INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 8-9, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mountain Edge Recovery Center 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to have clinical supervisors participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position in one of one applicable record reviewed.
Employee #2 was hired September 5, 2023 as counselor and was promoted to Clinical supervisor on February 1, 2025, and was current in that position during time of licensing process. However, there were no supervision meetings documented in the personnel record for the months of March 2025, April 2025, or May 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Immediate Corrective Action(s) for Clients/Staff Affected:
o On 11/12/2025, the Director of Clinical Services (DCS) conducted a retrospective supervisory meeting with Employee #2, specifically addressing the missing months (March, April, and May 2025). The discussions focused on performance, duties, and any areas requiring support or development during that period. This meeting was thoroughly documented and placed in Employee #2's personnel file.
o A comprehensive audit of all current clinical supervisors' personnel files was initiated on 11/12/2025 to identify any other instances of missing monthly supervisory meeting documentation for their first six months of employment. Any identified gaps will be addressed through retrospective meetings conducted by 11/26/2025, with full documentation.
2. Systemic Corrective Action(s) to Prevent Recurrence:
o Policy & Procedure Revision: The facility's Human Resources (HR) and Clinical Supervision policies and procedures will be revised by 12/10/2025. The updated policy will mandate a checklist for all new clinical supervisors, ensuring that monthly supervisory meetings for their initial six months are scheduled, conducted, and meticulously documented. This checklist will be a mandatory component of the personnel file.
o Mandatory Staff Training: All clinical supervisors and their direct supervisors will undergo mandatory training by 12/20/2025. This training will explicitly cover the regulatory requirement for documented monthly supervision during the initial six months of a clinical supervisor's tenure and detail the proper documentation procedures.
o Automated Tracking System: HR will implement a calendar-based tracking system by 12/31/2025 to send automated reminders to supervisors and clinical
staff regarding upcoming and due supervisory meetings, with particular emphasis on those staff members within their first six months in a supervisory role.
3. Monitoring and Auditing to Ensure Ongoing Compliance:
o The HR Director, in collaboration with the DCS, will conduct monthly audits of all new clinical supervisors' personnel files for a minimum of 12 months post-promotion/hire to confirm adherence to the supervision documentation policy.
o Audit results will be compiled quarterly and reviewed by the Executive Director and during the facility's Quality Improvement (QI) meetings. Any identified discrepancies will trigger immediate corrective action and targeted re-training.
4. Responsible Party(ies): HR Director, Director of Clinical Services.
5. Target Completion Date: 01/31/2026. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on review of administrative documents, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
The facility was unable to provide documentation of an annual financial audit for the year 2023 during the licensing process.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Immediate Corrective Action(s) for Clients Affected:
o While this deficiency does not directly impact client care, the facility immediately initiated contact with three independent certified public accounting (CPA) firms on 11/12/2025 to solicit proposals for the 2023 annual financial audit.
2. Systemic Corrective Action(s) to Prevent Recurrence:
o CPA Engagement: Mountain Edge Recovery Center, LLC will formally engage a qualified independent CPA firm by 11/26/2025 to conduct the annual financial audit for the calendar year 2023. The audit will be completed, and the audit report presented to the Executive Director, by 01/31/2026.
o Policy & Procedure Update: The facility's financial policies and procedures will be updated by 12/10/2025 to clearly outline the annual timeline and responsibilities for engaging a CPA and completing the annual financial audit, ensuring compliance with generally accepted accounting principles.
o Annual Audit Schedule: An annual schedule for initiating and completing financial audits will be established by 12/15/2025. The Executive Director and Financial Manager will be jointly responsible for initiating the process by specific dates each year (e.g., Q4 of the preceding year for the next year's audit).
3. Monitoring and Auditing to Ensure Ongoing Compliance:
o The Executive Director will ensure that the annual financial audit process is initiated by October 1st of each year for the preceding calendar year.
o Proof of engagement and completion of the annual audit will be reviewed by the Board of Directors during their first quarterly meeting of the subsequent year.
o The Financial Manager will maintain a comprehensive and easily accessible file of all audit engagement letters, reports, and related documentation.
4. Responsible Party(ies): Executive Director, Financial Manager, Board of Directors.
5. Target Completion Date: 03/31/2026 (including Board review for 2023 audit). |
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 facility 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 records reviewed.
Client #3 was admitted to the partial hospitalization level of care on March 31, 2025 and discharged on June 30, 2025. The informed and voluntary consent form for a family member was signed and dated March 31, 2025; however, there was no purpose of disclosure indicated on form.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from October 9, 2024 licensing inspection.
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Plan of Correction
1. Immediate Corrective Action(s) for Clients Affected:
o For Client #3, whose record was cited, if the client is still active or the disclosure is ongoing, the consent form was immediately reviewed with the client on 11/12/2025 to ensure the purpose of disclosure is clearly understood and explicitly documented. A new, fully compliant consent form was completed if necessary.
o A comprehensive audit of all active client records (as of 10/08/2025) was initiated on 11/12/2025 and will be completed by 11/26/2025 to verify that all "Consent for Disclosure of Information" forms include a clearly stated purpose of disclosure. Any forms found deficient will be immediately rectified with the respective client(s).
2. Systemic Corrective Action(s) to Prevent Recurrence:
o Form Revision: The facility's "Consent for Disclosure of Information" form will be revised by 12/10/2025. The updated form will incorporate a dedicated, prominent section specifically requiring the explicit written statement of the "Purpose of Disclosure" and a mandatory field for staff to initial upon completion to confirm this section has been fully addressed.
o Policy Update: The client record policy will be updated by 12/10/2025 to explicitly outline the requirement for detailed documentation of the purpose of disclosure on all consent forms, providing examples for clarity.
o Mandatory Staff Training: All clinical and administrative staff involved in obtaining client consent will undergo mandatory re-training by 12/20/2025 on the revised consent form and the critical importance of documenting the "Purpose of Disclosure" in accordance with 709.28(c)(3). The training will include practical scenarios and a knowledge assessment.
3. Monitoring and Auditing to Ensure Ongoing Compliance:
o The Clinical Director or a trained designee will conduct a weekly audit of 20% of all newly admitted client records and 10% of existing client records where new consent forms are executed. This audit will specifically review "Consent for Disclosure of Information" forms for complete and accurate documentation of the purpose of disclosure.
o Audit findings will be compiled monthly and reviewed during supervisory meetings and quarterly QI meetings. Persistent non-compliance will result in targeted re-training and potential performance management.
4. Responsible Party(ies): Clinical Director, Admissions Coordinator, Clinical Staff.
5. Target Completion Date: 01/31/2026. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the dated signature of the client in two of seven client records reviewed.
Client #2 was admitted to the partial hospitalization level of care on November 21, 2024 and was discharged on January 1, 2025. The informed and voluntary consent form for the funder was dated November 20, 2024, and did not include the client ' s signature.
Client #4 was admitted to the partial hospitalization level of care on May 9, 2025 and was discharged on August 7, 2025. The informed and voluntary consent form for the funder was dated May 7, 2025, and did not include the client ' s signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Immediate Corrective Action(s) for Clients Affected:
o For Clients #2 and #4 (both discharged), their records were reviewed to acknowledge the deficiency. The systemic changes below will prevent recurrence.
o A comprehensive audit of all active client records (as of 10/08/2025) was initiated on 11/12/2025 and will be completed by 11/26/2025 to verify that all "Consent for Disclosure of Information" forms include a clearly dated client signature. Any forms found deficient will be immediately rectified with the respective client(s).
2. Systemic Corrective Action(s) to Prevent Recurrence:
o Form Revision: The facility's "Consent for Disclosure of Information" form will be revised by 12/10/2025 to clearly highlight the "Client/Guardian Signature" and "Date" fields as mandatory completion fields. A "Staff Witness Signature" and "Date" field will also be added to verify the client's signature and date, emphasizing their importance.
o Policy Update: The client record policy will be updated by 12/10/2025 to explicitly state the requirement for a client's dated signature on all consent for disclosure forms and the staff's responsibility to verify and witness this signature and date.
o Mandatory Staff Training: All clinical and administrative staff involved in obtaining client consent will undergo mandatory re-training by 12/20/2025 on the revised consent form and the absolute necessity of obtaining the client's dated signature. This training will include practical exercises on verifying signatures and dates and the implications of missing information.
3. Monitoring and Auditing to Ensure Ongoing Compliance:
o The Clinical Director or a trained designee will conduct a weekly audit of 20% of all newly admitted client records and 10% of existing client records where new consent forms are executed. This audit will specifically review "Consent for Disclosure of Information" forms for the presence and accuracy of the client's dated signature.
o Audit findings will be compiled monthly and reviewed during supervisory meetings and quarterly QI meetings. Persistent non-compliance will result in targeted re-training and potential performance management.
4. Responsible Party(ies): Clinical Director, Admissions Coordinator, Clinical Staff.
5. Target Completion Date: 01/31/2026. |
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 facility failed to offer a copy of release of information forms for the funding source in seven of seven records reviewed.
Client #1 was admitted to the partial hospitalization level of care on May 15, 2025 and was discharged on July 26, 2025. The informed and voluntary consent form for the funder was signed and dated May 15, 2025; however, there was no documentation that a copy was offered
Client #2 was admitted to the partial hospitalization level of care on November 21, 2024 and was discharged on January 1, 2025. The informed and voluntary consent form for the funder was dated November 20, 2024; however, there was no documentation that a copy was offered.
Client #3 was admitted to the partial hospitalization level of care on March 31, 2025 and discharged on June 30, 2025. The informed and voluntary consent form for the funder was signed and dated March 31, 2025; however, there was no documentation that a copy was offered.
Client #4 was admitted to the partial hospitalization level of care on May 9, 2025 and was discharged on August 7, 2025. The informed and voluntary consent form for the funder was dated May 7, 2025; however, there was no documentation that a copy was offered.
Client #5 was admitted to the partial hospitalization level of care on July 17, 2025 and was active at time of licensing process. The informed and voluntary consent form for the funder was signed and dated July 17, 2025; however, there was no documentation that a copy was offered.
Client #6 was admitted to the partial hospitalization level of care on July 15, 2025 and was active at time of licensing process. The informed and voluntary consent form for the funder was signed and dated July 15, 2025; however, there was no documentation that a copy was offered.
Client #7 was admitted to the partial hospitalization level of care on July 9, 2025 and was active at time of licensing process. The informed and voluntary consent form for the funder was signed and dated July 9, 2025; however, there was no documentation that a copy was offered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Immediate Corrective Action(s) for Clients Affected:
o For all active clients (#5, #6, #7), a copy of their current "Consent for Disclosure of Information" for the funding source was immediately offered on 11/12/2025, and their receipt of the copy was documented in their chart.
o For previously discharged clients (#1, #2, #3, #4), a review of their records confirmed the deficiency. This information will inform systemic changes to prevent recurrence for future clients.
o A comprehensive audit of all active client records (as of 10/08/2025) will be completed by 11/26/2025 to ensure documentation of offering a copy of allconsent forms for disclosure to the client. Any discrepancies will be immediately rectified with active clients.
2. Systemic Corrective Action(s) to Prevent Recurrence:
o Form Revision: The facility's "Consent for Disclosure of Information" form will be revised by 12/10/2025 to include a mandatory "Client Acknowledgement of Receipt" signature line and date field for the client to confirm they received a copy. An accompanying "Staff Verification" initial field will also be added.
o Policy Update: The client record policy will be updated by 12/10/2025 to explicitly require that a copy of every signed consent for disclosure form is offered to the client and that this offer and receipt (or refusal) is documented in the client's record. This documentation will be a mandatory step in the consent process.
o Mandatory Staff Training: All clinical and administrative staff involved in obtaining client consent will undergo mandatory re-training by 12/20/2025 on the revised consent form and the explicit requirement to offer and document the offering of a copy of all signed consent forms to the client.
3. Monitoring and Auditing to Ensure Ongoing Compliance:
o The Admissions Coordinator, under the supervision of the Clinical Director, will conduct a weekly audit of 20% of all newly admitted client records. This audit will specifically review "Consent for Disclosure of Information" forms for documentation of offering a copy to the client and client acknowledgement of receipt.
o Audit findings will be compiled monthly and reviewed during supervisory meetings and quarterly QI meetings. Immediate corrective action and re-training will be implemented for any identified non-compliance.
4. Responsible Party(ies): Clinical Director, Admissions Coordinator, Clinical Staff.
5. Target Completion Date: 01/31/2026. |
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 the review of client records, the facility failed to provide counseling on regular and scheduled basis to include individual counseling, at least twice weekly in three out of seven records reviewed.
Client #1 was admitted to the partial hospitalization level of care on May 15, 2025 and was discharged on July 26, 2025. The facility only documented one individual counseling session for the weeks of May 19, 2025 through May 23, 2025, May 26, 2025 through May 30, 2025, June 2, 2025 through June 6, 2025, June 9,2025 through June 13, 2025, June 16, 2025 through June 20, 2025, and July 7, 2025 through July 11, 2025.
Client #6 was admitted to the partial hospitalization level of care on July 15, 2025 and was active at time of the licensing inspection. The facility only documented one individual counseling session for the weeks of September 15, 2025 through September 19, 2025, and September 29, 2025 through October 3, 2025. There was no documentation of individual sessions for the week of September 22, 2025 through September 26, 2025.
Client #7 was admitted to the partial hospitalization level of care on July 9, 2025 and was active at time of the licensing inspection. There was no documentation of individual sessions for the week of September 29, 2025 through October 3, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from October 9, 2024 licensing inspection.
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Plan of Correction
1. Immediate Corrective Action(s) for Clients Affected:
o For active clients #6 and #7, their current treatment plans and counseling schedules were immediately reviewed on 11/12/2025. Additional individual counseling sessions have been scheduled to meet the twice-weekly requirement, and make-up sessions for any identified missed periods are being provided where clinically appropriate and feasible. Documentation of these sessions is being meticulously entered into the EHR.
o A comprehensive review of the individual counseling schedules and documentation for all active clients (as of 10/08/2025) was initiated on 11/12/2025 and will be completed by 11/26/2025. Any clients identified as not receiving twice-weekly individual counseling will have their schedules immediately adjusted, and make-up sessions arranged as clinically appropriate.
o For Client #1 (discharged), the record deficiency has been noted and will inform systemic improvements.
2. Systemic Corrective Action(s) to Prevent Recurrence:
o Policy & Procedure Revision: The facility's "Treatment and Rehabilitation Services" Policy and Procedure will be revised by 12/10/2025 to clearly emphasize the mandatory twice-weekly individual counseling requirement for all clients and outline robust scheduling, cancellation management, and documentation protocols.
o Caseload Assessment & Adjustment: The Clinical Director will conduct a thorough review of all clinical staff caseloads by 11/30/2025 to ensure they are manageable and consistently allow for the delivery of twice-weekly individual counseling sessions per client. Caseload adjustments and/or staffing increases will be implemented as necessary.
o Scheduling System Enhancement: The Electronic Health Record (EHR) or an auxiliary tracking tool will be configured/implemented by 12/31/2025 to automatically flag and alert the assigned counselor and their supervisor if a client has not received their mandated twice-weekly individual counseling sessions within a given week.
o Mandatory Staff Training & Supervision: All clinical staff will receive mandatory re-training by 12/20/2025 on the regulatory requirement for twice-weekly individual counseling and the critical importance of accurate, timely, and
complete documentation within the EHR. Clinical supervisors will reinforce this requirement during weekly individual and group supervision sessions.
3. Monitoring and Auditing to Ensure Ongoing Compliance:
o The Clinical Director or designee will conduct a weekly audit of 25% of active client records, specifically checking for documented evidence of twice-weekly individual counseling sessions.
o The scheduling system's (or tracking tool's) compliance reports will be reviewed daily by the Clinical Director to identify any clients falling below the mandated frequency, triggering immediate follow-up with the assigned counselor.
o Audit results and compliance rates will be presented monthly at staff meetings and quarterly at QI meetings to track progress and ensure sustained compliance.
4. Responsible Party(ies): Clinical Director, Clinical Supervisors, all Clinical Staff.
5. Target Completion Date: 01/31/2026. |
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 have a complete client record on an individual which includes information relative to the client's involvement with the project, including follow-up information within 7 days and 30 days, per facility policy, in two out of four applicable records reviewed.
Client #1 was admitted to the partial hospitalization level of care on May 15, 2025 and was discharged on July 26, 2025. There was no follow-up information documented in the record.
Client #2 was admitted to the partial hospitalization level of care on November 21, 2024 and was discharged on January 1, 2025. There was no follow-up information documented in the record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Immediate Corrective Action(s) for Clients Affected:
o While Clients #1 and #2 are discharged, their records were reviewed to identify the specific gaps in follow-up documentation. This information has been utilized to inform and refine our systemic approach.
o For all currently active clients nearing discharge or recently discharged (as of 10/08/2025), the Clinical Director ensures that all required 7-day and 30-day follow-up information, as per facility policy, is obtained and meticulously documented. This review will be completed by 11/26/2025.
2. Systemic Corrective Action(s) to Prevent Recurrence:
o Policy & Procedure Revision: The facility's "Client Records Policy and Procedure," specifically related to discharge planning and follow-up, will be comprehensively revised by 12/10/2025. This revision will clearly define the specific types of follow-up information required, the methods for collection (e.g., phone calls, surveys), the mandatory timelines (7-day and 30-day post-discharge), and the designated staff responsibilities for each stage.
o Dedicated Follow-up Process & Coordinator: A dedicated staff member (e.g., Lead Case Manager) or a clearly defined and assigned process will be established by 12/20/2025 to manage all client follow-up activities, including scheduling calls, sending reminders, and ensuring accurate documentation of outcomes in the EHR.
o EHR System Enhancement: The EHR system will be configured by 12/31/2025 to include mandatory fields and automated alerts/tasks for 7-day and 30-day
follow-up documentation post-discharge. This will ensure that staff are prompted and required to complete |