INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 20, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, STR Addiction Counseling, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of seven records reviewed. There was no consent to release information form for the funding source. Facility staff confirmed billing had occurred.
Client #1 was admitted on January 29, 2026, and discharged on May 28, 2026.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Client #1 was discharged at the time of inspection.
Program Manager and Executive Director retrained staff on the completion and documentation of required areas of a release of information. The training took place on 8/27/26 and 8/28/26.
Moving forward, Executive Director will perform weekly random chart audits to ensrue compliance. |
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.
|
Observations
Based on a review of outpatient client records, the facility failed to provide a complete client record, which is to include follow-up information in five out of six applicable records reviewed. The facility's policy and procedures manual states follow-up shall occur 30 days after discharge.
Client #1 was admitted on January 29, 2026 and discharged on May 28, 2026.
Client #2 was admitted on February 9, 2026 and discharged on April 9, 2026.
Client #3 was admitted on March 24, 2026 and discharged on June 5, 2026.
Client #6 was admitted on April 28, 2026 and discharged on July 14, 2026.
Client #7 was admitted on April 23, 2026 and discharged on June 6, 2026.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the September 23, 2025 licensing inspection.
|
Plan of Correction
Client #1, 2, 3, 6, and 7 were followed up with on 8/28/26.
Program Manager retrained staff on the policy and required documentation for follow up calls on 8/27/26.
Moving forward, Executive Director will audit all discharged clients on a weekly basis to ensure required follow up calls were completed on time. |