INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 27, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Synergy Treatment LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the personnel records, the facility failed to provide a written individual training plan developed annually for each employee, in two of eight employee records reviewed.
Employee # 1 has been in the position of Project Director since August 1, 2024. The personnel record did not contain a completed training plan as of the date of the inspection.
Employee # 6 has been in the position of counselor since May 5, 2025. Employee # 6 should have had an initial individual training plan developed within 30 days of the date of hire; however, a written individual training plan was not developed until June 12, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Operations will audit training plans annually and ensure all training plans are submitted by staff within 30 days of their hire date and/or in the month of January at the beginning of each new year.
On September 8 2025, Employee #1 completed a training plan for the remainder of the year. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one of twelve records reviewed.
Client # 10 was admitted to the outpatient level of care on January 2, 2025 and was active at the time of the inspection. There was evidence of disclosures to a family member during a family counseling session on July 31, 2025; however, the consent to release information form allowing the disclosures was not signed by the client until August 21, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations will audit 3 charts monthly for clients engaged in family therapy and confirm that all releases for everyone engaged in family therapy including siblings are signed.
On September 15, 20205, the Director of Operations will provide a documentation training to all staff and focus on compliance with releases of information for all individuals engaged in family therapy.
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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 that the client was given the opportunity to request reconsideration of a decision terminating treatment in two of two applicable records reviewed.
Client # 7 was admitted to the outpatient level of care on November 20, 2024 and was administratively discharged on April 30, 2025.
Client # 9 was admitted to the outpatient level of care on December 20, 2024 and was administratively discharged on August 11, 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations updated the EMR Document "Discharge Follow-Up Call" on September 8, 2025 to offer a checkbox option for involuntary discharges that confirms the client was notified of their opportunity to request reconsideration of a decision terminating treatment.
On September 8, 2025, the Director of Clinical Operations confirmed with the primary therapist for Client #7 and Client #9 that they were notified of this ability upon discharge.
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709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within five days of admission, per the facility policy, in two of four applicable records reviewed.
Client # 3 was admitted to the partial level of care on July 29, 2025 and was transferred to a lower level of care on August 8, 2025. The individual treatment and rehabilitation plan was due to be completed by August 3, 2025; however, the plan was not completed until August 7, 2025.
Client # 5 was admitted to the partial level of care on July 10, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by July 15, 2025; however, the plan was not completed until July 23, 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On September 8, 2025, the Director of Clinical Operations created a documentation timeline for clients in the partial hospitalization program and sent to all staff.
On September 15, 2025, The Director of Operations will provide a documentation training to all staff and focus on treatment plan timelines for new LOC offered.
In addition to this, the Director of Clinical Operations will conduct month chart audits to ensure compliance with the Department of Drug and Alcohol regulations.
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709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in two of four client records reviewed.
Client # 4 was admitted to the partial level of care on August 4, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 8, 2025; however, the plan did not include documentation of the proposed type of support services.
Client # 5 was admitted to the partial level of care on July 10, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 23, 2025; however, the plan did not include documentation of the proposed type of support services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On September 15, 2025, The Director of Operations will provide a documentation training for all staff and focus on adding support services to treatment plans. The clinical staff will be educated on what support services are typically utilized for the population we treat and the importance of them being present in all treatment plans.
In addition to this, the Director of Clinical Operations will conduct month chart audits to ensure compliance with the Department of Drug and Alcohol regulations.
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of five client records, the facility failed to document treatment plan updates within the regulatory timeframe in one of one applicable record reviewed.
Client # 5 was admitted to the partial level of care on July 10, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 23, 2025, and the treatment plan update was due no later than August 22, 2025; however, no treatment pan updates were completed prior to the date of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On September 8, 2025 the Director of Clinical Operations created a documentation timeline for clients in the partial hospitalization program and sent to all staff.
On September 15, 2025, The Director of Operations will provide a documentation training to all staff and focus on treatment plan timelines for new LOC offered.
In addition to this, the Director of Clinical Operations will conduct month chart audits to ensure compliance with the Department of Drug and Alcohol regulations.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in three of seven records reviewed.
Client # 8 was admitted on December 2, 2024 and was discharged on July 14, 2025. A treatment plan update was completed on March 28, 2025, and the next treatment plan update was due no later than May 27, 2025; however, the next treatment plan update was not completed until May 29, 2025.
Client # 9 was admitted on December 20, 2024 and was discharged on August 11, 2025. A treatment plan update was completed on April 24, 2025, and the next treatment plan update was due no later than June 23, 2025; however, the next treatment plan update was not completed until June 28, 2025.
Client # 10 was admitted on January 2, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 12, 2025 and the treatment plan update was due no later than July 11, 2025; however, the treatment plan update was not completed until July 17, 2025.
This is a repeat citation from the July 19, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On September 8, 2025 the Director of Clinical Operations created a documentation timeline for clients in the intensive outpatient program and sent to all staff.
On September 15, 2025, The Director of Operations will provide a documentation training to all staff and focus on treatment plan reviews for IOP.
In addition to this, the Director of Clinical Operations will conduct month chart audits to ensure compliance with the Department of Drug and Alcohol regulations.
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