INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mid-Atlantic Rehabilitation Services - A.T.P. 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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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.Client #2 was admitted on January 6, 2025 and was active at the time of the inspection. The facility had the client sign a release of information form for the incorrect funding source on January 6, 2025, when billing had verified that the client had a different funding source, prior to the client ' s admission. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A new ROI was executed and updated in file.
How to correct:
Billing will verify funding source and assessor will ensure that funding source matches what is on file for client to ensure correct ROI information.
Training supplied: A training will be held in January to overview correct protocol and processes
Preventing reoccurrence: Auditing will be completed by quality assurance (assessment leads)
Person responsible for overseeing change: Assessment Supervisor
CAP completed: 2/1/26
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in one of seven client records reviewed.Client #2 was admitted on January 6, 2025 and was active at the time of the inspection. A release of information form for a probation officer, signed by the client on May 9, 2025, did not specify the specific information to be disclosed.The findings were reviewed with project staff during the licensing process.
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Plan of Correction
A new ROI will executed and updated in the client file by 1/1/26.
How to correct: Through quality assurance and individual supervision, human error will be detected and corrected.
Training supplied: A training will be held in January on obtaining releases of information and the individual components involved for a complete form.
Preventing reoccurrence: Auditing will be completed by quality assurance. If deficiencies are found in releases of information, another document will be completed with client. Clinician's supervisor will be informed and clinician will undergo additional training
Person responsible for overseeing change: Quality Assurance Director, Clinical Supervisor
CAP completed: 2/1/26
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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 project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one of seven client records reviewed.Client #2 was admitted on January 6, 2025 and was active at the time of the inspection. A release of information form for a probation officer, signed by the client on May 9, 2025, did not specify the purpose of disclosure.The findings were reviewed with project staff during the licensing process.
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Plan of Correction
A new ROI will executed and updated in the client file by 1/1/26.
How to correct: Through quality assurance and individual supervision, human error will be detected and corrected.
Training supplied: A training will be held in January on obtaining releases of information and the individual components involved for a complete form.
Preventing reoccurrence: Auditing will be completed by quality assurance on a monthly basis. If deficiencies are found in releases of information, another document will be completed with client. Clinician's supervisor will be informed and clinician will undergo additional training
Person responsible for overseeing change: Quality Assurance Director, Clinical Supervisor
CAP completed: 2/1/26
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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 project failed to offer a copy of the release of information form in one of seven client records reviewed.Client #2 was admitted on January 6, 2025 and was active at the time of the inspection. There was no documentation that the client was offered a copy of the release of information form for the probation office; signed and dated by the client on May 9, 2025.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A new ROI will executed and updated in the client file by 1/1/26.
How to correct: Through quality assurance and individual supervision, human error will be detected and corrected.
Training supplied: A training will be held in January on obtaining releases of information and the individual components involved for a complete form.
Preventing reoccurrence: Auditing will be completed by quality assurance on a monthly basis. If deficiencies are found in releases of information, another document will be completed with client. Clinician's supervisor will be informed and clinician will undergo additional training
Person responsible for overseeing change: Quality Assurance Director, Clinical Supervisor
CAP completed: 2/1/26
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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 the review of outpatient client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in four of six applicable records reviewed. Client #1 was admitted on November 11, 2024, and was active at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on January 28, 2025, with the next update due no later than March 28, 2025; however, there was no updated treatment and rehabilitation plans documented in the client record until April 29, 2025. Additionally, an updated treatment and rehabilitation plan was documented in the record on May 22, 2025, with the next update due no later than July 22, 2025; however, there was no updated treatment and rehabilitation plans documented in the client record until August 27, 2025.Client #5 was admitted on January 29, 2025, and was discharged on August 29, 2025. An updated comprehensive treatment and rehabilitation plan was documented in the record on June 11, 2025, with the updated treatment and rehabilitation plans due no later than August 11, 2025; however, there were no updated treatment and rehabilitation plans documented in the client record until August 27, 2025.Client #6 was admitted on January 30, 2025, and was discharged on September 30, 2025. An updated comprehensive treatment and rehabilitation plan was documented in the record on June 16, 2025, with the updated treatment and rehabilitation plans due no later than August 16, 2025; however, there were no updated treatment and rehabilitation plans documented in the client record until August 21, 2025.Client #7 was admitted on October 29, 2024, and was discharged on May 8, 2025. An updated comprehensive treatment and rehabilitation plan was documented in the record on January 23, 2025, with the updated treatment and rehabilitation plans due no later than March 23, 2025; however, there were no updated treatment and rehabilitation plans documented in the client record until May 6, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How to correct: Clinicians will be instructed to document in clinical notes when treatment plans are updated. Clinical staff will submit treatment plans on or before date due.
Training supplied: A training will be held in January to overview correct protocol and processes.
Preventing reoccurrence: Auditing will be completed by quality assurance on a monthly basis. If ongoing issues are identified, quality assurance will inform clinical supervisor and additional trainings will be held with clinician on proper protocol.
Person responsible for overseeing change: Quality Assurance Director, Clinical Supervisor
CAP completed: 2/1/26
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709.93(a)(5) LICENSURE Client records
709.93. 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include progress notes entered within seventy-two hours of the date of service, per the facility's policy, in three of seven records reviewed.Client #1 was admitted on November 11, 2024, and was active at the time of the inspection. The record contained progress notes for individual counseling sessions occurring on November 19, 2024, December 12, 2024, December 26, 2024, and February 27, 2025, that were not documented in the record until November 29, 2024, December 21, 2024, January 1, 2025, and March 12, 2025, respectively. Additionally, the record contained progress notes for group counseling sessions occurring on November 15, 2024; November 18, 2024, November 20, 2024, November 22, 2024, November 25, 2024, and December 9, 2024, that were not documented in the record until November 22, 2024, November 26, 2024, November 29, 2024, November 29, 2024, December 3, 2024, and December 21, 2024, respectively.Client #4 was admitted on December 26, 2024, and was discharged on July 2, 2025. The record contained progress notes for individual counseling sessions occurring on February 5, 2025, February 19, 2025, March 12, 2025, April 9, 2025, April 30, 2025, May 21, 2025, May 28, 2025, June 5, 2025 and June 25, 2025, that were not documented in the record until February 17, 2025, March 3, 2025, March 27, 2025, April 21, 2025, May 6, 2025, June 4, 2025, June 5, 2025, June 12, 2025 and July 1, 2025, respectively. Client #5 was admitted on January 29, 2025, and was discharged on August 29, 2025. The record contained progress notes for individual counseling sessions occurring on February 11, 2025, April 10, 2025, April 21, 2025, April 30, 2025, May 8, 2025, June 5, 2025, July 3, 2025, July 31, 2025 and August 28, 2025, that were not documented in the record until February 17, 2025, April 21, 2025, May 8, 2025, May 13, 2025, May 16, 2025, June 18, 2025, July 14, 2025, August 19, 2025 and September 2, 2025, respectively. Additionally, the record contained progress notes for group counseling sessions occurring on January 31, 2025, February 6, 2025, February 28, 2025, and March 13, 2025, that were not documented in the record February 19, 2025, February 20, 2025, March 19, 2025, and March 31, 2025, respectively.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How to correct: The facility will be altering policy to allow clinicians more adequate time to submit clinical documentation.
Training supplied: A training will be held in January to overview correct protocol and processes
Preventing reoccurrence: Clinical supervision team will audit weekly through approval of services. A more in depth audit will occur on a monthly basis through the quality assurance department. Clinical supervisor will address any documentation challenges with clinician to remedy. Corrective action to clinicians will be conducted if repeated late submissions are found.
Person responsible for overseeing change: Quality Assurance Director, Program Director, Clinical Supervisor
CAP completed: 2/1/26
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709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include an aftercare plan entered one day prior to discharge, per the facility's policy, in one of two applicable records reviewed.Client #5 was admitted on January 29, 2025, and was discharged on August 29, 2025. Per the facility ' s policy, the client ' s aftercare plan was to be documented no later than August 28, 2025; however, the client ' s aftercare plan was not documented in the record until October 15, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How to correct: While aftercare plans will be conducted during final sessions with client, plan submissions will be extended to 14 days after discharge. This policy has been written, however, needs approval by the board of directors of our company. Anticipated date of implementation is March 31, 2026.
Training supplied: A training will be held in January to overview correct protocol and processes.
Preventing reoccurrence: Auditing will be completed by quality assurance and clinical supervisor monthly. Clinical supervisor will address any documentation challenges with clinician to remedy. Corrective action to clinicians will be conducted if repeated late submissions are found.
Person responsible for overseeing change: Quality Assurance Director, Program Director, Clinical Supervisor
CAP complete: 3/31/26
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709.93(a)(10) LICENSURE Client records
709.93. 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:
(10) Discharge summary.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include a discharge summary within seven days of discharge, per the facility's policy, in two of four applicable records reviewed.Client #4 was admitted on December 26, 2024, and was discharged on July 2, 2025. Per the facility ' s policy, the client ' s discharge summary was to be documented no later than July 11, 2025; however, the client ' s discharge summary was not documented in the record until August 5, 2025.Client #5 was admitted on January 29, 2025, and was discharged on August 29, 2025. Per the facility ' s policy, the client ' s discharge summary was to be documented no later than September 9, 2025; however, the client ' s discharge summary was not documented in the record until October 15, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
How to correct: The facility will be altering policy to allow clinicians more adequate time for discharge summary.
Training supplied: A training will be held in January to overview correct protocol and processes
Preventing reoccurrence: Auditing will be completed by quality assurance and clinical supervisor monthly. Clinical supervisor will address any documentation challenges with clinician to remedy. Corrective action to clinicians will be conducted if repeated late submissions are found.
Person responsible for overseeing change: Quality Assurance Director, Program Director, Clinical Supervisor
CAP completed: 2/1/26
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