INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 10, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PHMC Pathways to Recovery 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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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
At the time of the inspection, there were four fire extinguishers, located in the hallway and in the employee common workspace, that were last inspected in March 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will notify PHMC Facilities department to check fire extinguishers every 6 months. The local fire department will inspect and approve all fire extinguishers located at Pathways. Any extinguishers that are not in compliance will be replaced. Project Director will ensure that the fire department inspection will be done annually to secure that each extinguisher is in good working order.
Since the inspection on 6/10/26 all extinguishers were inspected, approved and properly tagged as of 6/22/2026.
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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 a review of client records, the facility failed to ensure a copy of a client consent to release information form was offered to the client in one of fourteen client records reviewed.
Client # 2 was admitted on May 11, 2026 and was still active at the time of the inspection. The release of information form to another treatment provider was signed and dated by the client on February 12, 2026, but there was no documentation in the record indicating a copy of the release form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will conduct an internal review of all active client's file documentation of Consent for the Release of Information (ROI), including that documentation includes 709.28 (d) ensuring that a copy of the client consent has been offered to the client and a copy maintained in the client chart by 8/30/2026
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that complete and valid ROI documentation is present in the official client record, and that ROIs are in use during communications with outside parties and a copy has been offered to the client. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2026.
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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 notify the client, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable client records reviewed.
Client #13 was admitted on September 4, 2025 and was involuntarily terminated on October 22, 2025. There was no documentation, in the record, indicating the client received written notice of the involuntary termination from the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by the Program Director on the requirements of 709.33 a) Notification of termination, by 8/15/26. Staff participation in this training will be kept in staff training files.
All clients involuntarily terminated from treatment program will be notified in writing of the decision to discontinue services. This notice will include reason (s) for termination. A copy of written notification will be mailed to client and copy of letter placed in chart.
Clinical Director will audit discharged client files monthly to ensure copy of notification letter placed in chart.
During bi-annual internal audits PHMC Compliance Department will monitor completion of notification letters in client files. The Compliance Department will report findings to Clinical Director and Program Manager for internal Plan of Correction.
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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 provide the client with an opportunity to request reconsideration of the decision to terminate the client ' s treatment in one of one applicable client records reviewed.
Client #13 was admitted on September 4, 2025 and was involuntarily terminated on October 22, 2025. There was no documentation, in the record, indicating the client was given an opportunity to request reconsideration of the involuntary termination from the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All participants at intake receive and sign for their receipt of a copy of their rights and the PHMC Grievance policy, which includes information on appealing treatment decisions like termination of services.
The termination letter template is updated to include the statement: "You have an opportunity to request reconsideration of the decision of terminating treatment. We are also providing you with a grievance form and information to submit a reconsideration request/ grievance, if you so choose. " A copy of the PHMC Grievance form will be attached to the termination letter.
Clinical Director will review and share 709.33 (b) requirements and the Termination letter template during the August 4,2026 clinical staff meeting.
Expected completion date 8/31/2026.
PHMC's Quality Management team will review charts for terminated participants for compliance with 709.33 (b) during regular chart reviews (e.g. quarterly) and will report compliance and any findings for follow-up to the Clinical Director and Project Director. |
709.81(b)(6) LICENSURE Intake and admission
709.81. 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, as part of their intake and admission process, a psychosocial evaluation of the client in three of seven client records reviewed.
Client #11 was admitted on December 30, 2025 and was discharged on March 16, 2026. There was no psychosocial evaluation documented in the record at the time of the inspection.
Client #12 was admitted on November 17, 2025 and was discharged on February 5, 2026. There was no psychosocial evaluation documented in the record at the time of the inspection.
Client #14 was admitted on December 29, 2025 and was discharged on March 3, 2026. There was no psychosocial evaluation documented in the record at the time of the inspection.
This is a repeat citation from the June 24, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by the Clinical Director and Admissions Manager on the requirements of 709.81 (b) (6) LICENSURE Intake and admission regulations by 8/15/26. Staff participation in this training will be kept in staff training files. The Admissions Manager will ensure Psychosocial evaluation is thoroughly completed and placed in client files. Clinical Director will audit charts weekly to ensure compliance. |
709.82(a)(1) 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:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to ensure there were short and long-term goals for treatment, formulated by both the staff and the client, documented on the individual treatment and rehabilitation plan in four of six applicable client records reviewed.
Client #8 was admitted on April 20, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 20, 2026; however, the plan did not include individualized short and long-term goals for treatment.
Client #11 was admitted on December 30, 2025 and was discharged on March 16, 2026. The individual treatment and rehabilitation plan was completed on December 30, 2025; however, the plan did not include individualized short and long-term goals for treatment.
Client #12 was admitted on November 17, 2025 and was discharged on February 5, 2026. The individual treatment and rehabilitation plan was completed on November 17, 2025; however, the plan did not include individualized short and long-term goals for treatment.
Client #13 was admitted on September 4, 2025 and was discharged on October 22, 2025. The individual treatment and rehabilitation plan was completed on September 4, 2025 and did not include individualized short and long-term goals for treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by the Program Manager on the requirements of 709.82 (a)(1) Treatment and rehabilitation services by 8/15/26. Staff participation of this training will be kept in staff training files.
The Clinical Director will review client charts during weekly Clinical Team Meeting to ensure all treatment plans are individualized, including short and long-term goals and formulated by both staff and clients.
The Clinical Director will document on counselor's weekly supervision note any decencies. Individual counselor will have 24 hours from the time of supervision to modify treatment plans.
During bi-annual client file audits, PHMC Compliance Department will monitor treatment plans for short and long-term goals. The Compliance Department will report findings to Program Manager and Clinical Director for internal Plan of Correction.
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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 client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in four of six applicable client records reviewed.
Client #10 was admitted on April 15, 2026 and was still active at the time of the inspection. The individual treatment plan was completed on April 14, 2026 and the first update was due no later than May 15, 2026; however, the update was completed on May 28, 2026.
Client #11 was admitted on December 30, 2025 and was discharged on March 16, 2026. The individual treatment plan was completed on December 30, 2025 and the first update was due no later than January 30, 2026; however, there was no update completed prior to discharge.
Client #12 was admitted on November 17, 2025 and was discharged on February 5, 2026. A treatment plan was completed on December 2, 2025 and the next update was due no later than January 2, 2026; however, the update was not completed prior to discharge.
Client #13 was admitted on September 4, 2025 and was discharged on October 22, 2025. The individual treatment plan was completed on September 4, 2025 and the first update was due no later than October 4, 2025; however, there was no update completed prior to discharge.
This is a repeat citation from the July 14, 2022, June 27, 2023, June 25, 2024 and June 24, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by the Program Director and Clinical Director on the requirements of 709.82 (b) Treatment and rehabilitation services by 8/16/26. Staff participation of this training will be kept in staff training files. The Clinical Director will review treatment plan completion and due-date status daily utilizing Pathways To Recovery Treatment Plan Tracker. All clinical staff will have a copy of up-to-date treatment plan tracker and consult with Clinical Director daily about treatment plan completion.
The Clinical Director will review treatment plan completion and due-date status during weekly clinical team meetings to ensure treatment plans are updated at least every thirty days. Compliance with dates for treatment plans will be monitored by Clinical Director during individual staff supervision and documented.
Clinical Director will report treatment plan completions to Program Director during biweekly supervision.
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709.82(c) LICENSURE Treatment and rehabilitation services
709.82. 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 counseling services were provided to the client according to the individual treatment and rehabilitation plan in six of six applicable records reviewed.
Client #8 was admitted on April 20, 2026 and was still active at the time of the inspection. The individual treatment plan dated April 20, 2026 and the treatment plan updates dated May 5, 2026 and June 5, 2026 indicated the client was to receive two individual counseling sessions per week. There was no documentation in the record indicating individual counseling services were provided to the client since admission through the date of the inspection.
Client #9 was admitted on May 6, 2026 and was still active at the time of the inspection. The individual treatment plan dated May 6, 2026 and the treatment plan update dated May 21, 2026 indicated the client was to receive two individual counseling sessions per week. There was no documentation in the record indicating individual counseling services were provided to the client since admission through the date of the inspection.
Client #10 was admitted on April 15, 2026 and was still active at the time of the inspection. The individual treatment plan dated April 14, 2026 and the treatment plan update dated May 28, 2026 indicated the client was to receive two individual counseling sessions per week. There was no documentation in the record indicating individual counseling services were provided to the client since admission through the date of the inspection.
Client #11 was admitted on December 30, 2025 and was discharged on March 16, 2026. The individual treatment plan dated December 30, 2025 indicated the client was to receive two individual counseling sessions per week. There was documentation of only two individual counseling sessions occurring during the period of December 30, 2025 through the date of discharge.
Client #12 was admitted on November 17, 2025 and was discharged on February 5, 2026. The individual treatment plan dated November 17, 2025 and the treatment plan update dated December 2, 2025 indicated the client was to receive two individual counseling sessions per week. There was documentation of only one individual counseling session occurring during the period of November 17, 2025 through the date of discharge.
Client #13 was admitted on September 4, 2025 and was discharged on October 22, 2025. The individual treatment plan dated September 4, 2025 indicated the client was to receive two individual counseling sessions per week. There was documentation of only two individual counseling sessions occurring during the period of September 4, 2025 through the date of discharge.
This is a repeat citation from the June 27, 2023, June 25, 2024 and June 24, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by the Program Director and Clinical Director on the requirements of 709.82( c) Treatment and rehabilitation services by 8/15/26. Staff participation in this training will be kept in staff training files.
The Clinical Director will conduct weekly review verifying counseling services are provided according to individual treatment plans using Pathways To Recovery Client Registry Services (CRS)
Clinical Director will review and document counseling services completion at weekly clinical team meetings with all counseling staff. The Clinical Director will review with counselors during individual supervision all clients on caseload are receiving counseling services twice a week.
Clinical Director will report to Program Director during supervision individual therapy session frequencies and compliance.
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on review of client records, the facility failed to ensure clients admitted to the partial hospitalization program received individual counseling, at least twice weekly, in seven of seven applicable client records reviewed.
Client #8 was admitted on April 20, 2026 and was still active at the time of the inspection. There was no documentation in the record indicating the client had received any individual counseling sessions as of the date of the inspection.
Client #9 was admitted on May 6, 2026 and was still active at the time of the inspection. There was no documentation in the record indicating the client had received any individual counseling sessions as of the date of the inspection.
Client #10 was admitted on April 15, 2026 and was still active at the time of the inspection. There was no documentation in the record indicating the client had received any individual counseling sessions as of the date of the inspection.
Client #11 was admitted on December 30, 2025 and was discharged on March 16, 2026. There was documentation of only two individual sessions occurring throughout the entire treatment episode.
Client #12 was admitted on November 17, 2025 and was discharged on February 5, 2026. There was documentation of only one individual session occurring throughout the entire treatment episode.
Client #13 was admitted on September 4, 2025 and was discharged on October 22, 2025. There was documentation of only two individual sessions occurring throughout the entire treatment episode.
Client #14 was admitted on December 29, 2025 and was discharged on March 3, 2026. There were less than two individual sessions documented in the record for each week from December 29, 2025 through February 5, 2025.
This is a repeat citation from the July 14, 2022, June 27, 2023, June 25, 2024 and June 24, 2025 annual licensing renewal inspections
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by the Program Manager on the requirements of 709.82 (d)(1) Treatment and Rehabilitation services by 8/15/26. Staff participation in this training will be kept in staff training files.
On a weekly basis, The Clinical Director will conduct reviews of individual counseling services provided to clients according to 709.82 (d) (1) utilizing the Pathways To Recovery Registry Service (CRS) Electronic Health Record.
The Clinical Director will review counseling services completion status at weekly Clinical Team Meeting as well as clinical staff supervisions to ensure clients are receiving individual counseling at least twice a week.
The Clinical Director will report to Program Manager during supervision compliance with counseling services frequency rate.
PHMC Compliance Department will monitor that counseling services are completed in a timely manner, at least twice weekly.
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709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of case consultation notes, in seven of seven applicable client records reviewed.
The facility's policy and procedure manual stated that case consultation notes will be completed every 30 days.
Client #8 was admitted on April 20, 2026 and was still active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client #9 was admitted on May 6, 2026 and was still active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client #10 was admitted on April 15, 2026 and was still active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client #11 was admitted on December 30, 2025 and was discharged on March 16, 2026. There were no case consultation notes documented in the record at the time of the inspection.
Client #12 was admitted on November 17, 2025 and was discharged on February 2, 2026. There were no case consultation notes documented in the record at the time of the inspection.
Client #13 was admitted on September 4, 2025 and was discharged on October 22, 2025. There were no case consultation notes documented in the record at the time of the inspection.
Client #14 was admitted on December 29, 2025 and was discharged on March 3, 2026. There were no case consultation notes documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ll staff will be trained by Program Director on the requirements of 709.83 (a)(4) LICENSURE Client records regulations, by 8/15/2026. Staff participation in this training will be kept in staff training files.
The Clinical Director will ensure case consultations are completed every 30 days for all clients. Case consultations are to be presented and signed by multi-disciplinary team members during weekly Clinical Team Meeting.
The Clinical Director will review the completion of case consultations with counselors during weekly supervision. The Clinical Director will review individual client charts with counselors during supervision to ensure case consultations are thoroughly completed and filed appropriately. Clinical Director will document on counselors' supervision note any missing and/or incomplete case consultations. If any missing and/or incomplete case consults are identified, individual therapist will have 24 hours from time of supervision to complete.
Clinical Director will report to Program Director during supervision status of completed case consultations as well as any missing and/or incomplete case consults.
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709.83(a)(6) LICENSURE Client records
709.83. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of aftercare plans when applicable, in two of four applicable client records reviewed.
Client #13 was admitted on September 4, 2025 and was discharged on October 22, 2025. There was no aftercare plan documented in the record at the time of the inspection.
Client #14 was admitted on December 29, 2025 and was discharged on March 3, 2026. There was no aftercare plan documented in the record at the time of the inspection.
This is a repeat citation from the June 24, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by Program Director on the requirements of 709.83 (a)(6) LICENSURE Client records regulations, by 8/15/2026. Staff participation in this training will be kept in staff training files.
The Clinical Director will review Aftercare plans completion at the time of discharge and will consult clinical staff daily about aftercare plan completions.
The Clinical Director will review aftercare plans completion at weekly Clinical Team Meeting and confer with staff about aftercare completions during that meeting.
The Clinical Director will review aftercare completion with counselors during weekly individual supervision and document on counselor's supervision notes.
Clinical Director will report aftercare completions to Program Director during weekly supervision.
During bi-annual client file reviews, PHMC Compliance Department will monitor if aftercare plans are completed in a timely manner and placed in client file. The Compliance Department will report findings to Program Manager for internal Plan of Correction.
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709.83(a)(11) LICENSURE Client records
709.83. 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 maintain a complete client record, which is to include the documentation of follow-up information, in three of four applicable client records reviewed.
Client #11 was admitted on December 30, 2025 and was discharged on March 16, 2026. There was no follow-up information documented in the record at the time of the inspection.
Client #12 was admitted on November 17, 2025 and was discharged on February 2, 2026. There was no follow-up information documented in the record at the time of the inspection.
Client #13 was admitted on September 4, 2025 and was discharged on October 22, 2025. There was no follow-up information documented in the record at the time of the inspection.
This is a repeat citation from the June 27, 2023, June 25, 2024 and June 24, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor staff and peer specialist will be trained by the Clinical Director on the requirements of follow up 709.83(a)(11) in Client Records by 8/31/2026.
The Clinical Director will review Client Discharges at every (e.g. weekly) Clinical Team Meeting using discharge reports from the Pathways to Recovery Client Registry Service (CRS) Electronic Health Record and will consult with counselor staff and peer specialist about individual follow-up with those discharges at that meeting.
The Clinical Director will report follow-up information completion to the Project Director during regular (e.g. monthly) Supervision meetings.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that follow-up information is completed in a timely manner according to 709.83(a)(11), with documentation presented in the official follow up client record. The Compliance Department will report any findings to the Clinical Director and Program Director of Addiction Services for internal Plan of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/31/2026
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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 document an individual treatment and rehabilitation plan, which is to be developed with the client and/or completed according to facility policy and procedure in five of seven client records reviewed.
The facility's policy and procedure manual stated that the individual treatment and rehabilitation plan will be completed within 3 days of admission.
Client # 1 was admitted on May 11, 2026 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed by the counselor on May 11, 2026; however, the treatment plan was not signed by the client as of the date of the inspection.
Client # 2 was admitted on May 11, 2026 and was active at the time of inspection. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
Client # 3 was admitted on April 20, 2026 and was active at the time of inspection. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
Client # 4 was admitted on April 29, 2026 and was active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed no later than May 2, 2026; however, the treatment plan was completed on May 13, 2026.
Client # 7 was admitted on May 8, 2026 and was active at the time of inspection. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical director will provide retraining for all clinical staff on DDAP regulation 709.92(a) emphasizing the requirement that treatment plans be developed collaboratively with the client and contain individual treatment planning in accordance with Pathways policy to have plans completed within 3 days of admission. A checklist will be implemented to verify completeness of plan for outpatient clients.
The Clinical Director will conduct reviews of plans a clinical treatment team meeting weekly.
PHMC compliance will conduct quarterly audits of at least 10% of active client records to ensure compliance with 709.92(a). Audit findings will be reviewed during clinical supervision, and any identified deficiencies will be corrected immediately with additional staff education as needed. Ongoing quarterly quality compliance reviews will continue after the initial monitoring period for corrective action. To be completed as of 8/31/2026. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to ensure there were short and long-term goals for treatment, formulated by both the staff and the client, documented on the individual treatment and rehabilitation plan in three of four applicable client records reviewed.
Client # 1 was admitted on May 11, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 11, 2026; however, the plan did not include individualized short and long-term goals for treatment.
Client # 5 was admitted on May 22, 2026 and was still active at the time of inspection. The individual treatment and rehabilitation plan was completed on May 22, 2026; however, the plan did not include individualized short and long-term goals for treatment.
Client # 6 was admitted on May 12, 2026 and was still active at the time of inspection. The individual treatment and rehabilitation plan was completed on May 12, 2026; however, the plan did not include individualized short and long-term goals for treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical director will retrain All clinical staff on DDAP regulation 709.92(a)(1), emphasizing the requirement that treatment plans be developed collaboratively with the client and counselor identifying both individualized short- and long-term goals for treatment in accordance with facility policy.
The Clinical director will review plans in weekly clinical treatment team meetings to ensure the individualized short -and long -term goals have been identified.
PHMC compliance will conduct quarterly audits of at least 10% of active client records to ensure compliance with Code 709.92(a)(1). Audit findings will be reported to Program director and reviewed during clinical supervision, and any identified deficiencies will be corrected immediately with additional staff education as needed. Ongoing quarterly quality compliance reviews will continue after the initial monitoring period ending 8/31/26 |
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 counseling services were provided to the client according to the individual treatment and rehabilitation plan in two of four applicable client records reviewed.
Client # 4 was admitted on April 30, 2026 and was active at the time of the inspection. The individual treatment plan dated May 13, 2026 indicated the client was to receive two individual counseling sessions per week. There was no documentation in the record indicating individual counseling services were provided to the client from April 29, 2026 to the date of the inspection.
Client # 6 was admitted on May 12, 2026 and was active at the time of the inspection. The individual treatment plan dated May 12, 2026 indicated the client was to receive 2 individual counseling sessions per week. There was no documentation in the record indicating individual counseling services were provided to the client during the weeks of May 12, 2026 through May 26, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by Program Director on the requirements of 709.92 (c) Treatment and rehabilitation services, by 8/15/2026. Staff participation in this training will be kept in staff training files.
On a weekly basis, The Clinical Director will conduct reviews of individual counseling services provided to clients according to 709.82 (c) utilizing the Pathways To Recovery Registry Service (CRS) Electronic Health Record.
The Clinical Director will review counseling services completion status at weekly Clinical Team Meeting as well as clinical staff supervisions to ensure clients are receiving individual counseling services according to appropriate level of care.
The Clinical Director will report to Program Manager during supervision compliance with counseling services frequency rate.
PHMC Compliance Department will monitor that counseling services are completed in accordance with Outpatient Treatment regulations.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include the documentation of case consultation notes, in three of three applicable client records reviewed.
The facility's policy and procedure manual stated that case consultation notes will be completed every 30 days.
Client # 3 was admitted on April 20, 2026 and was still active at the time of inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 4 was admitted on April 29, 2026 and was active at the time of inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 7 was admitted on May 8, 2026 and was active at the time of inspection. There were no case consultation notes documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will be trained by Clinical Director on the requirements of 709.93 (a)(8) licensure Client records regulations, by 8/31/2026.
The Clinical Director will collaborate with counselors to ensure case consultations are completed every 30 days for all clients. Case consultations are to be presented and signed by multi-disciplinary team members during weekly Clinical Team Meeting.
The Clinical Director will review the completion of case consultations with counselors during weekly supervision. The Clinical Director will review individual client charts with counselors during supervision to ensure case consultations are thoroughly completed and filed appropriately. Clinical Director will confirm and ensure completion of case consult documentation during counselors' supervision.
Clinical Director will report to Program Director during supervision status of completed case consultations as well as any missing and/or incomplete case consults. |
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.
Plans of correction for failing to ensure the completion of treatment plan updates within the regulatory timeframe were submitted and approved by the Department for the July 14, 2022, June 27, 2023, June 25, 2024 , and June 24, 2025 annual licensing inspections. Failing to complete treatment plan updates within the regulatory timeframe was again found to be a deficiency in the June 10, 2026 licensing inspection.
Plans of correction for failing to ensure individual counseling services were provided to partial hospitalization clients at least twice a week were submitted and approved by the Department for the July 14, 2022, June 27, 2023, June 25, 2024, and June 24, 2025 annual licensing inspections. Failing to provide individual counseling services at least twice a week to partial hospitalization clients was again found to be a deficiency in the June 10, 2026 licensing inspection.
Plans of correction for failing to ensure counseling services were being provided according to the individual treatment and rehabilitation plan were submitted and approved by the Department for the June 27, 2023, June 25, 2024, and June 24, 2025 annual licensing inspections. Failing to ensure counseling services were being provided according to the individual treatment and rehabilitation plan was again found to be a deficiency in the June 10, 2026 licensing inspection.
Plans of correction for failing to complete follow-up information were submitted and approved by the Department for the June 27, 2023, June 25, 2024, and June 24, 2025 annual licensing inspections. Failing to complete follow up information was again found to be a deficiency in the June 10, 2026 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors responsible for implementing Department approved plans of correction will be trained by Program Director of the requirements of 709.17 by 8/15/26. Staff participation in this training will be kept in staff training files.
Staff responsible for implementing the Department approved plans of correction will report plans implementation status to their supervisors during regular (e.g. monthly) Supervision meetings. Compliance with meeting plans of correction implementation will be documented in individual staff supervision notes.
Supervisors will report plans of correction implementation status to the Project Director during regular supervisions (monthly). Documentation of meetings with documented in individual staff supervision notes.
The Project Director will report plan correction implementation status to the Managing Director of Mental Health Services division. Documentation of these meetings will be documented in supervision notes.
During the regular (bi-annual) client file reviews, The Compliance Department monitor the plans of correction approved by the Department are implemented according to 709.17. The compliance department will report any findings to the Project Director for internal plan of correction.
The Project Director and Managing Director of Mental will report to PHMC's board of directors the plan of correction progress on a monthly basis. |