INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, High Focus Centers 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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709.92(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 treatment and rehabilitation plans were reviewed and updated at least every sixty days in one of two applicable client records reviewed.
Client #2 was admitted on August 12, 2024 and was discharged on October 23, 2025. A treatment plan update was completed on March 26, 2025 and the next update was due no later than May 26, 2025; however, the update was not completed prior to discharge.
This is a repeat citation from the January 18, 2024 and January 22, 2025 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor and SUD therapist will meet biweekly to review all SUD charts for active SUD clients to ensure that compliance is met. Therapist will create a file to track dates when treatment plan updates are required, and review with supervisor during these meetings. Clinical supervisor will meet with Executive Director monthly to complete monthly chart audits to ensure treatment plans are being completed within policy timeframe with expectation of full compliance by 3/30/26. |
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 ensuring the completion of treatment plan updates within the regulatory timeframe was submitted and approved by the Department for the January 18, 2024 and January 22, 2025 annual licensing inspections. Failing to complete treatment plan updates within the regulatory timeframe was again found to be a deficiency in the January 14, 2026 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will strengthen accountability and clinical oversight processes to ensure all treatment plan updates are completed within required regulatory timeframes. Beginning March 2, 2026, executive director and regional director will begin conducting monthly reviews of all active SUD clients and charts to ensure accurate delivery of services in accordance with regulatory compliance. These actions will establish clear expectations, strengthen staff performance, and ensure sustained compliance moving forward, with full implementation expected by March 30, 2026. |