INITIAL COMMENTS
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This report is a result of an on-site provisional licensure renewal inspection and complaint investigations conducted on May 13-15, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Angel's Light Addiction Specialists 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of staff records, the facility failed to document that each counselor met the qualifications for the position.
Staff #4 was hired as a counselor on April 28, 2025. Staff record #4 did not have documentation of a degree certificate or clinical experience. Clinical documentation indicated that staff #4 was performing clinical tasks as of her hire date.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #4 was awarded BSW on 5/18/25 per recent collection of updated transcripts. Effective immediately, the Clinical Director/Project Director will require submission of a degree and/or transcripts showing the awarded degree upon the first scheduled interview. The Project Director and/or Clinical Director will audit staff charts quarterly. |
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a comprehensive staff development program for agency personnel which included policies and procedures for teh program indicating who is responsible and the time frames for completion.
DDAP staff reviewed the facility's policy and procedure manual. The facility's policies did not address the assessment of staff training needs, an overall plan for addressing these needs, a mechanism to collect feedback on completed trainings and an annual evaluation of the overall training plan.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include a comprehensive staff development training plan, which includes the assessment of staff training needs, an overall plan for addressing these needs, a mechanism to collect feedback on completed trainings, and an annual evaluation of the overall training plan. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document an annual evaluation of the overall training plan for the January - December 2024 training year.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include a time frame of January each year to review the overall training plan from the previous year. The Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. The Project Director and/or Clinical Director will complete the evaluation for the agency training plan for the 2024 training year. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of staff training records, the facility failed to document that support staff persons received a minimum of 6 hours HIV/AIDS within the first two years of employment.
Staff #8 was hired as a support staff on February 7, 2022. HIV/AIDS training was due to be completed by February 7, 2024. Staff #8 completed HIV/AIDS training on May 6, 2025.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the Project Director will add HIV/AIDS to staff orientation training and incorporate it into the comprehensive 90-day staff development training plan. The Clinical Director/and or Project Director will oversee the trainings upon orientation and sign off on completion. All existing staff will complete mandatory HIV/AIDS and TB/STD training within the regulatory timeframes. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and staff schedules, the facility failed to provide documentation that at least one person trained in CPR was onsite during the project's hours of operation.
The staff schedules were reviewed for April 19 - May 16, 2025. Per the staff schedule, the following dates did not have CPR coverage for all shifts:
April 19, 21, 22, 23, 26, 27, 28 & 29 and May 3, 4, 5, 6, 10, 11, 12 & 13, 2025.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the Project Director will add CPR to staff orientation training and incorporate it into the comprehensive 90-day staff development plan. The clinical Director/and or Project Director will oversee the trainings upon orientation and sign off on completion. All other existing staff will renew CPR training prior to expiration. The Project Director and/or Clinical Director will audit staff charts quarterly. Effective immediately nursing staff will be present in the building 24/7 and the current staff have been instructed to complete the CPR training online. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
The following was observed by DDAP staff during the physical plant inspection:
16, cover missing from electrical outlet.
hallway near laundry room, exit sign hanging by electrical wires only.
hallway rear exit, damaged light cover
hallway rear exit, damaged ceiling tiles
Room, cover missing from electrical outlet
11, damaged ceiling tiles
5, damaged ceiling tiles
in poor condition with many potholes.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Electrical outlets and exit signs have been corrected. The office manager will schedule maintenance for ceiling tiles, light fixtures, and entry drive and parking of the facility to be completed by 7/31/25. Effective immediately, overnight behavioral technician staff have been given a list of duties to include a walk-through observation of facility maintenance/needs to be completed every overnight shift. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
It was observed by DDAP staff that the dining area of the facility had a video camera. The facility conducts group therapy sessions in this portion of this facility, this was also observed by DDAP staff.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will submit an exception for the video-only observation camera in the facility dining area by 7/31/25. Until the exception is granted and in the event it is denied, the designated group facilitator will ensure the camera is covered. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to maintain hot water not exceeding 120 degrees. DDAP staff recorded the water temperature in the women ' s bathroom as 140 degrees.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The office manager will schedule maintenance for Hot water tanks to be completed by 7/31/25. Effective immediately, overnight behavioral technician staff have been given a list of duties to include a walk-through observation of facility maintenance/needs to be completed every overnight shift. This list includes checking the water temperature. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on the physical plant inspection the facility failed to provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
DDAP staff observed that the men ' s and women ' s showers did not have slip-resistant surfaces in the shower stalls.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Slip-resistant mats have been placed in all client showers and corrected. The office manager will arrange the purchase of privacy partitions for client restrooms. Effective immediately, overnight behavioral technician staff have been given a list of duties to include a walk-through observation of facility maintenance/needs to be completed every overnight shift. |
705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, the facility failed to store al food items off the floor. DDAP staff observed a box of bananas and a package of bottled water being stored on the floor.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Effective immediately, the Kitchen manager and/or designated staff member will monitor the proper storage of all food products and supplies. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to not permit in the facility heaters that are not permanently mounted or installed. DDAP staff observed a portable heater in the admissions office.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective immediately, all space heaters have been removed from the facility. The project director will submit exceptions by 7/31/25. The office manager will schedule maintenance for the HVAC system to be completed by 7/31/25. Effective immediately, overnight behavioral technician staff have been given a list of duties to include a walk-through observation of facility maintenance/needs to be completed every overnight shift. This includes checking space heaters and the proper functioning of heating and air. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on the physical plant inspection the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
DDAP staff observed that the emergency exit in the hallway nearest to the women ' s bathroom was partially blocked by debris.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the overnight Behavioral Technician staff will complete a thorough walk-through of the building nightly to inspect the Fire Exits for obstructions. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from May 4, 2024, through April 17, 2025, the facility failed to conduct unannounced fire drills at least once a month. The facility was unable to provide documentation that a fire drill occurred during the month of January 2025.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Behavioral Technician Supervisor conducted fire safety training with the technician staff. Effective immediately, the Behavioral Technician Supervisor and/or designated staff member will review the documentation of fire drills weekly to ensure proper documentation. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from May 4, 2024, through April 17, 2025, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
DDAP staff observed the following documentation issues on the fire drill logs:
17, 2025, no evacuation time noted, no exit route specified.
25, 2025, no evacuation time noted, no exit route specified.
7, 2025, no evacuation time noted.
4, 2024, no exit route specified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Behavioral Technician Supervisor conducted fire safety training with the technician staff. Effective immediately, the Behavioral Technician Supervisor and/or designated staff member will review the documentation of fire drills weekly to ensure proper documentation. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from May 4, 2024, through April 17, 2025, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. A fire drill during sleeping hours was completed on May 4, 2024, the next sleeping hours drill was due no later than November 4, 2024; however, it was completed December 28, 2024.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Behavioral Technician Supervisor conducted fire safety training with the technician staff. Effective immediately, the Behavioral Technician Supervisor and/or designated staff member will review the documentation of fire drills weekly to ensure proper documentation. |
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 the policy and procedure manual, the facility failed to document written procedures for the management of treatment/rehabilitation services for clients that included timeframes for detox client record documentation and rehab case consultations.
The policy and procedure manual did not include a timeframe for the completion of case consultations. There were no case consultations observed in any of the ten client records reviewed. In addition, there were no timeframes documented for detoxification client records.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include timeframes for rehab case consultation documentation and detox client record documentation. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document written policies and procedures to address the utilization of volunteers.
Facility staff reported that while there are currently no volunteers, they have utilized them in the past and would be open to using them in the future.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include specific details of what the utilization of volunteers entails and what the volunteers will and will not have access to regarding client documentation. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.26 (a) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(3) Supervision of staff.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document written policies and procedures to address the supervision of staff.
There is a policy regarding the regulatory requirement of supervision of counselor assistants; however, there is no policy and procedures documented for the supervision of all other project staff.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include regulatory requirements of supervision for all project staff. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.26 (a) (4) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(4) Orientation of new employees.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document written policies and procedures to address staff orientation.
There is a policy that addresses topics covered during staff orientation; however, it does not include timeframes for staff orientation and who is responsible for conducting staff orientation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include a comprehensive 90-day staff development training plan to be completed upon hire and overseen by the Clinical Director and Project Director. The policy will also include pre- and post-training surveys. Effectively immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a physical plant inspection, the facility failed to maintain the confidentiality of client identity.
Upon DDAP staff entering the facility on May 13, 2025, a document with a client full name was laying out in the open, next to the visitor sign in sheet.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop a policy and procedure for client discharge to include the confidentiality of client discharge documentation. All client identifying information will be maintained upon discharge in a safe and secure location. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon final approval from the BOD. |
709.28 (a) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document written policies and procedures to address the identification of project staff having access to records and the methods by which staff gain access.
There is a policy that addresses the security of the client records; however, it does not include which staff positions are permitted to have access to client records.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include staff positions who are allowed access to client records. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. Staff are provided with login information that controls their permission to client records and limits access if necessary. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in the client record. The consent must be in writing and include, but not be limited to purpose of disclosure.
Client #1 was admitted on February 17, 2025, and was still an active client at the time of the inspection. A consent form for an emergency contact was signed on February 21, 2025; however, it did not specify the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director conducted training with admissions and clinical staff regarding confidentiality and proper consent documentation. Effective immediately, the Admissions Director and/or designated staff member will conduct weekly chart audits to monitor the proper completion of consents. Client #1 was discharged on 5/14/25, and the consent was not able to be amended. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records, the facility failed to ensure a copy of client consent shall be offered to the client and a copy maintained in the client record.
Client #6 was admitted on March 5, 2025, and discharged on March 31, 2025. Two consents, both dated March 5, 2025, and both for insurance providers did not document whether a copy of the consent was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director conducted training with admissions and clinical staff regarding confidentiality and proper consent documentation. Effective immediately, the admission Director and/or designated staff member will conduct weekly chart audits to monitor the proper completion of consents. |
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 the review of medication administration records, the facility failed to provide medication as prescribed by a physician in four out of nine applicable records reviewed.
DDAP staff observed the following in the client records:
#4 was admitted December 28, 2024, and discharged on January 27, 2025. This patient was prescribed 10mg of Buspirone three times a day, On January 22, 2025, and January 23, 2025, the dosing record notes that he only received (2) doses each day. There was no further documentation in the client record.
#5 was admitted April 4, 2025, and discharged on May 6, 2025. This patient was prescribed Buprenorphine twice a day. On April 13, 2025, and April 22, 2025, only one dose was noted in the dosing record. There was no further documentation in the client record.
#7 was admitted on February 17, 2025, and discharged on March 13, 2025. This patient was prescribed 800mg of Gabapentin four times a day. On March 2, 2025, the dosing record noted he only received (2) doses. On March 3, 2025, the dosing record noted he only received (3) doses. On March 7-8, 2025, the dosing record noted he only received (3) doses, each day. There was no further documentation in the client record.
Client #8 was admitted on February 27, 2025, and discharged on March 18, 2025. This patient was prescribed 20 mg of Prednisone twice a day. On March 11, 2025, the dosing record noted he received only (1), dose. On March 18, 2025, the dosing record noted he received only (1) dose. There was no further documentation in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Nursing has conducted training on the proper MAR documentation. Effective immediately, the DON and/or assigned nursing staff will conduct monthly MAR audits to ensure the completion of proper documentation. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document a written involuntary termination notice in two of two applicable client records reviewed.
Client #9 was admitted on February 18, 2025, and involuntarily terminated from treatment on March 4, 2025. There was no notice of involuntary termination documented in the client record.
Client #10 was admitted on December 4, 2024, and involuntarily terminated from treatment on February 13, 2025. There was no notice of involuntary termination documented in the client record.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective immediately the Clinical Director has designated the Behavioral Technician Staff to distribute Involuntary Termination Letters to the client(s) being administratively discharged before leaving the building as to give them the opportunity to request reconsideration of the termination. The Behavioral Technician staff has been provided with a binder to file the completed letters in, and the Clinical Director has gone over the direction of documentation for the letter(s). The Clinical Director and/or designated staff member will review the binder monthly to monitor the completion of termination letter(s) as needed. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to document clients were provided the opportunity to request reconsideration of the decision to involuntary terminate their treatment in two of two applicable client records.
Client #9 was admitted on February 18, 2025, and involuntarily terminated from treatment on March 4, 2025. There was no documentation that client #9 was provided the opportunity to request reconsideration of the decision to involuntary terminate their treatment.
Client #10 was admitted on December 4, 2024, and involuntarily terminated from treatment on February 13, 2025. There was no documentation that client #10 was provided the opportunity to request reconsideration of the decision to involuntary terminate their treatment.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective immediately the Clinical Director has designated the Behavioral Technician Staff to distribute Involuntary Termination Letters to the client(s) being administratively discharged before leaving the building as to give them the opportunity to request reconsideration of the termination. The Behavioral Technician staff has been provided with a binder to file the completed letters in, and the Clinical Director has gone over the direction of documentation for the letter(s). The Clinical Director and/or designated staff member will review the binder monthly to monitor completion of termination letters as needed. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a policy that addresses the response to an unusual incident that includes significant disruption of services due to a disaster such as a fire, storm, flood, or other occurrence which closes the facility for more than 1 day.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include disruption of services due to a disaster such as fire, storm, flood, or other occurrence that closes the facility for more than 1 day. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a policy that addresses the response to an unusual incident that includes fire or structural damage to the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include fire or structural damage to the facility. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a policy that addresses the response to an unusual incident that includes an outbreak of contagious disease requiring Center for Disease Control (CDC) notification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a policy that addresses the prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
The facility did document a policy which states that an analysis would be completed annually; however, it does not address what steps will be taken to review, in a prompt manner, each unusual incident when it occurs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include what steps will be taken to review, in a prompt manner, each unusual incident when it occurs. The Project Director and/or Clinical Director will record and report unusual incidents. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.62(a)(2) LICENSURE Tx methodology
709.62. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(2) Treatment methodology.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a written plan for intake and admission which included treatment methodology.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include a written plan for intake and admission, which includes treatment methodology. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.62(a)(3) LICENSURE Completion Requirements
709.62. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(3) Requirements for completion of treatment.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a written plan for intake and admission which included the requirements for completion of treatment.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include a written plan for intake and admission, which includes the requirements for completion of treatment. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.62(a)(4) LICENSURE Criteria - Discharge/termination
709.62. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a written plan for intake and admission which included involuntary discharge/termination criteria.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include a written plan for intake and admission, which includes involuntary discharge/termination criteria. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.64(f)(1) LICENSURE Outreach
709.64. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(1) Identifying persons in need of project services.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a written plan for providing outreach services which includes identifying persons in need of project services for detoxification.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include a written plan for outreach services, which includes identifying persons in need of project services for detoxification. Outreach services will be overseen by the Corporate Director of Business Development. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.64(f)(2) LICENSURE Outreach
709.64. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(2) Alerting persons and their families to the availability of project services.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a written plan for providing outreach services which includes alerting persons and their families to the availability of project services for detoxification.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include a written plan for outreach services, which includes alerting persons and their families to the availability of project services for detoxification. Outreach services will be overseen by the Corporate Director of Business Development. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.64(f)(3) LICENSURE Outreach
709.24. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(3) Encouraging persons to utilize the service delivery system.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a written plan for providing outreach services which includes encouraging persons to utilize the service delivery system for detoxification.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include a written plan for providing outreach services, which includes encouraging persons to utilize the service delivery system for detoxification. Outreach services will be overseen by the Corporate Director of Business Development. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records the facility failed to document disclosure to the client of criteria for admission, treatment, completion and discharge in five of ten records reviewed. The facility ' s policy is to document this information on the day of admission.
Client #3 was admitted on April 29, 2025, and was still active at the time of the inspection. The required documentation was due to be completed on April 29, 2025; however, it was completed on May 5, 2025.
Client #4 was admitted on December 28, 2024, and was discharged on January 27, 2025. The required documentation was due to be completed on December 28, 2024; however, it was completed December 30, 2024.
Client #7 was admitted February 17, 2025, and discharged on March 13, 2025. The required documentation was due to be completed on February 17, 2025; however, there was no documentation it had been completed in the client record.
Client #9 was admitted February 18, 2025, and discharged on March 4, 2025. The required documentation was due to be completed on February 18, 2025; however, it was completed February 20, 2025.
Client #10 was admitted December 4, 2024, and discharged on February 13, 2025. The required documentation was due to be completed on December 4, 2024; however, it was completed on December 16, 2024.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The Clinical Director conducted training regarding documentation timelines as well as provided the admissions staff with the facility policy during the training. Effective immediately, the Admissions Director and/or designated staff member will conduct monthly chart audits to monitor the completion of admission documentation within the designated timeframes. |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on a review of client records the facility failed to orient the client to the project which includes, but is not limited to, a familiarization with project policies in five of ten records reviewed. The facility ' s policy is to document the notification of the client on the day of admission.
Client #3 was admitted on April 29, 2025, and was still active at the time of the inspection. The required documentation was due to be completed on April 29, 2025; however, it was completed on May 5, 2025.
Client #4 was admitted on December 28, 2024, and was discharged on January 27, 2025. The required documentation was due to be completed on December 28, 2024; however, it was completed December 30, 2024.
Client #7 was admitted February 17, 2025, and discharged on March 13, 2025. The required documentation was due to be completed on February 17, 2025; however, there was no documentation it had been completed in the client record.
Client #9 was admitted February 18, 2025, and discharged on March 4, 2025. The required documentation was due to be completed on February 18, 2025; however, it was completed February 20, 2025.
Client #10 was admitted December 4, 2024, and discharged on February 13, 2025. The required documentation was due to be completed on December 4, 2024; however, it was completed on December 16, 2024.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The Clinical Director conducted training regarding documentation timelines, as well as provided the admissions staff with the facility policy during the training. Effective immediately, the Admissions Director and/or designated staff member will conduct monthly chart audits to monitor the completion of admission documentation within the designated timeframes. |
709.51(b)(2)(ii) LICENSURE Hours of Operation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of client records the facility failed to orient the client to the project which includes, but is not limited to, a familiarization with hours of operation in five of ten records reviewed. The facility ' s policy is to document the notification of the client on the day of admission.
Client #3 was admitted on April 29, 2025, and was still active at the time of the inspection. The required documentation was due to be completed on April 29, 2025; however, it was completed on May 5, 2025.
Client #4 was admitted on December 28, 2024, and was discharged on January 27, 2025. The required documentation was due to be completed on December 28, 2024; however, it was completed December 30, 2024.
Client #7 was admitted February 17, 2025, and discharged on March 13, 2025. The required documentation was due to be completed on February 17, 2025; however, there was no documentation it had been completed in the client record.
Client #9 was admitted February 18, 2025, and discharged on March 4, 2025. The required documentation was due to be completed on February 18, 2025; however, it was completed February 20, 2025.
Client #10 was admitted December 4, 2024, and discharged on February 13, 2025. The required documentation was due to be completed on December 4, 2024; however, it was completed on December 16, 2024.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The Clinical Director conducted training regarding documentation timelines, as well as provided the admissions staff with the facility policy during the training. Effective immediately, the Admissions Director and/or designated staff member will conduct monthly chart audits to monitor the completion of admission documentation within the designated timeframes. |
709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of client records the facility failed to orient the client to the project which includes, but is not limited to, a familiarization with the fee schedule in five of ten records reviewed. The facility ' s policy is to document the notification of the client on the day of admission.
Client #3 was admitted on April 29, 2025, and was still active at the time of the inspection. The required documentation was due to be completed on April 29, 2025; however, it was completed on May 5, 2025.
Client #4 was admitted on December 28, 2024, and was discharged on January 27, 2025. The required documentation was due to be completed on December 28, 2024; however, it was completed December 30, 2024.
Client #7 was admitted February 17, 2025, and discharged on March 13, 2025. The required documentation was due to be completed on February 17, 2025; however, there was no documentation it had been completed in the client record.
Client #9 was admitted February 18, 2025, and discharged on March 4, 2025. The required documentation was due to be completed on February 18, 2025; however, it was completed February 20, 2025.
Client #10 was admitted December 4, 2024, and discharged on February 13, 2025. The required documentation was due to be completed on December 4, 2024; however, it was completed on December 16, 2024.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The Clinical Director conducted training regarding documentation timelines, as well as provided the admissions staff with the facility policy during the training. Effective immediately, the Admissions Director and/or designated staff member will conduct monthly chart audits to monitor the completion of admission documentation within the designated timeframes. |
709.51(b)(2)(iv) LICENSURE Services Provided
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iv) Services provided.
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Observations
Based on a review of client records the facility failed to orient the client to the project which includes, but is not limited to, a familiarization services provided in five of ten records reviewed. The facility ' s policy is to document the notification of the client on the day of admission.
Client #3 was admitted on April 29, 2025, and was still active at the time of the inspection. The required documentation was due to be completed on April 29, 2025; however, it was completed on May 5, 2025.
Client #4 was admitted on December 28, 2024, and was discharged on January 27, 2025. The required documentation was due to be completed on December 28, 2024; however, it was completed December 30, 2024.
Client #7 was admitted February 17, 2025, and discharged on March 13, 2025. The required documentation was due to be completed on February 17, 2025; however, there was no documentation it had been completed in the client record.
Client #9 was admitted February 18, 2025, and discharged on March 4, 2025. The required documentation was due to be completed on February 18, 2025; however, it was completed February 20, 2025.
Client #10 was admitted December 4, 2024, and discharged on February 13, 2025. The required documentation was due to be completed on December 4, 2024; however, it was completed on December 16, 2024.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The Clinical Director conducted training regarding documentation timelines as well as provided the admissions staff with the facility policy during the training. Effective immediately the Admissions Director and/or designated staff member will conduct monthly chart audits to monitor the completion of admission documentation within the designated timeframes. |
709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records the facility failed to document consent to treatment as per facility policies and procedures in five of ten records reviewed. The facility ' s policy is to document consent to treatment on the day of admission to the facility.
Client #3 was admitted on April 29, 2025, and was still active at the time of the inspection. The required documentation was due to be completed on April 29, 2025; however, it was completed on May 5, 2025.
Client #4 was admitted on December 28, 2024, and was discharged on January 27, 2025. The required documentation was due to be completed on December 28, 2024; however, it was completed December 30, 2024.
Client #7 was admitted February 17, 2025, and discharged on March 13, 2025. The required documentation was due to be completed on February 17, 2025; however, there was no documentation it had been completed in the client record.
Client #9 was admitted February 18, 2025, and discharged on March 4, 2025. The required documentation was due to be completed on February 18, 2025; however, it was completed February 20, 2025.
Client #10 was admitted December 4, 2024, and discharged on February 13, 2025. The required documentation was due to be completed on December 4, 2024; however, it was completed on December 16, 2024.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The Clinical Director conducted training regarding documentation timelines, as well as provided the admissions staff with the facility policy during the training. Effective immediately, the Admissions Director and/or designated staff member will conduct monthly chart audits to monitor the completion of consent to treatment within the designated timeframe. |
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 client records, the facility failed to document a psychosocial evaluation, as per facility policies, in seven of ten client records. The facility ' s policy is to complete the evaluation within three days of admission.
Client #1 was admitted February 17, 2025, and was still active at the time of the inspection. As per the facility ' s policy, a psychosocial evaluation was to be completed no later than February 20, 2025; however, documentation indicated it was completed February 25, 2025.
Client #2 was admitted April 9, 2025, and was still active at the time of the inspection. As per the facility ' s policy, a psychosocial evaluation was to be completed no later than April 12, 2025; however, documentation indicated it was completed April 14, 2025.
Client #4 was admitted December 28, 2024, and was discharged on January 27, 2025. As per the facility ' s policy, a psychosocial evaluation was to be completed no later than Decenber 31, 2025; however, documentation indicated it was completed January 2, 2025.
Client # 6 was admitted March 5, 2025, and was discharged on March 31, 2025. As per the facility ' s policy, a psychosocial evaluation was to be completed no later than March 8, 2025; however, documentation indicated it was completed March 12, 2025.
Client #7 was admitted February 17, 2025, and was discharged on March 13, 2025. As per the facility ' s policy, a psychosocial evaluation was to be completed no later February 20, 2025; however, there was no documentation an evaluation was completed.
Client #9 was admitted February 18, 2025, and was discharged on March 14, 2025. As per the facility ' s policy, a psychosocial evaluation was to be completed no later than February 21, 2025; however, documentation indicated it was completed February 24, 2025.
Client #10 was admitted December 4, 2024, and was discharged on February 13, 2025. As per the facility ' s policy, a psychosocial evaluation was to be completed no later than December 7, 2024; however, documentation indicated it was completed December 17, 2024.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The Clinical Director conducted training regarding documentation timelines, as well as provided the clinical staff with the facility policy during the training. Effective immediately, the Clinical Director and/or designated staff member will conduct monthly chart audits to monitor the completion of documentation within the designated timeframes. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan within the timeframe specified by facility policies, in three out of ten records reviewed. The facility's policy and procedures manual states that the preliminary treatment plan must be completed on the day of admission.
Client #3 was admitted on April 29, 2025, and was still active at the time of the inspection. The preliminary treatment plan was to be completed no later than April 29, 2025; however, it was not completed until May 1, 2025.
Client #4 was admitted on December 28, 2024, and discharged on January 27, 2025. The preliminary treatment plan was to be completed no later than December 28, 2024; however, it was not completed until January 2, 2025.
Client #7 was admitted on February 17, 2025, and discharged on March 13, 2025. The preliminary treatment plan was to be completed no later than February 17, 2025; however, there was no documentation that a plan was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director conducted training regarding documentation timelines, as well as provided the admissions staff with the facility policy during the training. Effective immediately,y the Admissions Director and/or designated staff member will conduct monthly chart audits to monitor the completion of documentation within the designated timeframes. |
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 client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in eight out of ten records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within three days of admission.
Client #1 was admitted on February 17, 2025, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 20, 2025; however, it was not completed until March 5, 2025.
Client #2 was admitted on April 9, 2025, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 12, 2025; however, it was not completed until April 15, 2025.
Client #4 was admitted on December 28, 2024, and was discharged on January 27, 2025. A comprehensive treatment plan was due no later than December 31, 2025; however, it was not completed until January 9, 2025.
Client #6 was admitted on March 5, 2025, and was discharged on March 31, 2025. A comprehensive treatment plan was due no later than March 8, 2025; however, there was no documentation that a treatment plan had been completed.
Client #7 was admitted on February 17, 2025, and was discharged on March 13, 2025. A comprehensive treatment plan was due no later than February 20, 2025; however, it was not completed until March 5, 2025.
Client #8 was admitted on February 27, 2025, and was discharged on March 18, 2025. A comprehensive treatment plan was due no later than March 21, 2025; however, there was no documentation that a treatment plan had been completed.
Client #9 was admitted on February 18, 2025, and was discharged on March 4, 2025. A comprehensive treatment plan was due no later than February 21, 2025; however, it was not completed until February 24, 2025.
Client #10 was admitted on December 4, 2024, and was discharged on February 13, 2025. A comprehensive treatment plan was due no later than December 7, 2025; however, it was not completed until December 26, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director conducted training regarding documentation timelines, as well as provided the clinical staff with the facility policy during the training. Effective immediately, the Clinical Director and/or designated staff member will conduct monthly chart audits to monitor the completion of documentation within the designated timeframes. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in eight out of ten records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within three days of admission.
Client #1 was admitted on February 17, 2025, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 20, 2025; however, it was not completed until March 5, 2025.
Client #2 was admitted on April 9, 2025, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 12, 2025; however, it was not completed until April 15, 2025.
Client #4 was admitted on December 28, 2024, and was discharged on January 27, 2025. A comprehensive treatment plan was due no later than December 31, 2025; however, it was not completed until January 9, 2025.
Client #6 was admitted on March 5, 2025, and was discharged on March 31, 2025. A comprehensive treatment plan was due no later than March 8, 2025; however, there was no documentation that a treatment plan had been completed.
Client #7 was admitted on February 17, 2025, and was discharged on March 13, 2025. A comprehensive treatment plan was due no later than February 20, 2025; however, it was not completed until March 5, 2025.
Client #8 was admitted on February 27, 2025, and was discharged on March 18, 2025. A comprehensive treatment plan was due no later than March 21, 2025; however, there was no documentation that a treatment plan had been completed.
Client #9 was admitted on February 18, 2025, and was discharged on March 4, 2025. A comprehensive treatment plan was due no later than February 21, 2025; however, it was not completed until February 24, 2025.
Client #10 was admitted on December 4, 2024, and was discharged on February 13, 2025. A comprehensive treatment plan was due no later than December 7, 2025; however, it was not completed until December 26, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director conducted training regarding documentation timelines, as well as provided the clinical staff with the facility policy during the training. Effective immediately, the Clinical Director and/or designated staff member will conduct monthly chart audits to monitor the completion of documentation within the designated timeframes. |
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 client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in two out of seven applicable records reviewed.
Client #3 was admitted on April 29, 2025, and was still active at the time of the inspection. A treatment plan dated April 30, 2025, group therapy twice a day. A review of the client recorded noted the following:
4, 2025, no groups documented
5, 2025, only one group documented
6, 2025, only one group documented
Client #5 was admitted on April 4, 2025, and was discharged on May 6, 2025. A treatment plan dated April 8, 2025, group therapy twice a day. A review of the client recorded noted the following:
17, 2025, only one group documented
18, 2025, only one group documented
21, 2025, only one group documented
4, 2025, no groups documented
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director conducted training regarding documentation timelines, as well as providing the clinical staff with the facility policy during the training. Effective immediately, the Clinical Director and/or designated staff member will conduct monthly chart audits to monitor the completion of documentation within the designated timeframes. The clinical team has been directed to outline in the treatment plan the services offered such as group sessions 2x daily or 13x weekly. The Senior counselor will monitor the completion of proper group notes. |
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 client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of seven discharged records reviewed.
Client #6 was admitted on March 3, 2025, and was discharged on March 31, 2025. There was no documented follow-up in the client record.
Client #9 was admitted on February 18, 2025, and was discharged on March 4, 2025. There was no documented follow-up in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director has designated the follow-up calls to a lead behavioral technician to complete follow-ups within the designated timeframes. Effective immediately, the Clinical Director and/or designated staff member will review the Follow-Up Binder monthly to monitor the completion of the follow-ups. |
709.54(a)(1) LICENSURE Purchasing food/equipment
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(1) Purchasing of food and equipment.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures for dietetic services, which included the purchasing of food and equipment.
Prior to this inspection, the facility had utilized an outside food service company with daily meal delivery. The facility recently began onsite food preparation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include procedures for dietetic services, which include the purchasing of food and equipment. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.54(a)(2) LICENSURE Receiving/storing/preserving
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(2) Receiving, storing and preserving of food stuff.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures for dietetic services, which included the receiving, storing and preserving of food stuff.
Prior to this inspection, the facility had utilized an outside food service company with daily meal delivery. The facility recently began onsite food preparation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include procedures for dietetic services, which include the receiving, storing, and preserving of food items. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.54(d)(1) LICENSURE Outreach Identifying Persons
709.54. Project management services.
(d) The project shall develop a written plan providing for outreach services which includes, but is not limited to:
(1) Identifying persons in need of project services.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a written plan for providing outreach services which includes identifying persons in need of project services for inpatient rehabilitation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include providing outreach services, which include identifying persons in need of project services for inpatient rehabilitation. Outreach services will be overseen by the Corporate Director of Business Development. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.54(d)(2) LICENSURE Alerting Persons - Outreach
709.54. Project management services.
(d) The project shall develop a written plan providing for outreach services which includes, but is not limited to:
(2) Alerting persons and their families to the availability of project services.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a written plan for providing outreach services which includes alerting persons and their families to the availability of project services for inpatient rehabilitation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include alerting persons and their families to the availability of project services for inpatient rehabilitation. Outreach services will be overseen by the Corporate Director of Business Development. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |
709.54(d)(3) LICENSURE Encouraging Persons - Outreach
709.54. Project management services.
(d) The project shall develop a written plan providing for outreach services which includes, but is not limited to:
(3) Encouraging persons to utilize the service delivery system.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a written plan for providing outreach services which includes encouraging persons to utilize the service delivery system for inpatient rehabilitation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will revise the policy to include encouraging persons to utilize the service delivery system for inpatient rehabilitation. Outreach services will be overseen by the Corporate Director of Business Development. Effective immediately, the Clinical Director and Project Director will review and revise policies every 6 months moving forward. The policy will be sent to the BOD for final revision by 7/31/25. The Clinical Director and/or Project Director will hold a full staff training on revised policies upon the final approval from the BOD. |