INITIAL COMMENTS
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This report is a result of an on-site provisional licensure renewal inspection and complaint investigations conducted on September 15-18, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Passages to Recovery, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(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 clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor met the qualifications for the position in one of one personnel records.
Staff #2 was promoted to the position of clinical supervisor on June 9, 2024. At the time of the promotion, staff #2 had only one year of clinical experience and a qualifying bachelor ' s degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PTR's Director of
Clinical Services will serve as interim
Clinical Supervisor until May of 2026
when Staff # 2 earns 2 years of clinical
experience. Effective immediately, clinical supervisors will meet the required educational and experiential requirements for the position prior to the promotion or an exception will be submitted and granted prior to promotion. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor completed a core curriculum in clinical supervision.
Staff #2 was promoted to the position of clinical supervisor on Juen 9, 2024. At the time of the promotion, staff #2 did not have documentation of any clinical supervision experience. There was no documentation that staff #2 completed the required clinical supervision training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PTR's Director of
Clinical Services will serve as interim
Clinical Supervisor until May of 2026
when Staff # 2 earns 2 years of clinical
experience. Staff # 2 will have the required clinical supervision training prior to being put back into the clinical supervisor position. Moving forward, any clinical supervisor that does not have the required supervisory experience will complete the training prior to being hired / promoted. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to document staff persons received TB/STD training within the required timeframe in one of three applicable records.
Staff #2 was hired as a support staff on February 27, 2023 and promoted to a counselor on May 30, 2023. TB/STD training was due to be completed by May 30, 2024. There was no documentation of TB/STD training in staff record #2.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff # 2 completed TB/STD training on
10/29/25.
PTR is hosting onsite training on 11/19
OR 11/20 for active staff who are not
currently trained, to ensure compliance.
PTR's Training Specialist will oversee and monitor all required active employees to ensure timely completion according to position. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff schedules and CPR certification records, the facility failed to ensure that at least one person trained in CPR was onsite during the project's hours of operation.
This is a residential treatment facility and the hours of operation are 24 hours a day, seven days a week. Staff schedules were reviewed for August 1, 2025 - September 18, 2025. There were no staff certified in CPR onsite for the following shifts / times:
August 5, 2025 - 3rd shift, 4:00 PM - 12:00 AM.
August 8, 2025 - 3rd shift, 4:00 PM - 12:00 AM.
August 12, 2025 - 3rd shift, 8:00 PM - 12:00 AM.
August 14, 2025 - 3rd shift, 4:00 PM - 12:00 AM.
August 17, 2025 - 2nd shift, 8:00 AM - 9:00 AM.
August 19, 2025 - 3rd shift, 8:00 PM - 12:00 AM.
August 21, 2025 - 3rd shift, 4:00 PM - 12:00 AM.
August 22, 2025 - 3rd shift, 4:00 PM - 12:00 AM.
August 24, 2025 - 2nd shift, 8:00 AM - 9:00 AM.
August 26, 2025 - 3rd shift, 8:00 PM - 12:00 AM.
August 28, 2025 - 3rd shift, 4:00 PM - 12:00 AM.
September 2, 2025 - 3rd shift, 8:00 PM - 12:00 AM.
September 4, 2025 - 3rd shift, 4:00 PM - 12:00 AM.
September 5, 2025 - 3rd shift, 4:00 PM - 12:00 AM.
September 9, 2025 - 3rd shift, 8:00 PM - 12:00 AM.
September 11, 2025 - 3rd shift, 4:00 PM - 12:00 AM.
September 12, 2025 - 3rd shift, 4:00 PM - 12:00 AM.
September 16, 2025 - 3rd shift, 8:00 PM - 12:00 AM.
September 18, 2025 - 3rd shift, 8:00 PM - 12:00 AM.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
PTR understands the importance of keeping all client and staff safe. PTR management will ensure that the security schedule is staffed with at least one CPR certified staff member moving forward.
PTR's Training Specialist was trained as a CPR Trainer and will be conducting CPR training for all staff every other month to remain compliant.
PTR will incorporate CPR training into onboarding by 01/2026. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection, the facility failed to ensure slip-resistant surfaces in all bathtubs and showers.
DDAP staff observed, in the men ' s residential bathroom, two shower stalls with missing/damaged slip-resistant materials and one shower stall with no slip-resistant material.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Director of Operations submitted an
updated order to the floor mat rental company for appropriate
safety mat purchase and placement. PTR's Director of Clinical Compliance will ensure the monitoring of safety mats within shower areas. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure all heaters in the facility are permanently mounted or installed. A portable space heater was observed by DDAP staff in the facility's main security/reception area.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Director of Operations advised all staff of removal of any violating portable space heaters on 10/30/25. Any re-occurrence will result in employee discipline. PTR Management will regularly complete site checks to ensure staff are in compliance with this regulation. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of residential client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in two of two applicable records reviewed.
Per the requirement in the DDAP Licensing Alert 02-21 the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice.
Client # 6 was admitted to the inpatient non-hospital detoxification activity on April 17, 2024, and was discharged against medical advice on April 23, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client #4 was admitted to the inpatient non-hospital rehabilitation activity on June 6, 2025, and was discharged against medical advice on June 18, 2025. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client #5 was admitted to the inpatient non-hospital rehabilitation activity on August 15, 2025, and was discharged against medical advice on August 23, 2025. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice 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
Director of Clinical Services will update the emergency contact release of information to include discharge call - date and time by 11/7/25.
PTR's Intake Specialist will create an emergency contact binder. Binder will be accessible 24/7 by PTR's monitor staff. In the event of AMA discharge, as a requirement of discharge paperwork,
Monitor staff will be required to document on the emergency contact sheet the time the call was logged
and date. This will be retained in the client's paper chart. Security Supervisor will review and ensure compliance with this. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client medication administration records, the facility failed to provide documentation of medication being provided as prescribed by a physician in three of seven client records.
Client #3 was admitted on July 1, 2025, and was active at the time of the investigation. The medication administration record (MAR) was reviewed for July/August 2025.
Bupropion HCL/HL-150mg, was prescribed July 1, 2025, with physician instruction to take one tablet every morning, The MAR did not include documentation that the client received the medication as prescribed on July 30, 2025, and August 1, 2025.
Trazadone-150mg, was prescribed July 1, 2025, with the physician instruction to take one tablet in the evening. The MAR did not include documentation that the client received the medication as prescribed on July 6, 2025.
Client #6 was admitted on May 22, 2025, and was discharged on August 28, 2025. The medication administration record (MAR) was reviewed for July 2025.
Gabapentin-600mg was prescribed on May 22, 2025, with physician instructions to take one tablet three times a day: in the morning, at noon, and in the evening. The MAR did not include documentation that the client received any of the three required doses on July 14, 2025.
Client #7 was admitted on May 12, 2025, and discharged on August 26, 2025. The medication administration record (MAR) was reviewed for May/August 2024.
Quetiapine ER-200mg was prescribed on May 12, 2025, with physician instructions to take on tablet in the evening. The MAR did not include documentation that the client received the medication, as prescribed, on May 23, 2025, and July 6, 2025.
This is a repeat citation from the September 10, 2024, and March 26, 2025, onsite inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PTR's Director of Clinical Services and
Registered Nurse completed an overhaul
of medication logs and meds, separating
them by specific med calls in the med log book and med carts on 11/4/25.
By 12/5/25, PTR medication calls will occur by calling a single client vs. calling cohorts of clients at a time. Monitor Staff will be required to review each log and ensure documentation before calling
the next client. It will allow for less distractions.
Security Supervisor will assist with review of medication logs. Registered Nurse will work with Security Supervisor and Monitor Staff to ensure clients receive all medications as prescribed.
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of administrative documentation and staff interviews, the facility failed to document that a report was filed with DDAP within 3 business days following a report of sexual assault by a staff member.
On February 20, 2025, facility staff became aware of alleged sexual assault between a staff and a client. There was no documentation that facility reported this incident to DDAP.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PTR Directors reviewed unsual incident
requirements on 10/29/25. Directors will
ensure submitted incidents effective immediately. Chief of Staff will monitor the directors and submissions accordingly. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of residential client records, the facility failed to complete a biopsychosocial assessment within time frames specified by the facilities policy in two of six applicable records reviewed.
The facility ' s policy notes that a biopsychosocial assessment will be completed within three days of admission.
Client #2 was admitted on June 17, 2025, and was still active at the time of the inspection. A biopsychosocial assessment was due no later than June 20, 2025; however, it was not completed until June 23, 2025.
Client #3 was admitted on July 1, 2025, and was still active at the time of the inspection. A biopsychosocial assessment was due no later than July 4, 2025; however, it was not completed until July 6, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
PTR's EHR system Clinictracker has accessible compliance alerts. Director of Clinical Services has met and discussed with Clinictracker team to facilitate accurate alerts on 6/5/24, 12/17/24, 12/30/24, 1/6/25, 1/20/25, 8/22/25, 9/2/25, 9/16/25, 9/18/25, 10/2/25, 10/3/25, 10/6/25, 10/10/25, 10/14/25, 10/20/25, 10/22/25, 10/27/25. Compliance Alerts will be in place by 1/1/26.
Therapists have a scheduled, mandatory,
documentation training on 11/11/25 to review all necessary documentation and required timeframes of completion.
The biopsychsocial will be completed for each client within the timeframes requires by facility policy.
Director of Clinical Services, Director of Clinical Compliance, Chief of Staff will monitor for compliance. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of residential client records, the facility failed to complete initial treatment plans within time frames specified in the facility ' s policy, in three of six applicable records reviewed.
The facility ' s policy notes that the initial treatment plan will be completed within seven days of admission.
Client #1 was admitted on May 30, 2025, and was still active at the time of the inspection. An initial treatment plan was due no later than June 6, 2025; however, it was not completed until June 10, 2025.
Client #2 was admitted on June 17, 2025, and was still active at the time of the inspection. A treatment plan was due no later than June 24, 2025; however, it was not completed until June 25, 2025.
Client #3 was admitted on July 1, 2025, and was still active at the time of the inspection. A treatment plan was due no later than July 8, 2025; however, it was not completed until June 13, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
PTR's EHR system Clinictracker has accessible compliance alerts. Director of Clinical Services has met and discussed with Clinictracker team to facilitate accurate alerts on 6/5/24, 12/17/24, 12/30/24, 1/6/25, 1/20/25, 8/22/25, 9/2/25, 9/16/25, 9/18/25, 10/2/25, 10/3/25, 10/6/25, 10/10/25, 10/14/25, 10/20/25, 10/22/25, 10/27/25. Compliance Alerts will be in place by 1/1/26.
Therapists have a scheduled, mandatory,
documentation training on 11/11/25 to review all necessary documentation and timeframes.
Treatment Plans will be completed for each client within the timeframes requires by facility policy.
Director of Clinical Services, Director of Clinical Compliance, Chief of Staff will monitor for compliance.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of residential client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of six applicable records reviewed.
Client #1 was admitted on May 30, 2025, and was still active at the time of the inspection. An initial treatment plan was completed June 10, 2025. An updated treatment plan was due no later than July 10, 2025; however, it was not completed until July 13, 2025.
Client #2 was admitted on June 17, 2025, and was still active at the time of the inspection. An initial. treatment plan was completed June 25, 2025. An updated treatment plan was due no later than July 25, 2025; however, it was not completed until July 31, 2025.
Client #7 was admitted on May 12, 2025, and was discharged on August 26, 2025. An updated treatment plan was completed June 21, 2025. The next treatment plan was due no later than July 21, 2025; however, it was not completed until August 20, 2025.
This is a repeat citation from the March 26, 2025, onsite inspection.
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Plan of Correction
PTR's EHR system Clinictracker has accessible compliance alerts. Director of Clinical Services has met and discussed with Clinictracker team to facilitate accurate alerts on 6/5/24, 12/17/24, 12/30/24, 1/6/25, 1/20/25, 8/22/25, 9/2/25, 9/16/25, 9/18/25, 10/2/25, 10/3/25, 10/6/25, 10/10/25, 10/14/25, 10/20/25, 10/22/25, 10/27/25. Compliance Alerts will be in place by 1/1/26.
Therapists have a scheduled, mandatory,
documentation training on 11/11/25 to review all necessary documentation and required timeframes of completion.
Treatment plan updates will be completed for each client within the timeframes requires by facility policy.
Director of Clinical Services, Director of Clinical Compliance, Chief of Staff will monitor for compliance. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of residential client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in two out of six applicable records reviewed.
Client #3 was admitted on July 1, 2025, and was still active at the time of the inspection. A treatment plan dated August 13, 2025, indicated daily group therapy and individual therapy once a week. There was no documentation that the client received individual therapy during the week of August 31-September 6, 2025.
Client #7 was admitted on May 12, 2025, and was discharged on August 26, 2025. A treatment plan dated June 21, 2025, indicated twice daily group therapy and individual therapy once a week. There was no documentation that the client received individual therapy during the week of July 20-July 26, 2025.
This is a repeat citation from the September 10, 2024, and March 26, 2025, onsite inspections.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
PTR's EHR system Clinictracker has accessible compliance alerts. Director of Clinical Services has met and discussed with Clinictracker team to facilitate accurate alerts on 6/5/24, 12/17/24, 12/30/24, 1/6/25, 1/20/25, 8/22/25, 9/2/25, 9/16/25, 9/18/25, 10/2/25, 10/3/25, 10/6/25, 10/10/25, 10/14/25, 10/20/25, 10/22/25, 10/27/25. Compliance Alerts will be in place by 1/1/26.
Therapists have a scheduled, mandatory,
documentation training on 11/11/25 to review all necessary documentation and required timeframes of completion.
Clients will receive counseling in correspondence with their signed treatment plans.
Director of Clinical Services, Director of Clinical Compliance, Chief of Staff will monitor for compliance. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of residential client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedure manual in four out of six applicable records reviewed. The facility's policy and procedure manual states case consultations will occur within ten days of admission and must be completed every thirty days following admission.
Client #1 was admitted on May 30, 2025, and was still active at the time of the inspection. A case consultation was completed on June 5, 2025; however, only one staff member was documented as being involved in the review.
Client #3 was admitted on admitted on July 1, 2025, and was still active at the time of the inspection. A case consultation was completed on August 5, 2025. The next case consolation was due no later than September 5, 2025; however, there was no documentation of this consolation.
Client #6 was admitted on admitted on May 22, 2025, and discharged on August 28, 2025. A case consultation was completed on May 28, 2025; however, only one staff member was documented as being involved in the review.
Client #7 was admitted on admitted on May 12, 2025, and discharged on August 26, 2025. There were no case consultations documented in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
PTR's EHR system Clinictracker has accessible compliance alerts. Director of Clinical Services has met and discussed with Clinictracker team to facilitate accurate alerts on 6/5/24, 12/17/24, 12/30/24, 1/6/25, 1/20/25, 8/22/25, 9/2/25, 9/16/25, 9/18/25, 10/2/25, 10/3/25, 10/6/25, 10/10/25, 10/14/25, 10/20/25, 10/22/25, 10/27/25. Compliance Alerts will be in place by 1/1/26.
Therapists have a scheduled, mandatory,
documentation training on 11/11/25 to review all necessary documentation and required timeframes of completion.
Case Consultations will be completed for each client within the timeframes requires by facility policy.
Director of Clinical Services, Director of Clinical Compliance, Chief of Staff will monitor for compliance. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of residential client records, the facility failed to provide a complete client record, which includes follow-up information in one out of two applicable records reviewed.
The facility ' s policy is to contact the client within seven days and thirty days following discharge.
Client #4 was admitted on June 9, 2025, and was discharged June 18, 2025. There was no documentation of any follow-up contacts in the client record.
This is a repeat citation from the September 10, 2024, and March 26, 2025, onsite inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PTR's EHR system Clinictracker has accessible compliance alerts. Director of Clinical Services has met and discussed with Clinictracker team to facilitate accurate alerts on 6/5/24, 12/17/24, 12/30/24, 1/6/25, 1/20/25, 8/22/25, 9/2/25, 9/16/25, 9/18/25, 10/2/25, 10/3/25, 10/6/25, 10/10/25, 10/14/25, 10/20/25, 10/22/25, 10/27/25. Compliance Alerts will be in place by 1/1/26.
Therapists have a scheduled, mandatory,
documentation training on 11/11/25 to review all necessary documentation and required timeframes of completion.
Discharge Follow Ups will be completed for each client within the timeframes requires by facility policy.
Director of Clinical Services, Director of Clinical Compliance, Chief of Staff will monitor for compliance. |
709.53(a)(12) LICENSURE Work as treatment
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of residential client records, the facility failed to provide a complete client record, which is to include verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan in two out of six applicable records reviewed.
Client #5 was admitted on August 15, 2025, and was discharged on August 23, 2025. An initial treatment plan completed on August 20, 2025, did not reflect that chores completed by the client were part of their treatment.
Client #6 was admitted on May 22, 2025, and was discharged on August 28, 2025. An initial treatment plan completed on May 28, 2025, did not reflect that chores completed by the client were part of their treatment.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
PTR's EHR system Clinictracker has accessible compliance alerts. Director of Clinical Services has met and discussed with Clinictracker team to facilitate accurate alerts on 6/5/24, 12/17/24, 12/30/24, 1/6/25, 1/20/25, 8/22/25, 9/2/25, 9/16/25, 9/18/25, 10/2/25, 10/3/25, 10/6/25, 10/10/25, 10/14/25, 10/20/25, 10/22/25, 10/27/25. Compliance Alerts will be in place by 1/1/26.
Therapists have a scheduled, mandatory,
documentation training on 11/11/25 to review all necessary documentation and required timeframes of completion.
Work therapy will be included in all treatment plans.
Director of Clinical Services, Director of Clinical Compliance, Chief of Staff will monitor for compliance. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for medications being administered as prescribed by a physician was submitted and approved by the Department for the September 10, 2024 and March 26, 2025 onsite inspections. Medications being administered as prescribed was again found to be a deficiency in the September 18, 2025 onsite inspection.
A plan of correction for individual sessions being offered as stated in the treatment plan was submitted and approved by the Department for the September 10, 2024 and March 26, 2025 onsite inspections. Individual sessions not being offered as stated in the treatment plan was again found to be a deficiency in the September 18, 2025 onsite inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PTR is committed to following through with the current plan of correction. PTR Director of Clinical Services meets monthly with the entire clinical team to review documentation needs. PTR's security staff is under supervision of Security Supervisor who was hired to increase compliance of duties. PTR's executive leadership team is meeting regularly to ensure overview of compliance.
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