INITIAL COMMENTS
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This report is a result of an on-site provisional licensure renewal inspection and unusual incident investigation conducted on September 3-5 and 9-10, 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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704.3(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 staff schedules and staff and client interviews, the facility failed to employ staff in sufficient numbers to ensure efficient and safe operation of all the services provided by the project.
Staff schedules and staff and client interviews indicate that in late evening and early morning hours, there is one nurse and one tech in the facility providing supervision of the facility. Both the nurse and tech have multiple duties, putting the clients in the facility at risk. One primary care staff member is required to be in the detox at all times. It was determined that the nurse leaves the detox area in the evening to complete admission assessments and provide medications to the rehab clients. The techs are responsible for cleaning the facility, monitoring clients and providing transportation. A recent sexual assault occurred in the evening hours when there was only one tech onsite and they were the perpetrator of the assault.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Angel's Light has implemented the following corrective measures: (1) Revised staffing schedules to ensure a minimum of two direct care staff members (nurse and tech) are present during all shifts, with clear delineation of responsibilities. The nurse will focus on medical care and medication administration while the tech provides facility supervision and client monitoring. (2) Added an additional overnight tech position to ensure adequate coverage during late evening and early morning hours. (3) Implemented a staffing matrix that ensures coverage ratios meet regulatory requirements for all levels of care. (4) Enhanced staff training on safety protocols and emergency response procedures. Note: As of November 1, 2025, the 3.7 detoxification level of care has been discontinued, which reduces overall staffing demands and allows for better allocation of staff resources to remaining programs.
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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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of staff schedules and staff and client interviews, the facility failed to provide one primary care staff during primary care hours.
Licensing Alert 3-02 defines primary care staff as a group of individuals, including clinical supervisors, counselors, physicians, physician assistants, psychologists, registered nurses and licensed practical nurses who provide primary care services and those individuals who are responsible for developing and implementing the treatment plan. In addition, for the detoxification activity, primary care hours are 24 hours a day, seven days a week. Staffing levels of primary care staff must be maintained for each shift, 24 hours each day. These designated staff may not have any duties other than in the detoxification unit.
It was determined that one primary care staff, a nurse, is scheduled to work each shift. During the evening and early morning hours, that nurse is leaving the detox area to complete medication passes to the rehab clients and complete new admission intake assessments, leaving the detoxification area with no primary care staff.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Angel's Light has taken the following corrective actions: (1) As of November 1, 2025, the 3.7 detoxification level of care has been permanently discontinued. This deficiency is no longer applicable as the facility no longer operates a detoxification program. (2) For the remaining residential rehabilitation program, revised staffing schedules ensure appropriate primary care staff coverage during all primary care hours (7 days per week, 24 hours per day). (3) Implemented a staffing matrix that clearly defines primary care staff assignments and coverage responsibilities. (4) Cross-trained additional qualified staff to serve as backup primary care staff to prevent coverage gaps. (5) Established a policy prohibiting primary care staff from leaving their assigned unit unless adequate coverage is arranged.
Person Responsible:
Chief Operating Officer
Target Completion Date:
Completed - November 1, 2025
Evidence of Compliance:
Documentation of 3.7 level of care discontinuation, revised staffing schedules, staffing matrix, and updated coverage policy will be available for DDAP review.
Change of license was submitted and approved 11/20/2025
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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.
During the physical plant inspection, it was observed, by DDAP staff, that one of the electrical outlets in the work-out room did not have a cover.
Additionally, DDAP staff observed an HVAC ceiling register obstructed with tissues and paper towels in Room #11.
This is a repeat citation from May 15, 2025 onsite inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Angel's Light has taken the following corrective actions: (1) Installed an outlet cover on the uncovered electrical outlet in the work-out room. (2) Removed all obstructions from the HVAC ceiling register in Room #11 and cleaned the register. (3) Conducted a comprehensive facility walkthrough to identify and address any other maintenance or safety issues. All identified issues have been corrected. (4) Implemented a daily facility inspection checklist that includes electrical outlets, HVAC registers, and other safety items. (5) Established a maintenance request system where staff can report issues for prompt resolution. (6) Scheduled monthly facility inspections by the Facilities Manager to proactively identify and address maintenance needs.
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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.
It was observed that there were no blinds or window coverings over the window to the group room, allowing the clients attending group counseling to be seen from the exterior of the facility.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 15, 2025 licensing inspection.
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Plan of Correction
Plan of Correction:
Angel's Light has taken the following corrective actions: (1) Installed privacy window film on the group room window that allows natural light while preventing visibility from outside the facility. (2) Conducted a comprehensive review of all counseling spaces (individual and group) to ensure privacy standards are met. (3) Installed additional sound dampening materials in counseling areas to prevent conversations from being heard outside the rooms. (4) Established a policy requiring regular privacy assessments of counseling spaces. (5) Added privacy verification to monthly facility inspections.
Person Responsible:
Project Director
Target Completion Date:
Completed - December 02,2025
Evidence of Compliance:
Photos of installed privacy window film, sound dampening installation documentation, privacy assessment checklist, and updated facility inspection protocol will be available for DDAP review. |
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
does not apply |
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
does not apply |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
During the physical plant inspection it was observed, by DDAP staff, that the urinal in the men's room was broken and one of the sinks did not have a drain pipe installed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Angel's Light has taken the following corrective actions: (1) Repaired the broken urinal in the men's restroom, restoring it to full functionality. (2) Installed a drain pipe on the sink that was missing one. (3) Conducted a comprehensive plumbing inspection of all bathrooms to identify and address any other issues. (4) Established enhanced cleaning protocols for all bathrooms, with documented cleaning schedules and checklists. (5) Implemented immediate reporting procedures for bathroom maintenance issues. (6) Designated staff to conduct bathroom inspections twice daily to ensure cleanliness and functionality. (7) Added bathroom condition checks to the daily facility inspection protocol.
Person Responsible:
Facilities Manager
Target Completion Date:
Completed - November 11, 2025
Evidence of Compliance:
Work orders for urinal repair and drain pipe installation, plumbing inspection report, enhanced cleaning schedules with completion documentation, and updated facility inspection protocol will be available for DDAP review. |
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 all food items off the floor.
During the physical plant inspection, 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
does not apply |
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
does not apply |
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 a physical inspection, the facility failed to ensure that exits from the residential facility are unobstructed.
A client was observed to be sitting in front of the exit door located in the dining / group room, blocking the exit from the facility.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 15, 2025 licensing inspection.
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Plan of Correction
Plan of Correction:
Angel's Light has taken the following corrective actions: (1) Immediately relocated client seating arrangements in the dining/group room to ensure all exits remain unobstructed at all times. (2) Marked exit pathways with floor decals and signage to clearly designate areas that must remain clear. (3) Established a policy prohibiting furniture placement or client activities within 36 inches of any exit door. (4) Provided staff training on fire safety requirements, emergency egress procedures, and the importance of maintaining clear exit routes. (5) Designated staff to monitor common areas and redirect clients or furniture that may obstruct exits. (6) Implemented hourly visual checks of all exit routes to ensure they remain clear. (7) Added exit obstruction checks to daily facility inspections.
Person Responsible:
Safety Officer
Target Completion Date:
Completed - November 15, 2025
Evidence of Compliance:
Photos of revised seating arrangements, exit route markings, unobstructed exits policy, staff training documentation, hourly check logs, and updated facility inspection protocol will be available for DDAP review.
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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
does not apply |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel training records, the facility failed to document that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Staff #1 was hired as a tech on August 14, 2025. There was no documentation of emergency training in staff record #1.
Staff #2 was hired as a tech on June 27, 2025. There was no documentation of emergency training in staff record #2.
Staff #3 was hired as a tech on July 19, 2025. There was no documentation of emergency training in staff record #3.
Staff #4 was hired as a tech on June 15, 2025. There was no documentation of emergency training in staff record #4.
Staff #5 was hired as a nurse on June 24, 2025. There was no documentation of emergency training in staff record #5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Angel's Light has taken the following corrective actions: (1) Provided comprehensive emergency response training to Staff #1, #2, #3, #4, and #5, documenting completion in their personnel files. (2) Developed a structured emergency response training curriculum that covers fire safety procedures, evacuation routes, client accountability, emergency equipment use, and role-specific responsibilities. (3) Implemented a policy requiring all new hires to complete emergency response training during their first week of employment, prior to working independently. (4) Integrated emergency response training into the onboarding checklist to ensure no staff member begins work without this critical training. (5) Established quarterly emergency response refresher training for all staff. (6) Designated the Safety Officer as responsible for tracking and documenting all emergency response training.
Person Responsible:
Safety Officer / Human Resources Director
Target Completion Date:
Completed - November 20, 2025
Evidence of Compliance:
Updated personnel files with emergency training completion records, emergency response training curriculum, new hire onboarding checklist, quarterly refresher training schedule, and training tracking system documentation will be available for DDAP review.
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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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of client records, the facility failed to authenticate verbal orders within 3 business days of the order being given in 4 of 4 applicable records reviewed.
Client #11 was admitted on August 30, 2025 and was active at the time of the inspection. Client record #11 included documented verbal orders for eight medications on August 30, 2025, none of which were authenticated with a physician signature.
Client #12 was admitted on August 4, 2025 and was active at the time of the inspection. Client record #12 included documented verbal orders for medications on August 20, 21, 25 and September 1, 2025, none of which were authenticated with a physician signature.
Client #13 was admitted on August 6, 2025 and was active at the time of the inspection. Client record #13 included documented verbal orders for medications on August 8 and 30, 2025, none of which were authenticated with a physician signature.
Client #14 was admitted on August 22, 2025 and was active at the time of the inspection. Client record #14 included documented verbal orders for medications on August 22 and 28, and September 7, 2025, none of which were authenticated with a physician signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Angel's Light has taken the following corrective actions: (1) Obtained physician authentication for all outstanding verbal medication orders for Clients #11, #12, #13, and #14, bringing all records into compliance. (2) Implemented an electronic tracking system for verbal orders that generates alerts when authentication is due within 2 business days and overdue at 3 business days. (3) Designated the Director of Nursing as responsible for monitoring verbal order authentication compliance and following up with physicians. (4) Established a procedure for nursing staff to fax or electronically send verbal orders to physicians within 24 hours with a request for authentication. (5) Implemented a policy requiring documentation of follow-up attempts to obtain authentication. (6) Added verbal order authentication compliance to the weekly nursing QA review. (7) Provided training to nursing staff on verbal order documentation requirements and authentication procedures. Note: As of November 1, 2025, the 3.7 detoxification level of care has been discontinued, which significantly reduces the volume of verbal orders.
Person Responsible:
Director of Nursing
Target Completion Date:
Completed - November 28, 2025
Evidence of Compliance:
Authenticated verbal orders for all clients, verbal order tracking system documentation, nursing follow-up logs, weekly QA review reports, and nursing staff training records will be available for DDAP review.
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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 client medication administration records, the facility failed to provide documentation of medication being provided as prescribed by a physician in five of fourteen applicable client records.
Client #7 was admitted on June 6, 2025, and was discharged on June 26, 2025. The medication administration record (MAR) was reviewed for June 2025.
Doxycycline HYC 100mg was prescribed June 15, 2025, with physician instruction to take one tablet twice a day for ten days. The MAR did not include documentation that the client received the medication as prescribed. On June 15 and June 19, 2025, there was no note of the 8pm dose. On June 22 and June 23, 2025, there was no note of the 8am dose.
Client #8 was admitted on June 9, 2025, and was discharged on July 1, 2025. The medication administration record (MAR) was reviewed for June 2025.
Clotrimazole 1% cream was prescribed June 9, 2025, with physician instructions to apply topically twice a day for seven days. The MAR did not include documentation that the client received an application of this medicine on June 20, 2025, at 8am.
Client #11 was admitted on August 30, 2025 and was an active client at the time of the inspection. The medication administration record (MAR) was reviewed for August and September 2025.
Lorazepam 1mg was prescribed on August 30, 2025, with physician instructions to take three times per day. There was no MAR documented for Lorazepam, only a medication inventory form. The medication inventory form did not include documentation that the client received the medication as prescribed on September 2, 3, 4, 5, 6, 7, 8 and 9, 2025.
Buprenorphine 8/2mg was prescribed on August 30, 2025, with physician instructions to take three times per day. The MAR did not include documentation that the client received the medication as prescribed on August 31 or September 1, 2 and 3, 2025. In addition, nursing staff reported that the medication was discontinued due to the client " cheeking " his medication; however, there was no documentation or order from the physician indicating this change.
Client #12 was admitted on August 4, 2025 and was an active client at the time of the inspection. The medication administration record (MAR) was reviewed for August and September 2025.
Gabapentin 800mg was prescribed on August 4, 2025, with physician instructions to take four times per day. The MAR did not include documentation that the client received the medication as prescribed on August 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30 and September 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 17, 2025.
Omeprazole 20mg was prescribed on August 5, 2025, with physician instructions to take two times per day. The MAR did not include documentation that the client received the medication as prescribed on August 10 and 29, 2025.
Valacyclovir 1mg was prescribed on August 14, 2025, with physician instructions to take three times per day. The MAR did not include documentation that the client received the medication as prescribed on August 14, 2025.
Epclusa 400mg was prescribed on August 14, 2025, with physician instructions to take once at bedtime. The MAR did not include documentation that the client received the medication as prescribed on August 10 and 16, 2025.
Escitalopram 20mg was prescribed on August 5, 2025, with physician instructions to take once per day. The MAR did not include documentation that the client received the medication as prescribed on August 10, 16 and 17, 2025.
Spironolactone 5mg was prescribed on August 5, 2025, with physician instructions to take once per day. The MAR did not include documentation that the client received the medication as prescribed on August 10, 16 and 17, 2025.
Quetiapine 100mg was prescribed on August 5, 2025, with physician instructions to take once per day. The MAR did not include documentation that the client received the medication as prescribed on August 14, 2025.
In addition, Buprenorphine was given to the client on August 5 and 6, 2025, as documented on a medication inventory card. There was no documentation of a physician order or a MAR for this medication in client record #12.
Client #14 was admitted to detox on August 22, 2025, then transferred to rehab on August 26, 2025, and was an active client at the time of the inspection. The medication administration record (MAR) was reviewed for August and September 2025.
Effexor XR 75mg was prescribed on August 23, 2025. The MAR did not include documentation that the client received the medication September 1, 2, 3, 4, 5, 6, 7, 8 and 9, 2025. The MAR stated that the medication was discontinued; however, there was no physician order documenting this change.
This is a repeat citation from May 15, 2025, November 15, 2024, and April 18, 2024 onsite inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Angel's Light has taken the following corrective actions: (1) Conducted comprehensive MAR audits for all active clients to identify and correct any missing or incomplete medication documentation. All identified gaps have been addressed with retroactive documentation where possible and incident reports where doses may have been missed. (2) Implemented a double-check system requiring nurses to verify MAR completeness at the end of each shift and initial that all prescribed doses are documented. (3) Established an electronic MAR system that generates alerts for missing documentation and prevents closing a shift until all scheduled doses are documented (administered, refused, or held with reason). (4) Provided intensive training to nursing staff on MAR documentation requirements including the need to document every prescribed dose, proper notation for refused or held doses, and the requirement for physician orders for all medication changes. (5) Implemented daily MAR audits by the Director of Nursing with immediate follow-up on any missing documentation. (6) Enhanced medication administration procedures to include documentation verification as part of the administration process. (7) Established weekly MAR compliance reviews with trending reports and corrective action for patterns of non-compliance. Note: As of November 1, 2025, the 3.7 detoxification level of care has been discontinued, significantly reducing medication administration volume and complexity.
Person Responsible:
Director of Nursing
Target Completion Date:
Completed - December 2, 2025
Evidence of Compliance:
Corrected MARs for all clients with identified deficiencies, electronic MAR system documentation, daily and weekly MAR audit reports, nursing staff training records on MAR requirements, and MAR compliance trending reports will be available for DDAP review.
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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
does not apply |
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
does not apply |
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
does not apply |
709.34 (a) (6) 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:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records and administrative documentation, the facility failed to file a report with DDAP for an event at the facility requiring the presence of ambulance personnel.
It was documented that an ambulance was called to the facility on August 31, 2025, for a client medical emergency. There was no documentation that an unusual incident report was filed with DDAP for this event.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Angel's Light has taken the following corrective actions: (1) Immediately filed the overdue unusual incident report with DDAP for the August 31, 2025 ambulance call. (2) Conducted a review of all documented ambulance calls or emergency medical responses to ensure all required unusual incident reports have been filed. Any additional missing reports have been submitted. (3) Enhanced the Unusual Incident Reporting Policy to explicitly include ambulance calls as reportable incidents requiring DDAP notification within 24 hours. (4)
Implemented a tracking log for all emergency medical responses including ambulance calls, with checkboxes to verify unusual incident report completion. (5) Provided training to
all staff on unusual incident reporting requirements, including specific examples of reportable incidents. (6) Designated the Compliance Officer as responsible for reviewing incident documentation and ensuring timely DDAP reporting. (7) Established a same-day
review process where any incident involving outside emergency responders triggers immediate unusual incident report filing.
Person Responsible:
Project Director
Target Completion Date:
Completed - November 30, 2025
Evidence of Compliance:
Filed unusual incident report for August 31, 2025 incident, audit results of all emergency responses, enhanced Unusual Incident Reporting Policy, emergency response tracking log, staff training documentation, and Compliance Officer review process will be available
for DDAP review. |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
709.64(e) LICENSURE Follow-up policy
709.64. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the policy and procedure manual and staff interviews, the facility failed to document a client follow-up policy which addresses follow-up for all types of client discharges.
The facility policy includes a procedure for follow-up for clients that have an aftercare plan in place; however, there was no follow-up policy for clients that have an unplanned discharge, such as involuntary termination, medical or against medical advice.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Angel's Light has developed and implemented a comprehensive Client Follow-Up Policy that addresses all discharge types: (1) Planned discharge follow-up procedures including
contact at 5 days, 30 days, 60 days, and 90 days post-discharge to assess status,
aftercare plan adherence, and service needs. (2) Involuntary termination follow-up procedures including contact within 5 business days to assess safety, provide crisis resources, offer referrals to other treatment providers, and encourage treatment re-engagement. (3) Against Medical Advice (AMA) discharge follow-up procedures including
contact within 5 business days to assess wellbeing, provide harm reduction information, and offer return-to-treatment opportunities. (4) Medical discharge follow-up procedures
including coordination with receiving medical provider and contact within 5 business days to assess medical status and readiness to resume treatment. (5) Administrative discharge follow-up procedures including contact within 5 business days to provide resource
information and alternative treatment options. (6) Documentation requirements for all follow-up attempts and contacts. (7) Graduated frequency of follow-up based on discharge type and client engagement. (8) Procedures for clients who cannot be reached. The Client
Follow-Up Policy has been added to the facility policy and procedure manual.
Person Responsible:
Clinical Director
Target Completion Date:
December 10, 2025
Evidence of Compliance:
Updated policy and procedure manual with comprehensive Client Follow-Up Policy
addressing all discharge types, follow-up contact schedules, documentation forms, and tracking system will be available for DDAP review. |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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
does not apply |
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 three days of admission, as per agency policy, in four of ten applicable records reviewed.
Client #2 was admitted on July 27, 2025, and was still active at the time of the inspection. An initial treatment plan was due no later than July 30, 2025; however, it was not completed until July 31, 2025.
Client #3 was admitted on August 12, 2025, and was still active at the time of the inspection. An initial treatment plan was due no later than August 15, 2025; however, it was not completed until August 19, 2025.
Client #5 was admitted on August 7, 2025, and was still active at the time of the inspection. An initial treatment plan was due no later than August 10, 2025; however, it was not completed until August 12, 2025.
Client #8 was admitted on June 9, 2025, and was discharged July 1, 2025. An initial treatment plan was due no later than June 12, 2025; however, it was not completed until June 16, 2025.
This is a repeat citation from the May 15, 2025 onsite inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Angel's Light has taken the following corrective actions: (1) Established structured treatment planning sessions within the first three days of admission where counselors work with clients to develop comprehensive treatment plans. (2) Implemented a tracking system that assigns treatment planning responsibility to counselors on Day 1 and generates alerts on Days 2 and 3 regarding pending treatment plans. (3) Revised counselor schedules to protect dedicated time for treatment planning in the first three days after each admission. (4) Developed comprehensive treatment plan templates that streamline the planning process while ensuring all required elements are addressed. (5)
Provided training to clinical staff on effective treatment planning and the regulatory requirement for 3-day completion. (6) Implemented daily review by the Clinical Director of all admissions from the prior 3 days to verify treatment plan completion. (7) Established backup coverage for treatment planning if counselors are absent. (8) Added treatment
plan timeliness compliance to weekly clinical documentation audits.
Person Responsible:
Clinical Director
Target Completion Date:
Completed - December 3, 2025
Evidence of Compliance:
Treatment planning schedule protecting time for new admissions, treatment plan tracking system with automated alerts, comprehensive treatment plan templates, clinical staff training documentation, Clinical Director daily review process, backup coverage policy, and weekly audit results will be available for DDAP review. |
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
does not apply |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of residential client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in two out of ten records reviewed.
Client #2 was admitted on July 27, 2025, and was still active at the time of the inspection. A treatment plan dated July 31, 2025, indicated individual therapy once a week. There was no documentation that the client received individual therapy during the weeks of July 27-August 2, 2025 and August 3-August 9, 2025.
Client #5 was admitted on August 7, 2025, and was still active at the time of the inspection. A treatment plan dated August 12, 2025, indicated individual therapy once a week. There was no documentation that the client received individual therapy during the weeks of August 17- August 23, 2025 and August 24-August 30, 2025.
This is a repeat citation from April 18, 2024, November 15, 2024, and May 15, 2025, onsite inspections.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Angel's Light has taken the following corrective actions: (1) Implemented a weekly counseling schedule tracking system that lists each client and their required individual therapy sessions per treatment plan. (2) Established a policy requiring counselors to schedule individual sessions with clients at the beginning of each week to ensure
treatment plan requirements are met. (3) Implemented mid-week check-ins where
counselors verify they are on track to complete required sessions for all clients. (4) Implemented end-of-week audits by the Clinical Director to verify all clients received
counseling services per their treatment plans. (5) Established protocols for rescheduling missed sessions within the same week to maintain treatment plan compliance. (6) Provided training to counselors on the importance of adhering to treatment plan service
frequencies and documentation requirements. (7) Implemented a backup counselor system for coverage when primary counselors are absent to prevent gaps in service provision. (8) Added treatment plan service provision compliance to weekly clinical audits.
Person Responsible:
Clinical Director
Target Completion Date:
Completed - December 3, 2025 |
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 five out of nine applicable records reviewed.
The facility's policy and procedures manual states case consultations will occur, at a minimum, every fifteen days, following the first individual clinical session.
Client #1 was admitted on July 15, 2025, and was still active at the time of the inspection. There were no case consultations documented in the client record.
Client #2 was admitted on admitted on July 27, 2025, and was still active at the time of the inspection. A case consultation was to be completed no later than August 11, 2025; however, it was not completed until September 2, 2025.
Client #5 was admitted on admitted on August 7, 2025, and was still active at the time of the inspection. There were no case consultations documented in the client record.
Client #8 was admitted on admitted on June 9, 2025, and discharged on July 1, 2025. There were no case consultations documented in the client record
Client #9 was admitted on admitted on June 7, 2025, and discharged on July 7, 2025. There were no case consultations documented in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Angel's Light has taken the following corrective actions: (1) Implemented a structured case consultation schedule requiring consultations every 15 days for all active clients, with tracking of due dates. (2) Established bi-weekly clinical team meetings where case
consultations are formally conducted and documented. (3) Developed a case consultation documentation form that includes date, participants, clinical issues discussed, recommendations, and follow-up plans. (4) Implemented an electronic tracking system that generates alerts when case consultations are due and overdue. (5) Designated the
Clinical Director as responsible for facilitating case consultations and ensuring documentation completion. (6) Provided training to clinical staff on case consultation requirements, effective consultation practices, and documentation expectations. (7)
Implemented weekly audits of case consultation compliance with immediate follow-up on missing consultations. (8) Established a policy requiring case consultations to be completed and documented within 1 business day of the consultation meeting.
Person Responsible:
Clinical Director
Target Completion Date:
Completed - December 5, 2025
Evidence of Compliance:
Bi-weekly case consultation schedule, case consultation documentation form, electronic tracking system with alerts, clinical team meeting agendas and minutes, staff training documentation, and weekly audit results will be available for DDAP review. |
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 five out of five applicable records reviewed.
The facility ' s policy is to contact any client with an active discharge plan within five business days of discharge.
Client #6 was admitted on June 6, 2025, and was discharged June 19, 2025. There was no documentation of any follow-up contacts in the client record.
Client #7 was admitted on June 6, 2025, and was discharged June 26, 2025. There was no documentation of any follow-up contacts in the client record.
Client #8 was admitted on June 9, 2025, and was discharged July 1, 2025. There was no documentation of any follow-up contacts in the client record.
Client #9 was admitted on June 7, 2025, and was discharged July 7, 2025. There was no documentation of any follow-up contacts in the client record.
Client #10 was admitted on July 21, 2025, and was discharged July 25, 2025. There was no documentation of any follow-up contacts in the client record.
This is a repeat citation from April 18, 2024, November 15, 2024, and May 15, 2025, onsite inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Angel's Light has taken the following corrective actions: (1) Implemented a discharge tracking system that generates follow-up task assignments for counselors within 24 hours of client discharge. (2) Established a policy requiring counselors to attempt follow-up contact within 5 business days of discharge and document all attempts (successful and unsuccessful) in the client record. (3) Developed a follow-up contact documentation form that includes date of contact attempt, method used (phone, email, mail), outcome (successful contact, left message, unable to reach), client status, and next steps. (4) Implemented weekly review by the Clinical Director of all discharges from the prior week to
verify follow-up attempts are documented. (5) Provided training to clinical staff on follow-up contact requirements, effective follow-up strategies, and documentation expectations. (6) Established protocols for multiple contact attempts if initial contact is unsuccessful. (7) Added follow-up contact compliance to weekly clinical documentation audits. (8) Created a follow-up call script and contact log for consistency in follow-up procedures.
Person Responsible:
Clinical Director
Target Completion Date:
Completed - December 5, 2025
Evidence of Compliance:
Discharge tracking system with follow-up task assignment, follow-up contact
documentation form, follow-up protocols including multiple attempt procedures, Clinical Director weekly review process, staff training documentation, and weekly audit results will be available for DDAP review. |
709.53(a)(12) LICENSURE Work as treatment
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of residential client records, the facility failed to provide a complete client record, which is to include verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan in seven out of nine applicable records reviewed.
Client #1 was admitted on July 15, 2025, and was still active at the time of the inspection. An initial treatment plan completed on July 18, 2025, did not reflect that chores completed by the client were part of their treatment.
Client #2 was admitted on July 27, 2025, and was still active at the time of the inspection. An initial treatment plan completed on July 31, 2025, did not reflect that chores completed by the client were part of their treatment.
Client #3 was admitted on August 12, 2025, and was still active at the time of the inspection. An initial treatment plan completed on August 19, 2025, did not reflect that chores completed by the client were part of their treatment.
Client #6 was admitted on June 6, 2025, and was discharged on June 19, 2025. An initial treatment plan completed on June 6, 2025, did not reflect that chores completed by the client were part of their treatment.
Client #7 was admitted on June 6, 2025, and was discharged on June 26, 2025. An initial treatment plan completed on June 10, 2025, did not reflect that chores completed by the client were part of their treatment.
Client #9 was admitted on June 7, 2025, and was discharged on July 7, 2025. An initial treatment plan completed on June 9, 2025, did not reflect that chores completed by the client were part of their treatment.
Client #10 was admitted on July 21, 2025, and was discharged on July 25, 2025. An initial treatment plan completed on July 22, 2025, did not reflect that chores completed by the client were part of their treatment.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Angel's Light has taken the following corrective actions: (1) Enhanced all treatment plan templates to include a dedicated section addressing Work/Chores as Treatment' that explains the therapeutic rationale for assigned responsibilities. (2) Developed treatment plan language that frames chores and facility maintenance responsibilities as treatment
interventions addressing recovery goals such as developing daily structure, building responsibility, enhancing self-esteem, practicing cooperation, and preparing for independent living. (3) Implemented a policy requiring counselors to explicitly document in
treatment plans how assigned chores contribute to the client's treatment and rehabilitation goals. (4) Provided training to clinical staff on integrating work/chore assignments as
therapeutic interventions and documenting them appropriately in treatment plans. (5) Created a menu of chore assignments with associated therapeutic goals that counselors
can reference when developing treatment plans. (6) Implemented quality checks during treatment plan reviews to verify work/chores are documented as treatment interventions. (7) Added work as treatment documentation compliance to weekly clinical audits.
Person Responsible:
Clinical Director
Target Completion Date:
Completed - December 5, 2025
Evidence of Compliance:
Enhanced treatment plan templates with work/chores as treatment section, therapeutic rationale documentation for chore assignments, chore assignment therapeutic goals menu, clinical staff training documentation, and weekly audit results will be available for
DDAP review. |
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
does not apply |
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
does not apply |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the policy and procedure manual and staff interviews, the facility failed to document a client follow-up policy which addresses follow-up for all types of client discharges.
The facility policy includes a procedure for follow-up for clients that have an aftercare plan in place; however, there was no follow-up policy for clients that have an unplanned discharge, such as involuntary termination, medical or against medical advice.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This deficiency is identical to citation 709.64(e) and has been addressed through the same corrective action. Angel's Light has developed and implemented a comprehensive Client Follow-Up Policy that addresses all discharge types including planned discharges,
involuntary terminations, AMA discharges, medical discharges, and administrative discharges. The policy includes contact timeframes (within 5 business days for unplanned
discharges), contact methods, documentation requirements, and graduated follow-up frequencies. See the full corrective action plan for 709.64(e) for complete details.
Person Responsible:
Clinical Director
Target Completion Date:
December 10, 2025
Evidence of Compliance:
All documentation referenced in the 709.64(e) corrective action plan will be available for DDAP review, as this addresses the same deficiency. |
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
does not apply |
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
does not apply |
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
does not apply |
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 May 15, 2025, November 15, 2024, and April 18, 2024 licensing inspections. Medications being administered as prescribed was again found to be a deficiency in the September 10, 2025 licensure 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 May 15, 2025, November 15, 2024, and April 18, 2024 licensing inspections. Individual sessions not being offered as stated in the treatment plan was again found to be a deficiency in the September 10, 2025 licensure inspection.
A plan of correction for not completing follow-up contact was submitted and approved by the Department for the May 15, 2025, November 15, 2024, and April 18, 2024 licensing inspections. Follow-up contact was again found to be a deficiency in the September 10, 2025 licensure inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Angel's Light acknowledges the serious nature of repeat deficiencies and takes full
responsibility for the failure of previously implemented corrective actions to achieve
sustained compliance. The following comprehensive systemic improvements have been
implemented to address the root causes of repeated non-compliance: (1) LEADERSHIP
ACCOUNTABILITY: Designated the Chief Operating Officer as ultimately responsible for
monitoring DDAP compliance across all deficiency areas. Weekly compliance reports are
now submitted to the COO reviewing status of all high-risk compliance areas. (2)
ENHANCED QUALITY ASSURANCE: Implemented a comprehensive QA program with
daily, weekly, and monthly audits of medication administration documentation, treatment
plan service provision, and discharge follow-up completion. Audit results are reviewed in
weekly leadership meetings with immediate corrective action for identified deficiencies. (3)
STAFFING IMPROVEMENTS: Increased nursing staff to ensure adequate coverage for
medication administration and documentation. Adjusted clinical staff caseloads to realistic
levels that allow time for both service provision and documentation. Note: Discontinuation
of the 3.7 detoxification level of care as of November 1, 2025 has significantly reduced
medication administration volume. (4) TECHNOLOGY ENHANCEMENT: Implemented
electronic systems for MAR completion, treatment planning tracking, and follow-up contact
scheduling that generate alerts and prevent oversight of required tasks. (5) INTENSIVE
STAFF TRAINING: Conducted comprehensive retraining of all clinical and nursing staff on
DDAP requirements, emphasizing the critical importance of compliance. Implemented
competency testing to verify understanding. (6) PROGRESSIVE DISCIPLINE: Established
clear accountability and progressive discipline procedures for staff who fail to meet
documentation and service provision requirements. (7) EXTERNAL CONSULTATION:
Retained external behavioral health compliance consultant to conduct monthly reviews
and provide recommendations for improvement. See individual citations 709.32(c)(4)(i)-(ii),
709.52(c), and 709.53(a)(11) for specific corrective actions addressing each deficiency.
COO compliance oversight structure and weekly reporting system, comprehensive QA
audit program and results, revised staffing plan and schedules, electronic tracking system
documentation, staff training and competency testing records, progressive discipline
policy, and external consultant engagement agreement and reports will be available for
DDAP review. |
709.17(a)(8) 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:
(8) Mistreating or abusing individuals cared for or treated by the facility.
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Observations
Based on a review of client records, administrative documentation, unusual incident reports and staff and client interviews, the facility failed to keep clients free from mistreatment and abuse.
An unusual incident report was filed with DDAP on September 2, 2025, which indicated that a sexual assault occurred on facility grounds by a staff member against a client. Upon investigations by the facility and DDAP staff, it was determined that these allegations were substantiated. The staff member involved was immediately placed on leave and is no longer employed by the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Angel's Light takes this matter with the utmost seriousness and has implemented
extensive measures to protect client safety and prevent any future incidents of mistreatment or abuse: (1) IMMEDIATE ACTIONS TAKEN: The staff member involved in the alleged sexual assault was immediately placed on administrative leave upon the facility becoming aware of the allegations. Following internal and DDAP investigations that substantiated the allegations, the staff member's employment was terminated. The facility fully cooperated with law enforcement and all regulatory investigations. (2) CLIENT SAFETY ENHANCEMENTS: Implemented enhanced staffing during evening and overnight hours to ensure at least two direct care staff members are present at all times
(addressed in citation 704.3(c)). Installed additional security cameras in common areas to enhance monitoring. Implemented hourly rounds during overnight hours with documentation. Established client safety protocols prohibiting one-on-one interactions
between staff and clients in private areas. (3) STAFF SCREENING AND TRAINING:
Enhanced pre-employment background check procedures including comprehensive
criminal background checks, abuse registry checks, and reference verification with specific
questions about professional boundaries. Implemented mandatory annual training on
professional boundaries, sexual harassment prevention, abuse recognition and reporting, and client rights. Established zero-tolerance policy for boundary violations with immediate
termination consequences. (4) REPORTING AND RESPONSE PROTOCOLS: Enhanced
unusual incident reporting procedures to ensure all allegations are immediately reported to DDAP, law enforcement, and facility leadership. Established mandatory reporting requirements for all staff. Implemented victim support protocols including immediate safety
planning, trauma-informed care, counseling services, and referrals to external victim advocacy services. (5) CULTURE AND CLIMATE: Conducted facility-wide meetings with clients and staff regarding client safety, reporting mechanisms, and zero tolerance for
abuse. Established confidential reporting mechanisms for clients to report concerns. Implemented client satisfaction surveys with specific questions about feeling safe at the
facility. (6) LEADERSHIP OVERSIGHT: Designated the Chief Operating Officer as responsible for client safety oversight with direct reporting to ownership. Established monthly client safety reviews examining incident reports, client complaints, and safety
climate indicators. Retained external consultant to conduct semi-annual client safety assessments.
Person Responsible:
Project Director
Target Completion Date:
Completed - December 10, 2025
Evidence of Compliance:
Documentation of investigation and staff termination, enhanced staffing schedules, security camera installation documentation, hourly rounds logs, enhanced background check procedures, mandatory training curriculum and attendance records, zero-tolerance
policy, unusual incident reporting protocols, victim support procedures, confidential reporting mechanism, client satisfaction surveys, client safety review process, and external consultant engagement will be available for DDAP review. |