INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on August 5-7, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clear Choices, 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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704.3(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 administration information and a physical plant inspection, the facility failed to employ clerical and other support staff in sufficient numbers to ensure efficient and safe operation of all of the services provided by the project.
The facility had no staff available at the front desk to greet and direct visitors and clients upon entry.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
To correct this deficiency a front desk administrative assistant has been hired, with staff scheduled to be present at the entrance during all hours of client operation. Effective 8/18/25, front desk coverage is in place from 6:45 AM ? 1:00 PM by an admin assistant and from 5:00 AM ? 6:45 AM by rotating current clinic staff. A secondary coverage backup plan has been created to ensure relief staff can step in when the front desk employee is unavailable. To prevent recurrence a clerical staffing schedule is maintained by the Operations Manager. The Operations Manager will confirm coverage and staff performance weekly. The deficiency has been fully addressed as of 8/18/25.
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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of administrative information, the facility failed to document an assessment of staff training needs, per their policy, for the training year January 1, 2025, through December 31, 2025.
Facility policy and procedures state that an assessment of staff training needs is completed annually. The facility training year is January-December, and the last assessment was completed on January 17, 2024. The next assessment was completed on June 23, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Director has finalized and submitted the overdue 2025 training needs assessments on June 23, 2025, and ensured it was placed in the appropriate administrative file for reference and internal accountability. Automated calendar reminders have been created in the Facility Director's and HR Manager's calendars to prompt development and approval of the annual training assessments each year by December 31. The deficiency has been addressed retroactively with the submission of the 2025 plan. The procedural safeguard of automated reminders will be fully in place by August 31, 2025, ahead of the 2026 planning cycle. |
704.11(a)(2) LICENSURE Overall Training 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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of administrative information, the facility failed to document an overall plan for addressing staff training needs, per their policy, for the training year January 1, 2025, through December 31, 2025.
Facility policy and procedures state that an overall training plan is completed annually. The facility training year is January-December, and the last overall plan was completed on January 17, 2024. The next overall plan was completed on June 23, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clear Choices acknowledges that the 2025 training plan was not completed within the policy timeframe by January 31, 2025. To correct this deficiency, the Facility Director has finalized and submitted the overdue 2025 training plan as of June 23, 2025, and ensured it is placed in the appropriate administrative file for reference and internal accountability. To prevent recurrence, the facility has implemented automated calendar reminders in the Facility Director's and HR Manager's calendars to prompt planning for each new year. The deficiency has been addressed retroactively with the submission of the 2025 plan. The procedural safeguard of automated reminders was fully in place by August 31, 2025. |
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 administrative information, the facility failed to document an evaluation of the overall training plan, per their policy, for the training year January 1, 2024, through December 31, 2024.
Facility policy and procedures state that an evaluation of the overall training plan for the previous training year is completed annually. The facility training year is January-December, and the last evaluation was completed on January 17, 2024. The next assessment was completed on June 23, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clear Choices acknowledges that an evaluation of the 2024 training year was not completed within the policy timeframe by January 31, 2025. To correct this deficiency, the Facility Director has finalized and submitted the overdue 2025 evaluation of the 2024 training plan as of June 23, 2025, and ensured it was placed in the appropriate administrative file for reference and internal accountability. To prevent recurrence, the facility has implemented automated calendar reminders in the Facility Director's and HR Manager's calendars to prompt evaluation each year of the previous training year by January 31. The deficiency has been addressed retroactively with the submission of the 2025 plan. The procedural safeguard of automated reminders was fully in place by August 31, 2025. |
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 administrative information, the facility failed to develop a written individual training plan for each employee, per their policy, in three of three applicable records.
Facility policy and procedures state that an individual training plan is to be developed for each employee annually or within 30 days of hire.
Staff #1 was hired February 28, 2025. There was no training plan for staff #1.
Staff #2 was hired March 11, 2025. There was no training plan for staff #2.
Staff #3 was hired April 18, 2022. There was no training plan for staff #3.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All identified staff members now have completed and signed ITPs on file, developed with their supervisors and tailored to their individual roles. To prevent future ITP noncompliance, new hire onboarding procedures now require ITPs to be completed within 30 days and verified by HR with an onboarding checklist. Annual ITP completion is now a December action item with the Facility Director and HR Manager having calendar alerts set to indicate that ITPs are due by Dec 31. Supervisors were retrained on ITP policy and deadlines during a supervisors meeting held Aug 27, 2025. Beginning October 2025, quarterly audits by HR Manager will include ITP documentation checks. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the personnel training records, the facility failed to have each counselor complete at least 25 clock hours of annual training in one of one record.
Staff #3 was hired as a counselor April 18, 2022. Staff #3 documented 19.5 hours of training for the January 1, 2024, through December 31, 2024, training year.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
To address this deficiency, the Facility Director has added quarterly audits of counselor training hours to prevent under-compliance. Staff development and training policy was reviewed at an all-staff meeting held on 9/9/2025. Additionally, a spreadsheet tracker with alerts for cumulative hours will be implemented by Clinical Supervisors by 10/1/2025. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative information, the facility failed to make an annual report available to the public.
The 2023 annual report was completed January 12, 2024. There was no report completed for 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The 2024 annual report will be finalized and posted publicly by Dec 31, 2025. The Facility Director has developed an annual calendar reminder for December and January each year to initiate the review and finalize the report by January 31. This will ensure future reports are completed and made available on time. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of administrative information, the facility failed to ensure the personnel records included an annual written individual staff performance evaluation in one of one applicable record.
Facility policy and procedures states performance reviews are completed annually during the salary determination cycle.
Staff #2 was hired April 18, 2022. There was no annual performance evaluation for the calendar year beginning January 1, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Annual staff performance evaluations were not documented as required by facility policy. To correct this the HR department will maintain a Performance Evaluation Tracker, which now includes checkpoints and firm deadlines. Supervisors are required to schedule annual evaluations during Q1 each year, with follow-up confirmation submitted to HR by February 15. An automated reminder has been implemented to notify supervisors starting January 2 each year. Quarterly HR compliance audits will include performance evaluation status reviews. |
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 a consent to release information form prior to releasing information in two of seven records.
Client #3 was admitted on October 20, 2021, and discharged on March 11, 2025. A fax was sent to a physician on November 22, 2024, and there was no consent to release information form in client #3 ' s record.
Client #6 was admitted on November 20, 2023, and discharged on February 24, 2025. A fax was sent to another treatment provider on November 15, November 21, and December 11, 2024, and the consent to release information form was not signed by client #6.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director implemented a file audit to ensure all active consents are documented prior to releasing any information. New training on release protocols will be delivered at a companywide meeting on 10/14/2025. A double-verification system that includes clinical and admin support staff is now required prior to any external communication. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records and incident reports, the facility failed to inform the Department of an unusual incident within the required three business days.
The facility was informed of the death of a client on June 18, 2025, and an incident report was due to be filed no later than June 23, 2025; however, it was filed August 6, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
A revised incident reporting workflow has been implemented requiring a 48-hour internal alert that includes the Clinical Supervisor, Clinical Director, and Operations Manager. The delayed death report from June 2025 was filed on August 6, 2025, but all subsequent incidents are now being reported on time. The Facility Director will review all reports weekly. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of medical staff coverage, the facility failed to provide narcotic treatment physician services for at least 1 hour per week onsite for every ten patients for three of sixteen weeks.
Physician service hours were reviewed from April 6, 2025, through July 25, 2025.
For the week of April 13, 2025, through April 19, 2025, the facility's census was 98 patients. The facility was required to provide 9.8 hours of onsite physician services; however, the physician hours totaled 8.5 hours.
For the week of May 25, 2025, through May 31, 2025, the facility's census was 100 patients. The facility was required to provide 10 hours of onsite physician services; however, the physician hours totaled 8.5 hours.
For the week of June15, 2025, through June 21, 2025, the facility's census was 98 patients. The facility was required to provide 9.8 hours of onsite physician services; however, the physician hours totaled 6 hours.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Physician hours were adjusted to meet the required 1 hour per 10 patients per week. The scheduling error that resulted in shortfalls for April, May, and June has been corrected. A compliance spreadsheet is maintained bi-weekly by the Operations Manager and verified by the Facility Director monthly. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to include the results of an annual physical reevaluation by the narcotic treatment physician in one of four applicable records.
Patient #7 was admitted on May 18, 2020, and discharged on July 2, 2025. The last annual physical was completed May 1, 2024. There was no annual physical documented for 2025 in patient #7 ' s record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Annual physicals will be tracked through a new EMR to be implemented 10/1/2025 with monthly audit reminders sent to the Clinical Supervisor and the Facility Director. Physicians will receive monthly lists of overdue evaluations from nursing staff beginning 9/1/2025. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to include the results of an annual clinical evaluation in one of four applicable records.
Patient #7 was admitted on May 18, 2020, and discharged on July 2, 2025. The last annual clinical evaluation was completed June 20, 2024. There was no annual clinical evaluation documented for 2025 in patient #7 ' s record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The annual evaluations due based on patient admission dates will be triggered automatically in a new EHR to be installed 10/1/2025. The Clinical Supervisor is now reviewing the list monthly. The Facility Director will monitor the Clinical Supervisor's tracking on a quarterly basis. All Counselor staff have received retraining on this process as of 9/1/2025. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in one of two applicable records.
The facility ' s policy and procedures state that the psychosocial evaluation must be completed within 30 days.
Client #5 was admitted on November 26, 2024, and discharged July 14, 2025. There was no psychosocial evaluation in client #5 ' s record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director will implement a 14-day reminder within the new EMR, to be installed Oct 1, 2025, to ensure psychosocial evaluations are completed within the 30-day window. Corrective training and policy review was issued to Counselors by the Facility Director during one-on-one supervision in August 2025. The Clinical Supervisor will sign off on all new intakes to ensure that biopsychosocial assessments are completed. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to develop a treatment plan with the client in one of two applicable records.
Client #5 was admitted on November 26, 2024, and discharged July 14, 2025. A treatment plan was developed on December 26, 2024, and did not indicate it was developed with the client.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 21-22, 2024 annual licensing inspection.
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Plan of Correction
Counseling staff have met with the Clinical Supervisor to review DDAP requirements and collaborative treatment planning. The Facility Director is implementing weekly chart monitoring by the Clinical Supervisor who will review a weekly report of all open upcoming or overdue treatment plans. The Clinical Supervisor will address upcoming and late treatment plans one on one with staff during regular supervision meetings. Starting October 2025, the Facility Director will initiate quarterly audits focused on documentation timelines for treatment plans, case consults, and progress notes. Clinical staff will receive retraining on treatment plan timelines during an August 2025 in-service session. Ongoing refreshers will be conducted during clinical supervision and during onboarding for all new clinical personnel. |
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 document treatment plan updates every 60 days in four of six applicable records.
Client #1 was admitted on September 21, 2023, and discharged on July 16, 2025. A treatment plan update was completed on January 24, 2025, and the next update was due no later than March 24, 2025; however, the next update was completed on March 28, 2025. The next update was due no later than May 28, 2025; however, it was completed on May 29, 2025.
Client #4 was admitted on January 13, 2025, and was still active at the time of the inspection. A treatment plan was developed on January 29, 2025, and an update was due no later than March 29, 2025; however, it was completed on May 12, 2025. The next update was due no later than July 12, 2025; however, there were no further updates documented in client #4 ' s record.
Client #5 was admitted on November 26, 2024, and discharged on July 14, 2025. A treatment plan update was completed on February 24, 2025, and the next update was due no later than April 24, 2025; however, it was completed on April 29, 2025.
Client #6 was admitted on November 20, 2023, and discharged on February 24, 2025. A treatment plan update was completed on October 14, 2024, and the next update was due no later than December 14, 2024; however, there were no further updates documented in client #6 ' s record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Counseling staff have met with the Clinical Supervisor to review DDAP requirements and collaborative treatment planning. The Facility Director is implementing weekly chart monitoring by the Clinical Supervisor who will review a weekly report of all open upcoming or overdue treatment plans. The Clinical Supervisor will address upcoming and late treatment plans one on one with staff during supervision meetings. Starting October 2025, the Facility Director will initiate quarterly audits focused on documentation timelines for treatment plans, case consults, and progress notes. Clinical staff will receive retraining on treatment plan timelines during an August 2025 in-service session. Ongoing refreshers will be conducted during clinical supervision and during onboarding for all new clinical personnel. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure the clients received counseling services according to their individual treatment plan in four of six applicable records.
Client #1 was admitted on September 21, 2023, and discharged on July 16, 2025.
Type and frequency on treatment plans indicate 2.5 hours of individual counseling per month. Client #1 had 1.25 hours of counseling documented in December 2024, and zero hours of counseling documented in March 2025.
Client #4 was admitted on January 13, 2025, and was still active at the time of inspection. Type and frequency on treatment plans indicate two individual counseling sessions per month. Client #4 had zero sessions documented in March 2025, one session documented in April 2025, zero sessions documented in June 2025, and one session documented in July 2025.
Client #5 was admitted on November 26, 2024, and discharged on July 14, 2025. Type and frequency on treatment plans indicate one individual counseling session per month. Client #5 had zero sessions documented in March 2025 and May 2025.
Client #7 was admitted on May 18, 2020, and discharged on July 2, 2025. Type and frequency on treatment plans indicate one individual counseling session per month. Client #7 had zero sessions documented for March 2025, April 2025, May 2025, and June 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Counseling frequency standards were reviewed with staff at an August 2025 in service session along with collaborative treatment planning with clients. Counseling session delivery is now cross-checked against each client's plan by Clinical Supervisor and addressed with Counselors during monthly supervision. Counselors have been issued scheduling expectations with monthly supervision check-ins to monitor compliance effective August 31, 2025. |
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, the facility failed to document a discharge summary, per their policy, in two of six applicable records.
The facility ' s policy and procedures state that the discharge summary must be completed within 7 days of discharge.
Client #2 was admitted on October 28, 2024, and discharged on December 3, 2024. The discharge summary was due no later than December 10, 2024; however, it was completed December 17, 2024.
Client #5 was admitted on November 26, 2024, and discharged on July 14, 2025. The discharge summary was due no later than July 21, 2025; however, it was completed August 5, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
During an August 2025 in-service meeting, discharge protocol was reviewed with all staff. A new workflow checklist has been developed by the Clinical Supervisor. The workflow checklist has a discharge summary within 7 days as an action item. The Clinical Supervisor will monitor the workflow process and address shortfalls in individual supervision sessions beginning 9/1/2025. Compliance reports will be reviewed by Facility Director and Clinical Supervisor monthly. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of three applicable records.
The facility's policy and procedures state follow-up contact is to be completed for all discharges within 30 days.
There was no follow-up information documented in client records #3 and #7.
Client #3 was admitted on October 20, 2021, and discharged on March 11, 2025.
Client #7 was admitted on May 18, 2020, and discharged on July 2, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will ensure the follow-up for all discharged clients within 30 days by adding this action item to a workflow checklist that will be maintained by administrative support staff. A 30-day automated reminder will be added to a new EMR that will be instituted on 10/1/2025. Admin support will conduct weekly follow-up tracking reports. The Clinical Supervisor will monitor the tracking reports and address any deficiencies with the appropriate staff person in individual supervision meetings beginning 9/1/2025. All current charts are compliant and all discharges since Aug 7th are being tracked. |