INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection and complaint investigations conducted on February 10-13, and March 5-6, 2026 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, Inc. 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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704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
Based on a review of administrative documentation, staff schedules, personnel record documentation and staff interviews, the facility failed to employ clerical and other support staff in sufficient numbers to ensure the safe and efficient operations of services.
Documentation was observed including support staff sleeping on the job, clients not receiving their medications as prescribed, clients missing medical appointments due to lack of transportation and client record documentation not being filed /present in the client records. Client transportation, filing/scanning client record documentation and supervision of medication self-administration are tasks assigned to support staff.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages has enhanced its staffing structure to ensure adequate coverage and operational efficiency across all service areas. A Security Supervisor has been hired to oversee security operations, including monitoring medication passes, ensuring compliance with established protocols, and documenting and reporting identified deficiencies to the Chief of Staff.
To further strengthen medication management practices, Passages has contracted with a staffing agency to provide an LPN and an RN to audit, medications, pass medications, and improve storage and management of medications. In addition, upon learning that our Medical Director was retiring. A new physician was hired as a medical director providing clinical oversight and consultation. A designated support staff has been assigned the task of scanning client documents into client records in a timely manner.
Passages has implemented weekly security staff meetings including a training review on proper documentation procedures related to security and medication monitoring. Ongoing supervision will include staff corrective action plans when necessary to address deficiencies and communicate the importance of adherence to policies. These efforts support the facility's commitment to maintaining 24-hour security coverage and ensuring that all medication passes are conducted in accordance with the established schedule and protocol. The Chief of Staff conducts weekly oversite reviews of medication management.
To improve transportation services, Passages has three (3) drivers to ensure reliable and timely transport for clients' needs. Medical and court appointments are posted on a shared digital calendar that connects case managers and transportation staff to ensure that all clients have transportation to scheduled medical, legal, and other essential appointments when staff provided transportation is required.
These corrective measures collectively ensure that Passages maintains sufficient staff to support safe, efficient, and compliant program operations. The center manager and clinical manager will ensure the plan of correction is implemented. Weekly oversite meetings will be held with the Clinical Supervisor, Facility Manager, Clinical Director, and Chief of Staff to assess and review the facility overall operations. Effective 4/30/2026
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704.3(d) LICENSURE 24 Hour Coverage
704.3. General requirements for projects.
(d) Inpatient nonhospital facilities except for transitional living facilities and licensed facilities providing halfway house services shall have awake staff coverage 24 hours a day. Halfway houses shall have at least one staff person on the premises at all times.
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Observations
Based on a review of administrative documentation and staff schedules, the facility failed to provide awake staff coverage 24 hours a day.
On February 6, 2026, a monitor support staff was observed to be sleeping while working and was difficult to wake. The same staff was observed to be sleeping while working on February 9, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning the week of March 30, 2026, security staff are required to attend weekly meetings/trainings that cover important and relevant topics to reinforce and refresh understanding of policies, procedures and agency expectations. These efforts support the facility's commitment to maintaining 24-hour security coverage. A corrective action plan was given to the security staff who were found asleep during the times mentioned in the inspection report. The staff member had requested additional shifts and overtime but was unable to manage the new schedule. The Chief of Staff immediately changed the schedule and reduced overtime for that individual. The Security Supervisor will begin spot checking of security staff overnight shifts the week of April 20, 2026, to ensure Passages security schedule is adequately covered. |
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 one 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 #2 was admitted to the inpatient non-hospital detoxification activity on November 17, 2025 and was discharged against medical advice on January 24, 2026. 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.
This is a repeat citation from the September 18, 2025 onsite inspection.
In addition, based on a review of client grievances, the facility failed to document the facility client grievance policy is being followed.
Facility policy states - " residents may file a grievance at any time by requesting a " Request for Administrative Remedy " form from any staff member. The resident will fill out part " A " and return it to the house monitor. The house monitor will assign the grievance a number and have the resident sign and date the receipt (part " C " ). A copy of the grievance will be given to the resident and the original will be forwarded to the Facility Manager. When deemed necessary, the Facility Manager or designee will conduct an investigation and prepare a written response on " part B " within seven business days. If the resident is not satisfied with the Level I response, he/she/they may, within five business days, appeal to Level II. "
The client grievances were requested on March 6, 2026. A cardboard box with loose paperwork was presented. Grievances dated November 4, 9 and 25, 2025 as well as January 27, 2026 were documented; however, there was no documentation of a " receipt - part C " or a written staff response, " part B " for these grievances.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery Inc. has implemented a comprehensive corrective action plan
to address deficiencies and ensure full compliance with DDAP regulations.
Administrative leadership has initiated structured operational improvements across
multiple domains including security, medication management, staffing, and clinical documentation.
Management staff are conducting weekly meetings to review overall operations.
These meetings focus on identifying deficiencies, monitoring progress, and
implementing corrective strategies related to program operations, staffing, and compliance requirements.
The Compliance Director has been reassigned to the position of Clinical Director to
strengthen clinical oversight.
The Compliance Officer has been moved into the role of Facility Manager to ensure proper coordination of client ancillary service appointments and to manage client relations.
An Interim Clinical Supervisor has been engaged through Delta Staffing to provide support to therapists and to assist the Director in assuring that all clinical milestones are met in a timely manner. The organization is actively working to secure a qualified Clinical Supervisor to join the
staff on a permanent basis. A Security Supervisor has been hired to oversee facility safety and medication
monitoring. After notification that our Medical Director was retiring, Passages engaged a new Medical Director to provide oversight of medical services.
A Nursing Agency has been contracted to provide LPNs and RNs to support medication management and medical documentation.
The addition of a Security Supervisor and contracted medical staff ensures that medication storage, administration, and monitoring procedures are properly followed. Medication storage is now consolidated into the medication carts, and the carts are under camera view at all times. These changes strengthen accountability and compliance with regulatory standards. Passages is implementing new data collection procedures to ensure that all client
information is stored in a centralized, Sharepoint secure system. This improvement is designed to enhance accessibility, organization, and audit readiness of clinical
records. The Facility Manager will ensure that all client medical and ancillary appointments are
attended as scheduled. Additionally, the Facility Manager is responsible for overseeing and properly documenting all client grievances to ensure compliance and quality of care.
The Interim Clinical Supervisor is now reviewing therapists' activities to assure that Biopsychosocial assessments, sessions, treatment plans, case
consultations, ASAM's, seven-day reviews,30-day reviews and post discharge follow-ups are performed on time and documented in our EHR.
Passages remains committed to continuous quality improvement. Weekly
administrative reviews, staffing enhancements, and system improvements will be monitored to ensure sustained compliance with DDAP standards and successful completion of the corrective action plan. An Emergency Contact Log for clients has been created and kept in the monitor's station. Monitoring staff have been instructed to contact the client's emergency contact person should the client leave AMA within 12 hours. The Clinical Supervisor will ensure a call and documentation that an emergency contact call was made to the client's emergency contact person. Passages to Recovery has a client grievance policy and procedures in place. All clients have been made aware of the protocol in new client orientation. The Center Manager oversees and conducts all client grievances. The Center Manager has a grievance log that verifies client grievances have been resolved and kept in Center Managers office.
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709.26 (b) (4) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(4) Disciplinary actions.
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Observations
Based on a review of personnel records, the facility failed to follow facility disciplinary procedures in two of two personnel records.
Staff #2, was hired as a monitor on May 12, 2025, was found sleeping on the job on two separate occasions. There was no documented disciplinary action documented in personnel record #2. Staff #2 was placed on the schedule by themselves after found to be sleeping on the job on February 15, 17 and 18, 2026 as well as March 1, 8, 15 and 16, 2026. In addition, a written warning and correction action plan dated October 10, 2025 was found in staff #2 ' s personnel record regarding a separate incident. As part of the corrective action plan, it was determined that that weekly supervision would be required, as well two trainings - Ethics and Language and Harassment, will need to be completed by November 15, 2025. There was no documentation of weekly supervision and only one training had been completed.
Staff #5, was hired as a monitor on September 15, 2025. Staff #5 was written warning and correction action plan dated October 10, 2025 was found in staff #2 ' s person issued a written warning on October 10, 2025. As part of the corrective action plan, it was determined that that weekly supervision would be required, as well two trainings - Ethics and Language and Harassment, will need to be completed by November 15, 2025. There was no documentation of weekly supervision and neither training had been completed. It was reported that staff #5 completed Ethics; however, there was documentation of completion.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery Inc. has implemented a comprehensive corrective action plan to address deficiencies and ensure full compliance with DDAP regulations. Administrative leadership has initiated structured operational improvements across multiple domains including security, medication management, staffing, and clinical documentation. Management staff are conducting weekly meetings to review overall operations. These meetings focus on identifying deficiencies, monitoring progress, and implementing corrective strategies related to program operations, staffing, and compliance requirements. The Compliance Director has been reassigned to the position of Clinical Director to strengthen clinical oversight. The Compliance Officer has been moved into the role of Facility Manager to ensure proper coordination of client ancillary service appointments and to manage client relations.
An Interim Clinical Supervisor has been engaged through Delta Staffing to provide support to therapists and to assist the Director in assuring that all clinical milestones are met in a timely manner. The organization is actively working to secure a qualified Clinical Supervisor to join the staff on a permanent basis
A Security Supervisor has been hired to oversee facility safety and medication monitoring.
After notification that our Medical Director was retiring, Passages engaged a new Medical Director to provide oversight of medical services.
A Nursing Agency has been contracted to provide LPNs and RNs to support medication management and medical documentation.
The addition of a Security Supervisor and contracted medical staff ensures that medication storage, administration, and monitoring procedures are properly followed. Medication storage is now consolidated into the medication carts, and the carts are under camera view at all times. These changes strengthen accountability and compliance with regulatory standards.
Passages is implementing new data collection procedures to ensure that all client information is stored in a centralized, Sharepoint secure system. This improvement is designed to enhance accessibility, organization, and audit readiness of clinical records.
The Facility Manager will ensure that all client medical and ancillary appointments are attended as scheduled. Additionally, the Facility Manager is responsible for overseeing and properly documenting all client grievances to ensure compliance and quality of care.
The Interim Clinical Supervisor is now reviewing therapists' activities to assure that Biopsychosocial assessments, individual sessions, treatment plans, case consultations, ASAM's, seven day seven-day reviews, 30- day reviews and post discharge follow-ups are performed on time and documented in our EHR.
Passages remains committed to continuous quality improvement. Weekly administrative reviews, staffing enhancements, and system improvements will be monitored to ensure sustained compliance with DDAP standards and successful completion of the corrective action plan.
A Security Supervisor has been hired to oversee facility safety. The security supervisor monitor camaras to ensure safety within the facility is being provided. The person sleeping during work hours, disciplinary action was taken. They were given a written and final warning regarding their lack of professionalism in the workplace.
Staff's disciplinary documented will be placed in their personnel record. Any violation of the written plan of correction may lead up to termination of employment. Staff has been made aware sleeping on the job is grounds for immediate termination.
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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, administrative documentation and staff interviews, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of one applicable records reviewed.
On November 7, 2025 an email was sent to staff from supervisory staff containing a client ' s medical information for the purpose of providing instructions regarding accommodations that were to be made. This email was printed by facility staff and hung in the facility, allowing other clients to view this confidential medical information. The information contained in the email was intended for staff use only. There was no documentation that consent to release information was obtained.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery will ensure that all clinical and medical staff obtain informed, written, and voluntary consent from clients prior to the disclosure of any information contained within the client's medical or clinical record, in accordance with DDAP 702.98 (c) Confidentiality requirements. The Clinical Director instructed all staff, under no circumstances will client personal or protected health information be emailed, printed, or displayed in any manner that could be accessed or viewed by other clients or unauthorized personnel. All documentation containing confidential information will be securely maintained in designated systems or locked storage areas with access limited to authorized staff only. Clinical and medical staff have received training and ongoing reinforcement regarding confidentiality standards, privacy protections, and proper handling of client information to ensure full compliance and prevent unauthorized disclosures. The Clinical Manager and Clinical Supervisor will conduct weekly chart audits. The Center Manager will conduct building inspections to ensure no clients confidential information is posted in any public areas within the facility. Monthly all staff bulletins will be posted regarding the importance of Confidentiality. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of client records, administrative documentation, medication records and staff interview, the facility failed to provide a record keeping system which allows for the efficient retrieval of data.
Facility staff were requested to provide documentation of all unusual incidents. The facility provided a spreadsheet of unusual incident reports that were already submitted to DDAP, but no additional incidents, including those not reportable, were able to be provided. Medication errors and medication inventory discrepancies require documentation of an incident report, per facility policy. Medication errors were reported to DDAP via onsite interviews and medication inventory discrepancies were observed in the medication administration record. There were no unusual incident reports documented regarding these incidents.
The client medication administration records were requested for review. May of them had not been scanned into the client record to date and paper records were required to be gathered. Incomplete medication administration records were provided for clients #3, 8 and 9. There were multiple places the medication administration records were kept.
Client grievances were requested for review. The auditor was provided with a cardboard box of loose documentation, including several different types of documents. The auditor had to sort through the loose documentation to pull out the client grievances, many of which were not addressed by facility staff.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery established a standardized electronic submission link for all unusual incidents. All submitted incidents are printed and placed in a centralized Unusual Incident Log maintained by the Facility Manager.
Passages has created a Medical Incident Report to address medical and medication issues and concerns. All medical incident reports will be submitted to management staff and stored on Sharepoint. All medication errors, medication inventory discrepancies and any unusual incidents will be logged by staff who have observed the reportable issue. These reports will be submitted to center management to be addressed and rectified.
All unusual incidents that occur within the facility will be addressed by the Facility Manager. All unusual incidents and misconduct reports are scanned and file on the Passages SharePoint Drive.
The Center Manager maintains a comprehensive grievance log that documents all client concerns. Clients are provided access to grievance forms and have been informed that all grievances must be submitted to the Center Manager for review. Each grievance is addressed within three (3) business days, with documentation of the resolution recorded in the log. The grievance log is securely maintained within a designated office.
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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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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 #1 was admitted on December 17, 2025, and discharged on January 9, 2026. The medication administration record (MAR) was reviewed for December 2025 and January 2026.
Levothyroxine 25 mcg, with physician instructions to be taken every morning, was started on December 17, 2025. The MAR did not include documentation that the client had this medication on January 2, 2026. In addition, it was documented that the client had this medication twice on January 5, 2026.
Divalproex, 500 mg, with physician instructions to be taken twice daily, was started on December 17, 2025. An additional dose of this medication, 250 mg was to be taken every morning. The MAR did not include documentation that the client had one of the morning doses and the evening dose of this medication on January 5, 2026.
Zonisamide 100mg, with physician instructions to take three capsules twice per day, was started on December 17, 2025. The MAR did not include documentation that the client was given the morning dose of this medication on January 2, 2026 and the evening dose of this medication on January 5, 2026. In addition, it was documented that the client had this medication twice on January 5, 2026. In addition, the medication administration record stated that the client had only one caplet, instead of three, as prescribed, for the morning doses December 17, 2025 - January 4, 2026, January 5, 2026 and January 7-8, 2026.
Client #2 was admitted on November 17, 2025 and discharged on January 24, 2026. The medication administration record (MAR) was reviewed for November 2025, December 2025 and January 2026.
Senna 8.6 mg, with physician instructions to take one tablet twice per day, was started on November 26, 2025. The MAR did not include documentation that the client was given the morning dose of this medication on November 27, 28, 29, December 2, 9, 21, 2025. The morning MAR for this medication ends at December 22, 2025; however, there is no documentation that this medication was discontinued. In addition, the MAR did not include documentation that the evening dose of this medication was given on January 3, 7, 8, 10, 11, 14, 15, 16, 17, 21, 22, 2026.
Clonidine .1mg, with physician instructions to take one tablet three times a day for three days. There was no MAR documenting this client was given this medication.
Gabapentin, 300mg, with physician instructions to take one tablet three times a day for three days. There was no documentation that the client was given the medication three times daily, as prescribed, on January 21, 22 and 23, 2026.
Client #3 was admitted on January 5, 2026 and was active at the time of the inspection. The medication administration record (MAR) was reviewed for January and February 2026.
Escitalopram, 10mg, with physician orders to take one tablet every evening, was started on January 7, 2026. The MAR for this medication starts on January 25, 2026. There was no documentation that the client had this medication as prescribed on January 7 - 25, 2026.
Mavyret, 100/40mg, with physician orders to take three tablets daily at breakfast was started on January 15, 2026. There was no MAR documented for this medication.
Hydroxyzine, 50mg, with physician orders to take one tablet daily every morning was started on January 13, 2026. There was no MAR documented for this medication.
Lurasidone, 80mg, with physician orders to take one-half tablet twice daily was started on January 13, 2026. There was no MAR documented for this medication.
Topraimate, 100mg, with physician orders to take one tablet twice daily was started on January 22, 2026. There was no documentation that the client was given the morning dose of this medication on February 7, 2026.
Client #4 was admitted on January 8, 2026 and was discharged on February 3, 2026. The medication administration record (MAR) was reviewed for January and February 2026.
Insulin Aspart, 100 unit/ml, with physician orders to inject fourteen units with breakfast, twelve units with lunch and ten units with dinner was started on January 21, 2026. The MAR that was documented for this medication was handwritten for the dates January 10, 2026 through January 24, 2026. There was no documentation that the client was given this medication from January 19 - February 3, 2026.
Lantus 100 unit/ml, with physician order to inject twenty units nightly was started on January 8, 2026. This dosage was increased to forty units nightly on January 21, 2026. There was no MAR documented for this medication.
Client #5 was admitted on January 8, 2026 and was active at the time of the inspection. The medication administration record (MAR) was reviewed for January and February 2026.
Lurasidone, 80mg, with physician order to take one-half tablet twice daily was started on January 8, 2026. There was no documentation that the medication was given to the client twice daily, as prescribed, on January 13, 18, 21, 23, 24, 27, 28, 30 and 31 and February 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12, 2026. In addition, the medication was documented to be given to the client three times on January 15, 2026. Each MAR entry for this medication from January 8, 2026 through February 12, 2026 indicates the " number taken " is one, not one-half, as prescribed by the physician.
Hydroxyzine, 50mg, with physician order to take two tablets daily at bedtime was started on January 8, 2026. The prescription was updated on January 13, 2026 to take two capsules daily at bedtime and one tablet daily in the morning was started on January 13, 2026. There was no documentation that the medication was given to the client as prescribed, on January 9, 11, 15, 16, 17, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 30 and February 1, 2, 3, 4, 6, 7, 8, 9, 10 and 11, 2026.
Topraimate, 25mg, with physician orders to take one tablet twice daily was started on January 22, 2026. There was no MAR documented for this medication.
Client #6 was admitted on January 9, 2026 and was active at the time of the inspection. The medication administration record (MAR) was reviewed for January and February 2026.
Paroxetine, 10mg, with physician orders to take three tablets every morning was started on January 9, 2026. There was no documentation that the medication was given to the client daily, as prescribed, on January 21, 25, 30, 31 and February 5, 7, 9, 10, 11 and 12, 2026.
Bupropion, 150mg, with physician orders to take one tablet by mouth daily was started on January 9, 2026. There was no documentation that the medication was given to the client daily, as prescribed, on January 22, 25, 30, 31 and February 5, 7, 9 and 10, 2026.
Client #7 was admitted on December 11, 2025 and discharged on February 6, 2026. The medication administration record (MAR) was reviewed for December 2025 and January and February 2026.
Therma-M, with physician orders to take two tablets daily was started on January 25, 2026. There was no documentation that the medication was given to the client daily, as prescribed, on January 27, 30, 31 and February 2, and 5, 2026.
Quetiapine 200mg, with physician orders to take one tablet twice daily was started on December 18, 2025. There was no documentation that the medication was given to the client twice daily, as prescribed, on December 19-31, 2025 and January 2, 7, 15-31, 2026. There was no February MAR documented for this medication.
Client #8 was admitted on November 24, 2025 and discharged on February 9, 2026. The medication administration record (MAR) was reviewed for November and December 2025 and January and February 2026.
Gabapentin, 600mg, with physician orders to take one capsule three times daily starting December 8, 2025. On January 14, 2026 the physician instructions are updated for this medication to two capsules twice daily. There is no December 2025 MAR for this medication. It was documented that the client had fifty capsules missing on December 15, 2025.
There is no documentation that the client received this medication as prescribed on January 26 - February 9, 2026. The MAR for this medication stops on January 25, 2026.
Cefdinir, 300mg, with physician orders to take one tablet twice daily was started on December 26, 2025. There was no documentation that the medication was given twice daily, as prescribed
On December 31, 2025 and January 1, 3, and 4, 2026. The MAR for this medication stops on January 8, 2026.
Amoxicillin/clavulanic acid 875/125mg, with physician orders to take one tablet twice daily was started on December 23, 2025. There was no documentation that the medication was given twice daily, as prescribed, on December 24, 29 and 30, 2025. The MAR for this medication stops on December 30, 2025.
Lidocaine 4% patch, with physician orders to apply one patch daily was started on December 4, 2025. There was no documentation that the medication was given once daily, as prescribed, on December 6, 10, 11, 12, 13, 14, 19, 20, 21, 22, 23, 25, 26, 28, 29, 30 and 31 and January 1, 2, 3, 4, 8, 9, 10, 11, 13, 17, 18 and 19, 2026. The MAR for this medication stops on January 20, 2026.
Sulfa -TMP DS, 800/160mg, with physician orders to take one tablet twice daily for seven days starting on December 15, 2025. There was no documentation that the client was given this medication twice daily for seven days, as prescribed, on December 18, 20, 21 and 22, 2026. The medication should have been finished on December 22, 2025; however, it was given one time on December 23, 25 and 27, 2025.
Buprenorphine 2mg, with physician order to take one film daily was started on January 3, 2026. There was no documentation that the client received this medication daily, as prescribed, on January 12, 2026. The MAR for this medication stops on January 25, 2026.
Hydroxyzine 25mg, with physician order to take one capsule twice daily was started on January 2, 2026. There was no documentation that the client had this medication at all for the month of January 2026, with the exception of one dose given on January 12, 2026.
Atorvastatin 10mg, with physician order to take two tablets daily in the evening was started on November 24, 2025. The MAR for this medication stops on December 24, 2025. There was no MAR documented for this medication for January and February 2026.
Client #9 was admitted on November 6, 2025 and was active at the time of the inspection. The medication administration record (MAR) was reviewed for November and December 2025 and January and February 2026.
Levetiracetam 500mg, with physician order to take one tablet twice daily was started on November 6, 2025. This medication was not given twice daily, as prescribed, on November 17, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, December 1, 2, 3, 4, 5, 6, 7, 11, 14, 20 and 28, 2025.
Bupropion XL 150mg, with physician order to take one tablet every morning for fourteen days, started on December 16, 2025. There was no documentation that the client was given this medication daily, as prescribed on December 27-30, 2025. The MAR for this medication stopped on December 26, 2025; however, the fourteenth day would have been December 30, 2025.
Buproprion XL 450mg, with physician order to take one tablet every morning was started on February 2, 2026. There was no documentation that the client was given this medication daily, as prescribed, on February 6, 2026, as it was documented that the client was given the medication twice on this day.
Gabapentin 800mg, with physician order to take one tablet by mouth three times daily, was started on December 8, 2025. There was no MAR for this medication documented for December 2025. There was documentation stating that this client was missing tablets of this medication that was delivered on December 8, 2025. There was no documentation that this client received this medication as prescribed on January 17, 19, 21, 22, 26, 27, 28, 29, 30, 31 and February 1, 2, 3, 4, 5, 6, 7, 10 and 11, 2026. In addition, this medication was documented to be given four times a day on January 16 and February 9, 2026.
This is a repeat citation from the September 10, 2024, and March 26, 2025 and September 18, 2025 onsite inspections.
Client #10 was admitted on February 19, 2026 and was active at the time of the inspection. The medication administration record (MAR) was reviewed for February and March 2026.
Topiramate 50mg, with physician order to take one tablet daily was started on February 23, 2026. There was no documentation that the client was given this medication daily, as prescribed, on February 26, 2026.
Nicotine CLR 21mg, with physician order to take one patch daily was started on February 26, 2026. There was no documentation that the client was given this medication daily, as prescribed, on February 27 and March 3 and 4, 2026.
Breo Ellipta 100-25mg, with physician order to take once daily was started on February 26, 2026. There was no documentation that the client was given this medication daily, as prescribed, on February 27 and 28 and March 3, 4 and 5, 2026.
Pantoprazole SOD DR 40mg, with physician order to take once every morning was started on February 23, 2026. There was no documentation that the client was given this medication daily, as prescribed, on February 25 and 26, 2026.
Thera-M, with physician order to take once daily was started on February 23, 2026. There was no documentation that the client was given this medication daily, as prescribed, on February 25 and 26, 2026.
Dairy Relife 3000 unit, with physician order to take three times daily with meals was started on February 26, 2026. There was no documentation that the client was given this medication daily, as prescribed, on February 28, 2026.
Baclofen 10mg, with physician order to take three times daily was started on February 26, 2026. There was no documentation that the client was given this medication three times daily, as prescribed, on February 26, and 27, 2026.
Famotidine 20mg, with physician order to take two times daily was started on February 26, 2026. There was no documentation that the client was given this medication two times daily, as prescribed, on February 27, 2026.
Client #11 was admitted on February 24, 2026 and was active at the time of the inspection. The medication administration record (MAR) was reviewed for February and March 2026.
Buspirone 30mg, with physician order to take two times daily was started on February 27, 2026. There was no documentation that the client was given this medication two times daily, as prescribed, on February 27, 28 and March 1, 2, 3, 4 and 5, 2026.
Mirtazapine 45mg, with physician order to take once daily was started on March 2, 2026. There was no documentation that the client was given this medication daily, as prescribed, on March 3 and 4, 2026.
Amlodipine 5mg, with physician order to take once daily every morning was started on February 27, 2026. There was no documentation that the client was given this medication daily, as prescribed, on February 28 and March 1, 2, 3, 4 and 5, 2026.
Quetiapine 300mg, with physician order to take two tabs daily every evening was started on March 2, 2026. There was no documentation that the client was given this medication daily, as prescribed, on March 2, 3 and 4, 2026.
Hydroxyzine pamoate 50mg, with physician order to take two tabs daily every evening was started on March 2, 2026. There was no documentation that the client was given this medication daily, as prescribed, on March 2, 3 and 4, 2026.
Client #12 was admitted on February 23, 2026 and was active at the time of the inspection. The medication administration record (MAR) was reviewed for February and March 2026.
Ramelteon 8mg, with physician order to take daily every morning was started on February 25, 2026. There was no documentation that the client was given this medication daily, as prescribed, on February 26, 2026.
Olanzpaine 20mg, with physician order to take daily every evening was started on February 23, 2026. There was no documentation that the client was given this medication daily, as prescribed, on February 24 and March 3, 2026.
Client #13 was admitted on October 2, 2025 and was active at the time of the inspection. The medication administration record (MAR) was reviewed for January, February and March 2026.
Sertraline 100mg, with physician order to take daily was started on January 21, 2026. There was no documentation that the client was given this medication daily, as prescribed, on January 23-31, February 1-2, 4, 6-7, 9-16, 18-19, 21, 24, and 26-28 and March 1-5, 2026.
Mirtazapine 30mg, with physician order to take daily in the evening was started on January 25, 2026. There was no documentation that the client was given this medication daily, as prescribed, on January 26-29 and February 4, 8, 13, 15, 18-19, 21, 24-25 and March 2, 2026.
Prazosin 2mg, with physician order to take daily at bedtime was started on January 25, 2026. There was no documentation that the client was given this medication daily, as prescribed, on January 26, 28-30, February 4, 8, 13, 15, 17-21, 25, and March 2, 2026.
Prednisone 10mg, with physician order to take four times daily for four days was started on March 2, 2026. There was no documentation that the client was given this medication daily, as prescribed, on March 3 and 4, 2026.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 10, 2024, March 26, 2025 and September 18, 2025, onsite inspections.
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Plan of Correction
Passages to Recovery has implemented the following corrective actions to ensure full compliance: Policy Revision Policies and procedures related to medication control and the management of client medications have been reviewed and updated to align with DDAP regulatory requirements.
Medical Oversight: A new Medical Director has been contracted to provide oversight of all medical services, including medication management, policy compliance, and quality assurance. Nursing Support Services: A Nursing Agency has been contracted to support medication management, ensure proper administration of medications, and maintain accurate medical documentation. Electronic MAR Implementation: Passages to Recovery will implement QuickMAR for electronic Medication Administration Record (MAR) documentation to improve accuracy, accountability, and accessibility of medication records. Staff Training: All nursing and support staff will receive training on: Updated medication policies and procedures, Proper medication administration protocols. Use of QuickMAR for documentation and tracking. Responsible Staff, Medical Director, Nursing Agency Staff, Clinical Director, Program Director, Direct Care and Support Staff.
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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 medication administration records (MARs), policy and procedures and staff interview, the facility failed to maintain accurate records of medications given, and an efficient system for medication control and accountability.
Per facility policy, each individual medication in the facility will be audited daily to ensure that no medication is missing or unaccounted for and to ensure that the participants are taking prescription medication as prescribed. If the log sheet does not match the physical medication count, the monitor will reconcile the medication record and prepare an incident report describing the error and forward to facility management and medical staff before the end of shift.
There were no incident reports documented for the medication discrepancies reviewed, as required per policy.
Client #1 was admitted on December 17, 2025 and discharged January 9, 2026. The MARs for December 2025 and January 2026 were reviewed.
Levothyroxine 25 mcg, with physician instructions to be taken every morning, was started on December 17, 2025. There was no documentation of a daily audit for this medication on December 18, 20 and 21 and December 22, 2025 - January 6, 2026. Medication audits / inventories were documented on December 22, 2025 and January 7, 2026. The counts do not match the administration record for this medication.
Divalproex, 500 mg, with physician instructions to be taken twice daily, was started on December 17, 2025. An additional dose of this medication, 250 mg was to be taken every morning. This medication was spread over three separate MARs for the same time period. There was no documentation of a daily audit for this medication on December 18, 20 and 21, December 22, 2025 - January 6, 2026. Medication audits / inventories were documented on December 22, 2025 and January 7, 2026. The counts do not match the administration record for this medication.
Zonisamide 100mg, with physician instructions to take three capsules twice per day, was started on December 17, 2025. There was no documentation of a daily audit for this medication on December 18, 20 and 21, December 22, 2025 - January 6, 2026. Medication audits / inventories were documented on December 22, 2025 and January 7, 2026. The counts do not match the administration record for this medication. In addition, the morning MAR for this medication states that the " number taken " was one; however, the evening dose of this medication states that the " number taken " was three.
Client #2 was admitted on November 17, 2025 and discharged January 24, 2026. The MARs for November and December 2025 and January 2026 were reviewed.
Gabapentin 300 mg, with physician instructions to be taken three times daily for three days, was started on January 21, 2026. There was no documentation of a daily audit for this medication on January 22-24, 2026. A medication audit/ inventory was documented on January 25, 2026, indicating there was none of this medication. The counts do not match the administration record for this medication.
Senna, 8.6 mg, with physician instructions to be taken twice daily, was started on November 26, 2025. There was no documentation of a daily audit for this medication on November 27-29, 2025, December 1-3, 5-7, 12-14, 17-21, 23-30, 2025 and January 1, 3-4, 7-8, 10-12, 14-22, 2026. Medication audits / inventories were documented on December 22, 2025 and January 7, 2026. The counts do not match the administration record for this medication.
Mirtazapine, 30 mg, with physician instructions to be taken once daily at bedtime, was started on November 19, 2025. There was no documentation of a daily audit for this medication on November 20-25, 27-29, 2025, December 1-3, 5-7, 2025. There is no MAR or medication audits / inventories for this medication documented for the time period of December 8 - January 4, 2026. There was no documentation of a daily audit for this medication on January 6-8, 10-12, 14-22, 2026. Medication audits / inventories were documented on December 22, 2025 and January 7, 2026.
Clonidine, .1 mg, with physician instructions to be taken three times daily for three days, was started on January 21, 2026. There was no documentation of a MAR or any medication audit / inventory for this medication.
Client #3 was admitted on January 5, 2026 and was current at the time of the inspection. The MARs for January and February 2026 were reviewed.
Escitalopram, 10mg, with physician instructions to be taken once daily in the evening, was prescribed on January 7, 2026 and started on January 25, 2026. There was no documentation of a daily audit for this medication on January 26-27 and 29-31 and February 1-6 and 8-10, 2026.
Topiramate, 100mg, with physician instructions to be taken twice daily, was started on January 25, 2026. There was no documentation of a daily audit for this medication on January 26-27 and 29-31 and February 1-7 and 8-10, 2026. The counts do not match the administration record for this medication.
Mavyret, 100/40mg, with physician orders to take three tablets daily at breakfast was started on January 15, 2026. There was no documentation of a MAR or any medication audit / inventory for this medication.
Hydroxyzine, 50mg, with physician orders to take one tablet daily every morning was started on January 13, 2026. There was no documentation of a MAR or any medication audit / inventory for this medication.
Lurasidone, 80mg, with physician orders to take one-half tablet twice daily was started on January 13, 2026. There was no documentation of a MAR or any medication audit / inventory for this medication.
Client #4 was admitted on January 8, 2026 and was discharged on February 3. 2026. The MARs for January and February 2026 were reviewed.
Biktarvy, 50/200/25mg, with physician instructions to be taken once daily in the evening, was started on January 8, 2026. There was no documentation of a daily audit for this medication on January 9-12 and January 14 - February 1- 3, 2026.
Ezetimibe, 10mg, with physician instructions to be taken once daily in the evening, was started on January 8, 2026. There was no documentation of a daily audit for this medication on January 9-12 and January 14 - February 1- 3, 2026.
Furosemide, 20mg, with physician instructions to be taken once daily in the morning, was started on January 8, 2026. There was no documentation of a daily audit for this medication on January 9-12 and January 14 - February 1- 3, 2026. The counts do not match the administration record for this medication.
Atomoxetine, 60mg, with physician instructions to be taken once daily in the morning, was started on January 8, 2026. There was no documentation of a daily audit for this medication on January 9-12 and January 15 - February 1- 3, 2026.
Sacubitril - Valsartan, 24/26mg, with physician instructions to be taken twice daily, was started on January 8, 2026. There was no documentation of a daily audit for this medication on January 9-12 and January 14 - February 1- 3, 2026. There is no MAR or medication audit / inventory for the January 21 - February 3, 2026. The counts do not match the administration record for this medication.
Insulin Aspart, 100 unit/ml, with physician orders to inject fourteen units with breakfast, twelve units with lunch and ten units with dinner was started on January 24, 2026. The MAR that was documented for this medication was handwritten on notebook paper for the dates January 10-18, 2026. There was no documentation that the client was given this medication from January 19 - February 3, 2026. There is no medication audit / inventory documented for this medication.
Lantus 100 unit/ml, with physician order to inject twenty units nightly was started on January 8, 2026. This dosage was increased to forty units nightly on January 21, 2026. There was no MAR or medication audit / inventory documented for this medication.
Client #5 was admitted on January 8, 2026 and was active at the time of the inspection. The MARs for January and February 2026 were reviewed.
Lurasidone, 80mg, with physician instructions to be taken one-half tablet twice daily, was started on January 8, 2026. There was no documentation of a daily audit for this medication on January 9-12 and January 15 - February 12, 2026. The physician instructions state to take one-half tablet; however, the " number taken " that is recorded on the MAR states one.
Hydroxyzine, 50mg, with physician instructions to be taken one capsule once daily in the morning and two capsules daily at bedtime, was started on January 8, 2026. There was no documentation of a daily audit for this medication on January 9-12 and January 15 - February 12, 2026.
Topiramate, 25mg, with physician instructions to be taken twice daily, was started on January 22, 2026. There was no documentation of a MAR or any medication audit / inventory for this medication.
Client #6 was admitted on January 9, 2026 and was active at the time of the inspection. The MARs for January and February 2026 were reviewed.
Paroxetine, 10mg, with physician instructions to be taken three tablets once daily in the morning, was started on January 9, 2026. There was no documentation of a daily audit for this medication on January 10-13 and January 15 - February 12, 2026.
Bupropion, 150mg, with physician instructions to be taken one tablet once daily, was started on January 9, 2026. There was no documentation of a daily audit for this medication on January 10-13 and January 15 - February 12, 2026.
Mirtazapine, 15mg, with physician instructions to be taken one tablet once daily in the evening, was started on January 9, 2026. There was no documentation of a daily audit for this medication on January 10-13 and January 15 - February 12, 2026.
Client #7 was admitted on December 11, 2025 and discharged on February 6, 2026. The MARs for December 2025 and January and February 2026 were reviewed.
Therma-M, with physician instructions to be taken once daily, was started on January 25, 2026. There was no documentation of any medication audit / inventory for this medication.
Quetiapine, 200mg, with physician instructions to be taken one tablet twice daily, was started on December 18, 2025. There was no documentation of a daily audit for this medication on December 19-30, 2025 January 1-12 and January 15 - February 6, 2026.
Client #8 was admitted on November 24, 2025 and discharged on February 9, 2026. The MARs for November and December 2025 and January and February 2026 were reviewed.
Gabapentin, 600mg, with physician instructions to be taken one tablet three times daily, was started on December 8, 2025. The physician instructions were updated on January 14, 2026 to take two capsules twice daily. There was no documentation of a daily audit for this medication on January 19, 24 and January 26 - February 9, 2026. There was no documentation of a MAR or any medication audit / inventory for this medication from December 8, 2025 - January 8, 2026. There is documentation stating that this medication was missing in December 2025.
Cefdinir, 300mg, with physician instructions to be taken one tablet twice daily, was started on December 26, 2025. There was no documentation of a daily audit for this medication on December 27-29 and 31, 2025 and January 1-31, 2026. There was no documentation of a MAR or any medication audit / inventory for this medication from January 9 - February 9, 2026.
Amoxicillin/clavulanic acid 875/125mg, with physician orders to take one tablet twice daily was started on December 23, 2025. There was no documentation of any medication audit / inventory for this medication.
Lidocaine patch, 4%, with physician instructions to apply once daily, was started on December 4, 2025. There was no documentation of a daily audit for this medication on December 9-15 and December 18, 2025 - January 14, 2026. There were no MAR entries or medication audits documented from January 20 - February 9, 2026. The counts do not match the administration record for this medication.
Sulfa TMP DS, 800/160mg, with physician instructions to take one tablet twice daily for seven days, was started on December 15, 2025. There was no documentation of a daily audit for this medication on December 18-27, 2025. The medication was not taken as prescribed and the last dose was taken on December 27, 2025.
Hydroxyzine, 25mg, with physician instructions to take two capsules every evening, was started on November 24, 2025. There was no documentation of a daily audit for this medication on November 27 - December 1, 2025, December 5-7, 9-14, 18-24, 2025. The last entry on the MAR for this medication was documented December 24, 2025.
Atorvastatin, 10mg, with physician instructions to take two tablets daily in the evening was started on December 19, 2025. The physician instructions were updated on January 2, 2026 to one capsule twice daily. There was no documentation of a daily audit for this medication on December 20-30, 2025 and January 1, 3-11, 2026. The last entry on the MAR for this medication was documented January 13, 2026. The counts do not match the administration record for this medication.
Client #9 was admitted on November 6, 2025 and was active at the time of the inspection. The MARs for November and December 2025 and January and February 2026 were reviewed.
Quetiapine, 300mg, with physician instructions to take two tablets daily at bedtime was started on November 6, 2025. There was no documentation of a daily audit for this medication on November 7-9, 12-13, 14-16, 18-19, 22-25, 2025 November 27 - December 2, 2025, December 5- 7, 9-10, 12-14, 18, 20-21, 23-29, 31 2025 and January 2-6, 8-11, 13-14, 15-19, 21-31,2026 and February 1-4, 6-12, 2026. The counts do not match the administration record for this medication.
Levetiraceta, 500mg, with physician instructions to take one tablet twice daily was started on November 6, 2025. There was no documentation of a daily audit for this medication on November 7-9, 12, 15-16, 18-19, 22-25, 2025 November 27 - December 2, 2025, December 5- 7, 9-10, 12-14, 18, 20-21, 23-29, 31, 2025 and January 3-6, 9-30, 2026 and February 1-12, 2026. The counts do not match the administration record for this medication.
Bupropion HCL XL 150mg, with physician instructions to take one tablet every morning for fourteen days was started on December 16, 2025. There was no documentation of a daily audit for this medication on December 18, 20-21, 23, 25-26, 2025. The MAR entries end for this medication on December 26, 2025. The prescription and instructions for this medication was changed to 450mg daily on February 2, 2026. There was no documentation of a daily audit for this medication on February 3-4, 6-11, 2026. The counts do not match the administration record for this medication. There was no documentation of a MAR or any medication audit / inventory for this medication from December 26 - February 1, 2026.
Fluoxetine, 10mg, with physician instructions to take one capsule daily was started on November 6, 2025. There was no documentation of a daily audit for this medication on November 7-9, 12-13, 14-16, 18-19, 22-25, 27-30, 2025 and December 1-2, 5-7, 9-14, 16, 2025. The MAR and audits stop for this medication on December 16, 2025.
Gabapentin, 800mg, with physician instructions to be taken one tablet three times daily, was started on December 8, 2025. There was no documentation of a daily audit for this medication on January 22, 24 and 25 and February 9-10, 2026. There was no documentation of a MAR or any medication audit / inventory for this medication from December 8, 2025 - January 13, 2026. There is documentation stating that this medication was missing in December 2025.
Client #10 was admitted on February 19, 2026 and was active at the time of the inspection. The medication administration record (MAR) was reviewed for February and March 2026.
Topiramate 50mg, with physician order to take one tablet daily was started on February 23, 2026. There was no documentation of a daily audit for this medication on February 24 - March 1, and March 3-5, 2026.
Hydroxyzine HCL 25mg, with physician order to take two tablets daily, as needed was started on March 2, 2026. There was no documentation of a daily audit for this medication on March 3-5, 2026. In addition, the counts do not match the administration record for this medication.
Paliperidone ER 3mg, with physician order to take one tablet daily, was started on February 26, 2026. There was no documentation of a daily audit for this medication on February 27- March 5, 2026.
Nicotine CLR 21mg, with physician order to take one patch daily, was started on February 26, 2026. There was no documentation of a daily audit for this medication on February 27- March 5, 2026.
Pantoprazole 40mg, with physician order to take one tablet every morning, was started on February 23, 2026. There was no documentation of a daily audit for this medication on February 24- March 5, 2026.
Mirtazapine 15mg, with physician order to take one tablet daily, was started on February 26, 2026. There was no documentation of a daily audit for this medication on February 27- March 5, 2026.
Thera-M, with physician order to take one tablet daily, was started on February 23, 2026. There was no documentation of a daily audit for this medication on February 24- March 1 and March 3-5, 2026.
Rosuvastatin Calcium 20mg, with physician order to take one tablet daily, was started on February 26, 2026. There was no documentation of a daily audit for this medication on February 27 - March 5, 2026.
Dairy Relife 3000 unit, with physician order to take two tablets daily, was started on February 26, 2026. There was no documentation of a daily audit for this medication on February 27- March 5, 2026.
Baclofen 10mg, with physician order to take one tablet three times daily, was started on February 26, 2026. There was no documentation of a daily audit for this medication on February 27 - March 5, 2026.
Famotidine 20mg, with physician order to take one tablet twice daily, was started on February 26, 2026. There was no documentation of a daily audit for this medication on February 27 - March 5, 2026.
Client #11 was admitted on February 24, 2026 and was active at the time of the inspection. The medication administration record (MAR) was reviewed for February and March 2026.
Buspirone 30mg, with physician order to take one tablet twice daily, was started on February 27, 2026. There was no documentation of a daily audit for this medication on February 28 - March 1 and March 3-5, 2026.
Mirtzapine 45mg, with physician order to take one tablet daily, was started on March 2, 2026. There was no documentation of a daily audit for this medication on March 3-5, 2026.
Amlodipine 5mg, with physician order to take one tablet daily, was started on February 27, 2026. There was no documentation of a daily audit for this medication on February 28 - March 1 and March 3-5, 2026.
Quetiapine 300mg, with physician order to take two tablets daily, was started on March 2, 2026. There was no documentation of a daily audit for this medication on March 3-5, 2026.
Hydroxyzine pamoate 50mg, with physician order to take daily, was started on March 2, 2026. There was no documentation of a daily audit for this medication on March 3-5, 2026.
Client #12 was admitted on February 23, 2026 and was active at the time of the inspection. The medication administration record (MAR) was reviewed for February and March 2026.
Ramelteon 8mg, with physician order to take daily, was started on February 25, 2026. There was no documentation of a daily audit for this medication on February 25 - March 2, 2026.
Olanzapine 20mg, with physician order to take daily, was started on February 23, 2026. There was no documentation of a daily audit for this medication on February 23 - March 3, 2026.
Client #13 was admitted on October 2, 2025 and was active at the time of the inspection. The medication administration record (MAR) was reviewed for January, February and March 2026.
Cyclobenzaprine 10mg, with physician order to take one tablet twice daily as needed, was started on January 28, 2026. There was no documentation of a daily audit for this medication on January 29 - February 7, February 9 -16, 18-19, 21-22 and February 24 - March 6, 2026.
Sertraline 100mg, with physician order to take once daily, was started on January 21, 2026. There was no documentation of a daily audit for this medication on January 22 - February 7, February 9 -16, 18-19, 21-22 and February 24 - March 6, 2026.
Biotin 10000mcg, with physician order to take once daily, was started on January 12, 2026. There was no documentation of a daily audit for this medication on January 15 - 20, January 22 -February 7, 9-16, 18-19, 21-22 and February 24 - March 6, 2026.
Mirtazapine 30mg, with physician order to take once daily, was started on January 25, 2026. There was no documentation of a daily audit for this medication on January 26 - February 7, February 9-16, 18-19, 21-22 and February 24 - March 6, 2026.
Prazosin 1mg, with physician order to take twice daily, as needed, was started on January 25, 2026. There was no documentation of a daily audit for this medication on January 26 - February 7, February 9-16, 18-19, 21-22 and February 24 - March 6, 2026.
Prazosin 2mg, with physician order to take once daily at bedtime, was started on January 25, 2026. There was no documentation of a daily audit for this medication on January 26 - February 7, February 9-16, 18-19, 21-22 and February 24 - March 6, 2026.
Magnesium Oxide 400mg, with physician order to take once daily, was started on January 20, 2026. There was no documentation of a daily audit for this medication on January 21 - February 7, February 9-16, 18-19, 21-22 and February 24 - March 6, 2026.
Hydroxyzine 50mg, with physician order to take once four times per day, as needed, was started on January 20, 2026. There was no documentation of a daily audit for this medication on January 21 - February 1, February 3-7, 9-16, 18-19, 21-22 and February 25 - March 6, 2026.
Prednisone 10mg, with physician order to take four times daily for four days, was started on March 2, 2026. There was no documentation of a daily audit for this medication on March 3-6, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery has implemented enhanced policies and procedures to ensure full compliance with 709.32 Medication Control requirements, specifically regarding the control, accountability, and documentation of medications.
Authorized Removal of Drugs: Passages Administrative Staff has established a formal protocol identifying authorized personnel responsible for the removal of medications. Only licensed nursing staff and designated, trained support staff are permitted to remove discontinued medications from medication carts. All authorized personnel have completed documented training on medication control procedures, including proper handling, documentation, and disposal processes.
Control and Accountability of Discontinued Medications: All discontinued medications are immediately documented in a Discontinued Medication Log by authorized staff. Medications are then secured in a locked discontinued medication cabinet with restricted access. A dual verification process is in place, requiring both a licensed nurse and authorized staff member to count and reconcile discontinued medications. Both individuals are required to sign and date the log to ensure accountability. Discontinued medications are returned to the contracted pharmacy in accordance with established timelines and regulatory requirements.
Medication Recording System: Passages will utilize the QuickMAR electronic medication administration record (eMAR) system to ensure accurate and complete documentation of all medications. The system records, at minimum, the following required elements: Name of the medication, Dosage administered, Identity of the staff person administering the medication, Date and time of administration, Monitoring and Compliance: Program leadership and nursing staff conduct ongoing monitoring through routine audits of medication logs, eMAR documentation, and storage practices. Any documentation review to ensure sustained compliance. The Chief of Staff will oversee and closely monitor the nurses and consult with the medical director to ensure medications are being administered and documented as prescribed.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on 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 November 17, 2025 and discharged on January 24, 2026. A biopsychosocial assessment was due no later than November 20, 2025; however, it was not completed until November 21, 2025.
Client #6 was admitted on January 9, 2026, and was still active at the time of the inspection. A biopsychosocial assessment was due no later than January 12, 2026; however, it was not completed until January 19, 2026.
This is a repeat citation from the September 18, 2025 onsite inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Passages to Recovery clinical staff will adhere to established intake and admission policies and procedures to ensure compliance with psychosocial evaluation requirements. A comprehensive biopsychosocial assessment will be completed for all clients within three (3) days of admission. The Clinical Supervisor will be responsible for oversight and verification that all biopsychosocial assessments are completed within the required timeframe. Ongoing monitoring will include routine chart reviews to ensure timely completion and continued compliance with regulatory standards and internal policies. |
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 one of six applicable records reviewed.
The facility ' s policy notes that the initial treatment plan will be completed within seven days of admission.
Client #5 was admitted on January 8, 2026, and was still active at the time of the inspection. A treatment plan was due no later than January 15, 2026; however, it was not completed until January 19, 2026.
This is a repeat citation from the September 18, 2025 onsite inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Passages to Recovery clinical staff will adhere to individual treatment rehabilitation plan policies and procedures. The clinical staff will complete the initial treatment plan within seven days of admission. The Clinical Supervisor will be responsible for oversight and verification that all initial treatment plans are completed within the required timeframe. Ongoing monitoring will include routine chart reviews to ensure timely completion and continued compliance with regulatory standards and internal policies. The documented monitoring will begin the week of April 13, 2026. |
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 three out of nine applicable records reviewed.
Client #2 was admitted on November 17, 2025 and discharged on January 24, 2026. A treatment plan dated November 25, 2025, indicated daily group therapy and individual therapy once a week.
There was no documentation that the client received individual therapy during the weeks of:
December 7 - 13, 2025
December 14 - 20, 2025
December 21 - 27, 2025
December 28 - January 3, 2026
January 4 - 10, 2026
January 11 - 17, 2026
January 18 - 24, 2026
Client #6 was admitted on January 9, 2026 and was active at the time of the inspection. A treatment plan dated January 15, 2026, indicated daily group therapy and individual therapy once a week.
There was no documentation that the client received individual therapy during the weeks of:
January 18 -24, 2026
February 1 - 7, 2026
Client #9 was admitted on November 6, 2025 and was active at the time of the inspection. Treatment plan updates dated December 12, 2025 and January 19, 2026, indicated daily group therapy and individual therapy once a week.
There was no documentation that the client received individual therapy during the weeks of:
December 28 - January 3, 2026
January 11 - 17, 2026
January 18 -24, 2026
February 1 - 7, 2026
This is a repeat citation from the September 10, 2024, March 26, 2025 and September 18, 2025 onsite inspections.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Passages to Recovery will ensure that counseling services are provided in accordance with each client's individualized treatment and rehabilitation plan. The Clinical Supervisor will oversee the delivery of services by conducting weekly team meetings and performing routine chart audits to ensure compliance with program requirements. All clinical staff will be trained and directed to provide, at a minimum, one individual counseling session per week for each assigned client. Training will be complete by April 22, 2026. Compliance will be monitored through ongoing supervision, documentation review, and corrective feedback on a weekly basis. |
709.52(e)(1) LICENSURE Medical/dental support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based on a review of client records, the facility failed to assist the client with medical support services when necessary.
Client #9 was admitted to treatment on November 6, 2025 and was active at the time of the inspection. Client #9 was scheduled for two medical specialist appointments on December 12, 2025. The client was not provided transportation to the appointments, resulting in the appointments being missed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery will ensure that all clients have access to necessary medical and dental support services in accordance with regulatory requirements. Case management staff will be responsible for coordinating and assisting clients in obtaining medical and dental care based on identified needs within the individualized treatment plan. The Clinical Supervisor and Facility Manager will oversee the provision of medical and dental services through weekly team meetings, during which all client needs, referrals, and appointment follow-ups will be reviewed and documented. These documented meetings will begin the week of April 13, 2026. To address prior barriers related to transportation, Passages to Recovery has hired three (3) drivers to provide reliable and timely transportation for all scheduled appointments. The Facility Manager will conduct daily coordination discussions to verify that transportation is scheduled and that clients attend all medical, dental, legal, and other essential appointments as required.
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709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, including medication administration records, in three of nine applicable records reviewed.
Client #3 was admitted on January 5, 2026 and was active at the time of the inspection. Client #3 was prescribed medication starting January 7, 2026. The medication administration records provided did not start until January 25, 2026.
Client #8 was admitted on November 25, 2025 and discharged on February 9, 2026. The client was prescribed Gabapentin with a refill the beginning of December 2025. There was no medication administration record for Gabapentin for December 2025. In addition, it was documented that client #8 was missing 50 tablets of Gabapentin on December 15, 2025.
Client #9 was admitted to treatment on November 6, 2025 and was active at the time of the inspection. Client #9 was admitted to the facility being prescribed Gabapentin. There was no medication administration record for Gabapentin documented for the months of November 2025 and December 2025. In addition, it was documented that client #9 was missing Gabapentin tablets from the December 8, 2025 pharmacy delivery.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery will ensure that a complete and accurate client record is maintained for every individual receiving services. All clinical, case management, and medical staff are required to document services in accordance with program policy and DDAP regulatory standards. All client records, including clinical documentation, case management notes, and medical records, will be maintained within the program's centralized electronic health record (EHR) system. Medication documentation will be completed in the QuickMAR electronic medication administration record (eMAR) system to ensure accuracy, completeness, and real-time tracking of all medications administered. Staff will be trained in QuickMAR by May 11, 2026
Implementation Steps: All staff will be retrained in documentation requirements, including timeliness, completeness, and accuracy of client records. The Clinical Supervisor and Nursing Staff will ensure that all required documentation is entered into the EHR and eMAR systems within required timeframes. Policies and procedures regarding client record documentation will be reviewed and reinforced with all staff by May 11, 2026.
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of residential client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in two out of seven applicable records reviewed. The facility's policy and procedures manual states case consultations will occur within ten days of admission and must be completed every thirty days following admission.
Client #5 was admitted on January 8, 2026, and was still active at the time of the inspection. There was no documentation that a case consultation was conducted within ten days of admission, per facility policy. The only case consultation documented in client record #5 was documented on February 4, 2026.
Client #6 as admitted on January 9, 2026, and was still active at the time of the inspection. There was no documentation that a case consultation was conducted within ten days of admission, per facility policy. The only case consultation documented in client record #6 was documented on February 9, 2026.
This is a repeat citation from the September 18, 2025 onsite inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Passages to Recovery will ensure that all case consultation notes accurately reflect each client's participation and involvement in treatment services, in accordance with regulatory requirements. All clients will have a documented case consultation completed within ten (10) days of admission. Case consultation documentation will include, at a minimum, clinical progress, engagement in services, identified needs, and any recommended updates to the treatment plan. The Clinical Supervisor, in collaboration with assigned clinicians and case management staff, will be responsible for ensuring timely completion and accuracy of all case consultation notes. Monitoring and Compliance: The Clinical Supervisor will conduct weekly chart audits to verify that case consultations are completed within the required timeframe and that documentation reflects active client participation in treatment. Any deficiencies will be addressed through staff supervision, corrective feedback, and additional training as needed to ensure ongoing compliance with Passages to Recovery's policies and procedures.
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709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of residential client records, the facility failed to provide a complete client record, which includes follow-up information in three out of three applicable records reviewed.
The facility ' s policy is to contact the client within seven days and thirty days following discharge.
Client #1 was admitted on December 17, 2025 and was discharged January 9, 2026. There was no documentation of any follow-up contacts in the client record.
Client #2 was admitted on November 17, 2025 and was discharged January 24, 2026. There was no documentation of any follow-up contacts in the client record.
Client #4 was admitted on January 8, 2026 and was discharged February 3, 2026. There was no documentation of any follow-up contacts in the client record.
This is a repeat citation from the September 10, 2024, March 26, 2025 and September 18, 2025, onsite inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery will ensure compliance with follow-up requirements by implementing standardized procedures for documenting post-discharge contact. Clinical staff are required to complete and document follow-up contact with all discharged clients on 7 days and 30 days post-discharge in the electronic health record. The Clinical Supervisor will oversee compliance by conducting weekly chart audits of all discharges to assure that the follow-up is scheduled at and then to verify that follow-up attempts and/or completed contacts are documented within required timeframes. Audit results will be tracked using a monitoring tool and reviewed during weekly clinical team meetings. All clinical staff have been retrained on follow-up documentation requirements, including timeframes and proper recording in the electronic system. Documentation expectations have been incorporated into staff performance standards. Monitoring and Accountability: Weekly chart audits conducted by the Clinical Supervisor for a minimum of 90 days beginning April 13, 2026. Monthly compliance reports will be reviewed by Clinical Director. Any identified deficiencies will be documented by the Clinical Director and addressed directly with staff.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for medications being administered as prescribed by a physician was submitted and approved by the Department for the September 10, 2024, March 26, 2025 and September 18, 2025 onsite inspections. Medications being administered as prescribed was again found to be a deficiency in the February 13, 2026 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, March 26, 2025 and September 18, 2025 onsite inspections. Individual sessions not being offered as stated in the treatment plan was again found to be a deficiency in the February 13, 2026 onsite inspection.
A plan of correction for follow up contact was submitted and approved by the Department for the September 10, 2024, March 26, 2025 and September 18, 2025 onsite inspections. Follow up contact was again found to be a deficiency in the February 13, 2026 onsite inspection.
This is a repeat citation from the September 18, 2025 onsite inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Passages to Recovery Inc. has implemented a comprehensive corrective action plan to address deficiencies and ensure full compliance with DDAP regulations. Administrative leadership has initiated structured operational improvements across multiple domains including security, medication management, staffing, and clinical documentation.
Management staff are conducting weekly meetings to review overall operations. These meetings focus on identifying deficiencies, monitoring progress, and implementing corrective strategies related to program operations, staffing, and compliance requirements.
The Compliance Director has been reassigned to the position of Clinical Director to strengthen clinical oversight.
The Compliance Officer has been moved into the role of Facility Manager to ensure proper coordination of client ancillary service appointments and to manage client relations.
An Interim Clinical Supervisor has been engaged through Delta Staffing to provide support to therapists and to assist the Director in assuring that all clinical milestones are met in a timely manner. The organization is actively working to secure a qualified Clinical Supervisor to join the staff on a permanent basis. A Security Supervisor has been hired to oversee facility safety and medication monitoring.
After notification that our Medical Director was retiring, Passages engaged a new Medical Director to provide oversight of medical services.
A Nursing Agency has been contracted to provide LPNs and RNs to support medication management and medical documentation.
The addition of a Security Supervisor and contracted medical staff ensures that medication storage, administration, and monitoring procedures are properly followed. Medication storage is now consolidated into the medication carts, and the carts are under camera view at all times. These changes strengthen accountability and compliance with regulatory standards.
Passages is implementing new data collection procedures to ensure that all client information is stored in a centralized, Sharepoint secure system. This improvement is designed to enhance accessibility, organization, and audit readiness of clinical records.
The Facility Manager will ensure that all client medical and ancillary appointments are attended as scheduled. Additionally, the Facility Manager is responsible for overseeing and properly documenting all client grievances to ensure compliance and quality of care.
The Interim Clinical Supervisor is now reviewing therapists activities to assure that Biopsychosocial assessments, individual sessions, treatment plans, case consultations, ASAM's, seven-day reviews, 30-day reviews and post discharge follow-ups are performed on time and documented in our EHR.
Passages remains committed to continuous quality improvement. Weekly administrative reviews, staffing enhancements, and system improvements will be monitored to ensure sustained compliance with DDAP standards and successful completion of the corrective action plan.
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709.17(a)(4) 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:
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
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Observations
Based a review of client and personnel records, medication records, policy and procedures, administrative documentation and staff interviews, it was found that gross incompetence, negligence and/or misconduct was present at the facility during a complaint investigation and provisional follow up inspection that occurred on February 10 - 13, 2026.
There were a total of four citations that were consecutively cited for a total of four onsite inspections - Client follow up contact, failure to follow an approved plan of correction, medication administration, and individual counseling being provided to clients as documented on their treatment plans.
Client record #9 included documentation that two medical specialists appointments were missed. It appears that client #9 was not transported to these appointments by facility staff.
Client #10 was admitted to treatment on February 19, 2026. She was documented to have a complex medical history, including traumatic brain injury, and was on several medications. She brought the medications to the facility, but was unable to take them due to facility policy. The client had a seizure and had to be taken to the emergency room.
Client #13 was admitted to treatment on October 2, 2025. She was prescribed an injectable medication. There was no nursing staff onsite, and the client attempted to self-administer the medication with staff observation. The medication was not administered correctly and ended up being wasted. There was no incident report regarding this error and no documentation that anything was done to assist the client to replace the dose or figure out another plan. Further, when symptoms started to arise, she was initially denied being able to get assessed at the hospital.
All of the clients records reviewed during this inspection did not include documentation that medications were being administered as prescribed.
Client records #8 and #9 included documentation that medication was missing and unable to be located.
Client records #8 and #9 did not include medication administration records for December 2025. These records were unable to be located. Client records # 2 and 3 did not include medication administration records for all medications prescribed.
One support staff was reported to be sleeping on the job on two occasions, February 6 and February 9, 2026. There was no written documentation of disciplinary action. In addition, this staff was scheduled to be by themselves at the facility on February 15, 17, 18 and March 1, 8, 15 and 16, 2026.
The client administration records are not documented consistently. It appears that medication administration documentation is not consistent with all staff and additional training and monitoring is needed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative leadership has initiated structured operational improvements across multiple domains including security, medication management, staffing, and clinical documentation.
Administrative staff are conducting weekly meetings to review overall operations. These meetings focus on identifying deficiencies, monitoring progress, and implementing corrective strategies related to program operations, staffing, and compliance requirements. The Compliance Director has been reassigned to the position of Clinical Director to strengthen clinical oversight. The Compliance Supervisor has been moved into the role of Facility Manager to ensure proper coordination of client medical and ancillary service appointments. The organization is actively working to secure a qualified Clinical Supervisor. A Security Supervisor has been hired to oversee facility safety and medication monitoring. A new Medical Director has been contracted to provide oversight of medical services. A Nursing Agency has been contracted to support medication management and medical documentation.
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