of a financial audit report of activities associated with the project's drug and alcohol services.
A new CFO is scheduled to start work by 6/30/2026. The new CFO will assume oversight of the financial health and reporting for the agency.
The Quality Assurance Department will request the financial audit or status of the audit during QA meetings.
Responsible Party:
CFO
Monitoring:
Division Director
CEO
Quality Assurance Director |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
|
Observations
Based on a physical plant inspection, the facility failed to ensure all hard copy client records were secured within locked storage containers.
At the time of the physical plant inspection, conducted on May 7, 2026 at approximately 10:45 a.m., there was unsecured client identifying documentation on the desk in room #228, which is a vacant office.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 6/30/2026:
The vacated office was cleared of all documentation on 5/8/2026. The files were stored in the locked cabinet and the files identified as duplicates were shredded.
All of the vacated offices will be thoroughly checked by a Program Manager to ensure that no copies of documents were left behind.
A program Manager will thoroughly check the offices of any staff who relocate or separate from employment
Responsible Party:
Program Manager
Monitoring:
Division Director |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
|
Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 6 was admitted on November 23, 2015 and was discharged on April 1, 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 June 11, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 6/30/2026:
The Admissions Supervisor will facilitate training for all new Business Office Registrars.
The Clinical Assessors will review the consent packets for completion prior to initiating the assessment service.
The Clinical Assessors will review and sign any incomplete consent with the new patient and inform the Admissions Supervisor of the error.
The Admissions Supervisor will discuss the error with the Business Office Manager and provide a review of requirements if needed.
Responsible Party:
Business Office Registrar
Business Office Manager
Clinical Assessor
Admissions Supervisor
Monitoring:
Division Director
Quality Assurance Auditing Team |
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.
|
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 on a consent to release information form in one of seven client records reviewed.
Client # 4 was admitted on October 28, 2021 and was discharged on March 18, 2026. There was a blank release of information form, and release of information forms to a transportation company and a primary care physician, signed by the client on October 28, 2025; however, none of the release forms included documentation of the name of the person, agency or organization to whom the disclosures would be made.
This is a repeat citation from the June 11, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 6/30/2026
The Clinical Assessors will review the consent packets for completion prior to initiating the assessment service.
The Clinical Assessors will review and sign any incomplete consent with the new patient and inform the Admissions Supervisor of the error.
The Admissions Supervisor will discuss the error with the Business Office Manager and provide a review of requirements if needed.
Responsible Party:
Business Office Registrar
Business Office Manager
Clinical Assessor
Admissions Supervisor
Monitoring:
Division Director
Quality Assurance Auditing Team
|
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.
|
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 one of seven client records reviewed.
Client # 4 was admitted on October 28, 2021 and was discharged on March 18, 2026. There were release of information forms to a transportation company and a primary care physician signed by the client on October 28, 2025; however, both release forms did not include documentation of the specific information to be disclosed.
This is a repeat citation from the May 22, 2024 and June 11, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 6/30/2026
The Clinical Assessors will review the consent packets for completion prior to initiating the assessment service.
The Clinical Assessors will review and sign any incomplete consent with the new patient and inform the Admissions Supervisor of the error.
The Admissions Supervisor will discuss the error with the Business Office Manager and provide a review of requirements if needed.
Responsible Party:
Business Office Registrar
Business Office Manager
Clinical Assessor
Admissions Supervisor
Monitoring:
Division Director
Quality Assurance Auditing Team
|
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
|
Observations
Based on a review of client records, the facility failed to document the written acknowledgment by clients that they have been notified of their regulatory client rights in three of three applicable client records reviewed.
Client # 2 was admitted on October 29, 2025 and was still active. There was a client rights acknowledgement form signed by the client; however, all the regulatory-required client rights were not included on the acknowledgement form and there was no other documentation in the record indicating the client rights were presented to the client.
Client # 3 was admitted on January 20, 2026 and was still active. There was a client rights acknowledgement form signed by the client; however, all the regulatory-required client rights were not included on the acknowledgement form and there was no other documentation in the record indicating the client rights were presented to the client.
Client # 7 was admitted on October 22, 2025 and was discharged on December 9, 2025. There was a client rights acknowledgement form signed by the client; however, all the regulatory-required client rights were not included on the acknowledgement form and there was no other documentation in the record indicating the client rights were presented to the client.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 7/31/2026:
The Client Rights Form will be updated to include all missing elements.
The charts for patients #2 and #3 will be made whole. The assigned Therapist will review the Client Rights Document with each patient and request that an updated signature page be completed and enter into the records.
Additionally, all active patients will review and sign the updated Client Rights Form. The updated form will be included in the charts.
The EMR Administrator and the Program Manager will meet to review the EMR document to ensure there i no glitch with the form.
The Quality Assurance Manager will add the document to the chart auditing tool.
Clinical Supervisors will identify the tool when auditing charts.
The QA Department will review for this form during their quarterly audit activities and discuss results during the monthly CQI meetings.
Responsible Party:
Clinical Supervisors
EMR Administrator
Division Director
Monitoring:
Division Director
Quality Assurance Director/Team audit activities
|
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to transfer patient files, which includes the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, for a patient transferring to another narcotic treatment provider in one of three applicable patient records reviewed.
Patient # 5 was admitted on November 6, 2024 and was transferred to another narcotic treatment provider on October 31, 2025. There was no documentation, in the record, indicating patient files were transferred to the other narcotic treatment provider at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 6/30/2026;
The Transfer policy will specifically include the requirement to prepare and send a complete transfer packet to all receiving NTPs, including inpatient levels of care, with the required transfer documents listed on the transfer consent.
The transferring clinician will package the pdf with all of the sent documents, and name and date the packet indicating a transfer.
Retraining and supervision will be provided as needed.
The clinical supervisor and QA department staff will review for this process during chart audits.
Responsible staff:
Transferring clinician
Clinical Supervisor
Monitoring: via audit results
Quality Assurance Director
Division Director - |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
|
Observations
Based on a review of client records, the facility failed to document the disclosure to the client the criteria for admission, treatment, completion, and discharge during intake in three of three applicable client records reviewed.
Client # 2 was admitted on October 29, 2025 and was still active at the time of the inspection. There was no documentation in the record indicating the disclosure to the client of the criteria for admission, treatment, completion, and discharge at the time of the inspection.
Client # 3 was admitted on January 20, 2026 and was still active at the time of the inspection. There was no documentation in the record indicating the disclosure to the client of the criteria for admission, treatment, completion, and discharge at the time of the inspection.
Client # 7 was admitted on October 22, 2025 and was discharged on December 9, 2025. There was no documentation in the record indicating the disclosure to the client of the criteria for admission, treatment, completion, and discharge at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Effective 6/30/2026:
The charts for patients #2 and #3 will be made whole. A new Orientation Form Checklist was recently developed to capture the missing information as well as the patient's signature.
Responsible Party:
The Clinical Supervisor will ensure that the missing information is reviewed with Patients #2 and #3, and the chart is made whole wit the new Orientation Form Checklist.
Responsible Party:
Clinical Supervisor
Clinical Assessor
Monitoring:
Admissions Clinical Supervisor
Division Director
The Clinical Assessors will ensure that the new Orientation Form Checklist is reviewed and signed by the newly admitted patient during the intake process |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
|
Observations
Based on a review of client records, the facility failed to document client orientation to the project during intake in three of three applicable client records reviewed.
Client # 2 was admitted on October 29, 2025 and was still active at the time of the inspection. There was no documentation in the record indicating client orientation was completed at the time of the inspection.
Client # 3 was admitted on January 20, 2026 and was still active at the time of the inspection. There was no documentation in the record indicating client orientation was completed at the time of the inspection.
Client # 7 was admitted on October 22, 2025 and was discharged on December 9, 2025. There was no documentation in the record indicating client orientation was completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Effective 6/30/2026:
The charts for patients #2 and #3 will be made whole. A new Orientation Checklist was recently developed to capture the missing information as well as the patient's signature. THIS form also includes a check box to indicate that the patient received a personal copy of the Member Handbook.
The Clinical Supervisor will ensure that the patients receive a hard copy of the Member's Handbook, the missing information is reviewed with Patients #2 and #3, and the chart is made whole with the new Orientation Form Checklist.
The Admissions Supervisor will include proof of Orientation during weekly audits of the new admissions charts.
The Quality Assurance Director/Team will review for proof of Orientation signature page during quarterly audits.
Responsible Party:
Clinical Assessor
Clinical Supervisor
Monitoring:
Admissions Clinical Supervisor
Division Director
Quality Assurance Director/Team
|
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:
|
Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan, which is to be developed with the client and per facility policy, in one of three applicable client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within 30 days of admission.
Client # 2 was admitted on October 29, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by November 28, 2026, per facility policy; however, the plan was not completed until April 24, 2026.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 7/31/2026:
The Therapist will schedule the new patient's first individual session within 10 business days of their admissions date. The Therapists and new admit will develop the Comprehensive Treatment Plan during the first session.
The Clinical Supervisor will review the new admission charts within 14 days of admissions to to check for the Comprehensive Treatment Plan. If the plan is not completed, the Clinical Supervisor will schedule/reschedule the new admit on the Therapist's clinical calendar to ensure the assignment is completed. The Clinical Supervisor will audit the chart to ensure timely completion of the Comprehensive Treatment Plan.
The QA Department will review for compliance of this POC during quarterly audits and discuss results during the monthly CQI meetings.
Responsible Party:
Therapists
Clinical Supervisors
Monitoring:
Division Director
Quality Director/Team
|
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to assure that counseling services were provided according to the induvial treatment and rehabilitation plan in three of seven client records reviewed.
Client # 1 was admitted on April 11, 2022 and was still active at the time of the inspection. The treatment plan updates, completed on September 30, 2025, November 11, 2025, January 8, 2026, February 26, 2026 and April 1, 2026, indicated the client was to receive one individual counseling session per week. Based on the progress notes and record of services, the client only received 2 individual sessions during the month of October 2025 and 2 individual sessions during the month of November 2025.
Client # 3 was admitted on January 20, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on February 18, 2026, indicated the client was to receive two individual counseling sessions per month. Then, the treatment plan update, completed on April 15, 2026, indicated the client was to receive one individual counseling session per week. Based on the progress notes and record of services, the client received zero individual counseling sessions during the month of March 2026.
Client # 6 was admitted on November 23, 2015 and was discharged on April 1, 2026. The treatment plan update, completed on November 3, 2025, indicated the client was to receive two individual counseling sessions per month. Then, the treatment plan update, completed on January 2, 2026, indicated the client was to receive one individual counseling session per week. Based on the progress notes and record of services, the client received zero individual counseling sessions from the week of October 23, 2025 until the client was discharged.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 6/30/2026:
The Treatment Plans for patients #1 and #3 will be updated to reflect their actual treatment schedules.
The Clinical Supervisor will ensure that all Treatment Plans include the patient's current treatment schedule before signing the plan.
The Clinical Supervisors will review this requirement with the Therapists during Group Supervision.
The Therapists will place reminder calls to the patients and place reminders of their appointments in the patients dosing screens. Patients who continue to avoid appointments will be placed on hold to meet with their clinical team. Reasonable accommodations will be made to assist patients who have attendance challenges.
The QA Team will review compliance with the POC during quarterly audits and discuss results during the monthly CQI meetings.
Responsible Party:
Therapists
Clinical Supervisors
Monitoring:
Division Director
Quality Assurance Director |
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.
|
Observations
Based on a review of administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to document the specific information to be disclosed on consent to release information forms was submitted and approved by the Department for the May 22, 2024 and June 11, 2025 annual licensing inspections. Failing to document the specific information to be disclosed on consent to release information forms was again found to be a deficiency in the May 6, 2026 through May 7, 2026 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective 7/31/2026:
At the end of every week, the ADMISSIONS CLINICAL SUPERVISOR will confirm to the Division Director, via email, that all intake charts were audited and all required elements on the consents are satisfied.
The POC document will be submitted to the Quality Assurance Team who will include a review of compliance to the documented plans in their quarterly audit process. The QA Team will inform the program of the current level of compliance and review the status of corrections during the monthly CQI meetings.
Responsible Party:
Admissions Supervisor
Division Director
Monitoring:
Quality Assurance Team audit activities
Auditing Tool
Monthly CQI Meetings
|