INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 05, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Christian Counseling Associates of Western Pennsylvania 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
|
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling rooms.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Director will ensure that camera is removed from the group counseling room by 1/15/26. Director will meet with the Counselor to review the importance of privacy. The Counselor will ensure that a camera is not installed again after the current camera is removed. Director will add this item to our Counselor Supervision meeting agenda. Camera will be unplugged and screen covered with tape until it is removed. |
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 an informed and voluntary consent from the client for the disclosure of information contained in the client record in seven out of seven records reviewed. Client #1 was admitted on December 12, 2024, and was discharged on October 08, 2025. There was documentation that information was disclosed to another organization; however, there was no documentation of an informed and voluntary consent from the client for the disclosure of information. Client #2 was admitted on March 24, 2025, and was discharged on November 09, 2025. There was documentation that information was disclosed to another organization and the funder; however, the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information. Client #3 was admitted on January 31, 2025, and was discharged on May 10, 2025. There was documentation that information was disclosed to another organization; however, the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information. Client #4 was admitted on January 23, 2025, and was discharged on May 29, 2025. There was documentation that information was disclosed to another organization; however, the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information. Client #5 was admitted on January 10, 2025, and still active at the time of the inspection. There was documentation that information was disclosed to another organization and the; however, the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information. Client #6 was admitted on February 11, 2025, and was discharged on April 11, 2025. There was documentation that information was disclosed to another; however, the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information. Client #7 was admitted on July 09, 2025, and discharged on October 08, 2025. There was documentation that information was disclosed to another organization while the client was in treatment; however, the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director will meet with the Counselor by 1/15/26 to tell Counselor that all clients must have informed and voluntary consents properly completed and signed by client for this other organization. Director wil demonstrate proper consent completion for Counselor by 1/15/26. Facility will be in compliance by 1/15/26. The Quality Assurance Team will audit charts monthly to ensure these consents are completed. |
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).
|
Observations
Based on a 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. which included the dated signature of the client in one out of seven records reviewed. Client #4 was admitted on January 23, 2025, and discharged on May 29, 2025. An informed and voluntary consent from the client for the disclosure of information contained in the client record dated January 23, 2025, for an outside organization, did not include the dated signature of the client. The facility confirmed disclosure had occurred. This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Director will meet with the Counselor by 1/15/26 to remind Counselor of the necessity of the client's dated signature on all consent forms. Facility will be in compliance by 1/15/26. The Quality Assurance team will audit charts monthly to ensure proper adherence to this policy. |
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.
|
Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in six out of seven client records reviewed. Client #1 was admitted on December 12, 2024, and discharged on October 08, 2025. A consent form signed and dated December 12, 2024, for a charity organization, did not have documentation that the client was offered a copy of the consent form.Client #2 was admitted on March 24, 2025, and discharged on November 09, 2025. A consent form signed and dated March 24, 2025, for a charity organization, did not have documentation that the client was offered a copy of the consent form.Client #4 was admitted on January 23, 2025, and discharged on May 29, 2025. A consent form signed and dated January 23, 2025, for a charity organization, did not have documentation that the client was offered a copy of the consent form.Client #5 was admitted on January 10, 2025, and was still active at the time of the inspection. A consent form signed and dated January 10, 2025, for a charity organization, did not have documentation that the client was offered a copy of the consent form.Client #6 was admitted on February 11, 2025, and discharged April 11, 2025. A consent form signed and dated February 11, 2025, for a charity organization, did not have documentation that the client was offered a copy of the consent form.Client #7 was admitted on July 09, 2025, and discharged on October 08, 2025. A consent form signed and dated July 09, 2025, for a charity organization, did not have documentation that the client was offered a copy of the consent form.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director will meet with the Counselor by 1/15/26 regarding the necessity of documenting that copies of consent forms were offered to clients. Facility will be in compliance by 1/15/26. The Quality Assurance Team will audit charts to ensure this policy is being followed. Active client will have an updated and corrected consent form by 1/15/26. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
Based on a review of client records, the facility failed to include documentation of all required client rights including, clients receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment in six out of seven client records reviewed.Client #1 was admitted on December 12, 2024 and discharged on October 08, 2025. There was no documentation that the client was informed of all of their rights, to include no clients may be deprived of a civil rights solely by reason of treatment. Client #2 was admitted on March 24, 2025 and discharged November 09, 2025. There was no documentation that the client was informed of all of their rights, to include no clients may be deprived of a civil rights solely by reason of treatment. Client #3 was admitted on January 31, 2025, and discharged on May 10, 2025. There was no documentation that the client was informed of all of their rights, to include no clients may be deprived of a civil rights solely by reason of treatment. Client #4 was admitted on January 23, 2025, and discharged on May 29, 2025. There was no documentation that the client was informed of all of their rights, to include no clients may be deprived of a civil rights solely by reason of treatment. Client #5 was admitted on January 10, 2025, and was still active at the time of the inspection. There was no documentation that the client was informed of all of their rights, to include no clients may be deprived of a civil rights solely by reason of treatment. Client #6 was admitted on February 11, 2025, and discharged on April 11, 2025. There was no documentation that the client was informed of all of their rights, to include no clients may be deprived of a civil rights solely by reason of treatment. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director will ensure that all clients will be informed of their civil rights. Facility will be in compliance by 1/15/26. The current active client will have his client rights documented by 1/15/26. Facility will be in compliance by 1/15/26. The Quality Assurance Team will audit charts monthly to confirm policy is being followed. Director will add reviewing Intake forms to our Supervision meeting agenda to ensure this deficiency does not recur and Quality Assurance Team will look for the client rights form (Client Agreement Form) in audits. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on a review of client records, the facility failed to notify clients that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in six out of seven records reviewed.Client #1 was admitted on December 12, 2024 and discharged on October 08, 2025. There was no documentation that the client was notified that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. Client #2 was admitted on March 24, 2025 and discharged November 09, 2025. There was no documentation that the client was notified that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. Client #3 was admitted on January 31, 2025, and discharged on May 10, 2025. There was no documentation that the client was notified that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. Client #4 was admitted on January 23, 2025, and discharged on May 29, 2025. There was no documentation that the client was notified that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. Client #5 was admitted on January 10, 2025, and was still active at the time of the inspection. There was no documentation that the client was notified that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. Client #6 was admitted on February 11, 2025, and discharged on April 11, 2025. There was no documentation that the client was notified that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director will meet with the Counselor by 1/15/26 to ensure that the Counselor is completing the Client Agreement for Counseling form during Intake. This form contains the non-discrimination clause. The Quality Assurance Team will audit charts monthly to confirm this policy is followed. Facility will be in compliance by 1/15/26. This particular client has already been notified of their rights via their completion of the Client Agreement Form. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
|
Observations
Based on a review of client records, the facility failed to inform the clients that they have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record in six out of seven records.Client #1 was admitted on December 12, 2024 and discharged on October 08, 2025. There was no documentation that the client was informed that they have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record in six out of seven records.Client #2 was admitted on March 24, 2025 and discharged November 09, 2025. There was no documentation that the client was informed that they have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record in six out of seven records.Client #3 was admitted on January 31, 2025, and discharged on May 10, 2025. There was no documentation that the client was informed that they have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record in six out of seven records.Client #4 was admitted on January 23, 2025, and discharged on May 29, 2025. There was no documentation that the client was informed that they have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record in six out of seven records.Client #5 was admitted on January 10, 2025, and was still active at the time of the inspection. There was no documentation that the client was informed that they have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record in six out of seven records.Client #6 was admitted on February 11, 2025, and discharged on April 11, 2025. There was no documentation that the client was informed that they have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record in six out of seven records.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director will meet with Counselor by 1/15/26 to ensure Counselor is completing the Client Agreement for Counseling form. This form contains the right-to-inspect records clause. Facility will be in compliance by 1/15/26. The Quality Assurance Team will audit charts monthly for policy adherence. Current client chart will be updated with this right by 1/15/26. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
|
Observations
Based on a review of client records, the facility failed to inform the client that they have the right to appeal a decision limiting access to their records to the director in six out of seven records.Client #1 was admitted on December 12, 2024 and discharged on October 08, 2025. There was no documentation that the client was informed they have the right to appeal a decision limiting access to their records to the director. Client #2 was admitted on March 24, 2025 and discharged November 09, 2025. There was no documentation that the client was informed they have the right to appeal a decision limiting access to their records to the director. Client #3 was admitted on January 31, 2025, and discharged on May 10, 2025. There was no documentation that the client was informed they have the right to appeal a decision limiting access to their records to the director. Client #4 was admitted on January 23, 2025, and discharged on May 29, 2025. There was no documentation that the client was informed they have the right to appeal a decision limiting access to their records to the director. Client #5 was admitted on January 10, 2025, and was still active at the time of the inspection. There was no documentation that the client was informed they have the right to appeal a decision limiting access to their records to the director. Client #6 was admitted on February 11, 2025, and discharged on April 11, 2025. There was no documentation that the client was informed they have the right to appeal a decision limiting access to their records to the director. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director will meet with the Counselor by 1/15/26 regarding the necessity of having the Client Agreeement for Counseling form present in all charts. This form contains the right-to-appeal clause. Facility will be in compliance by 1/15/26. Current active client's chart will be in compliance by 1/15/26. Quality Assurance Team will audit charts to ensure compliance. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
|
Observations
Based on a review of client records, the facility failed to inform the client of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in six out of seven records.Client #1 was admitted on December 12, 2024 and discharged on October 08, 2025. There was no documentation that the client was informed they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record.Client #2 was admitted on March 24, 2025 and discharged November 09, 2025. There was no documentation that the client was informed they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record. Client #3 was admitted on January 31, 2025, and discharged on May 10, 2025. There was no documentation that the client was informed they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record.Client #4 was admitted on January 23, 2025, and discharged on May 29, 2025. There was no documentation that the client was informed they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record.Client #5 was admitted on January 10, 2025, and was still active at the time of the inspection. There was no documentation that the client was informed they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record.Client #6 was admitted on February 11, 2025, and discharged on April 11, 2025. There was no documentation that the client was informed they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director will meet with the Counselor to ensure the Client Agreement Form (which contains the correction-request clause) is being completed during the first session. The active client has already completed a Client Agreement Form. Facility will be in compliance by 1/15/26. The Quality Assurance Team will audit charts monthly to ensure the Client Agreement Form is present in the charts. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
|
Observations
Based on a review of client records, the facility failed to inform the client they have the right to submit rebuttal data or memoranda to their own records in six out of seven records reviewed.Client #1 was admitted on December 12, 2024 and discharged on October 08, 2025. There was no documentation that the client was informed that they have the right to submit rebuttal data or memoranda to their own record. Client #2 was admitted on March 24, 2025 and discharged November 09, 2025. There was no documentation that the client was informed that they have the right to submit rebuttal data or memoranda to their own record. Client #3 was admitted on January 31, 2025, and discharged on May 10, 2025. There was no documentation that the client was informed that they have the right to submit rebuttal data or memoranda to their own record. Client #4 was admitted on January 23, 2025, and discharged on May 29, 2025. There was no documentation that the client was informed that they have the right to submit rebuttal data or memoranda to their own record. Client #5 was admitted on January 10, 2025, and was still active at the time of the inspection. There was no documentation that the client was informed that they have the right to submit rebuttal data or memoranda to their own record.Client #6 was admitted on February 11, 2025, and discharged on April 11, 2025. There was no documentation that the client was informed that they have the right to submit rebuttal data or memoranda to their own record. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director will meet with the Counselor by 1/15/26 to review this policy. The Client Agreement Form contains this right. Facility will be in compliance by 1/15/26. Active client has already completed the Client Agreement Form, which contains this right. Quality Assurance Team will audit charts monthly for adherence to this policy. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
Based on a review of client records, the facility failed to include documentation of the client ' s medical history in three out of seven records reviewed. Client #1 was admitted on December 12, 2024, and discharged on October 08, 2025. There was no documentation of the client ' s medical history. Client #4 was admitted on January 23, 2025, and discharged on May 29, 2025. There was no documentation of the client ' s medical history. Client #7 was admitted on July 09, 2025, and discharged on October 08, 2025. There was no documentation of the client ' s medical history. This finding were reviewed with facility staff during the licensing process.
|
Plan of Correction
Director will meet with the Counselor by 1/15/26 to ensure the necessity of fully completing the Personal History Form, which contains medical history. Facility will be in compliance by 1/15/26. To ensure medical history is documented in all future charts, the Quality Assurance Team will audit charts. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Based on a review of client records, the facility failed to include documentation of a drug or alcohol history in three out of seven records reviewed. Client #1 was admitted on December 12, 2024, and discharged on October 08, 2025. There was no documentation of the client's drug or alcohol history. Client #4 was admitted on January 23, 2025, and discharged on May 29, 2025. There was no documentation of the client's drug or alcohol history. Client #7 was admitted on July 09, 2025, and discharged on October 08, 2025. There was no documentation of the client's drug or alcohol history. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Director will meet with the Counselor by 1/15/26 to ensure full completion of the entire Personal History Form, which contains drug and alcohol history. Facility will be in compliance by 1/15/26. The Quality Assurance Team will audit charts to prevent failure to maintain this policy. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on a review of client records, the facility failed to include documentation of a personal history of the client in three out of seven records reviewed. Client #1 was admitted on December 12, 2024, and discharged on October 08, 2025. There was no documentation of the client's personal history. Client #4 was admitted on January 23, 2025, and discharged on May 29, 2025. There was no documentation of the client's personal history. Client #7 was admitted on July 09, 2025, and discharged on October 08, 2025. There was no documentation during the client's personal history.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Director will meet with Counselor by 1/15/26 to review our policy on timely and correct completion of Personal History Forms. Facility will be in compliance by 1/15/26. Director will add Personal History to Supervision Agenda to audit and prevent future violations and Quality Assurance Team will audit charts monthly. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in three out of seven records reviewed.Client #1 was admitted on December 12, 2024 and discharged October 25, 2025. The client record did not contain a psychosocial evaluation. Client #4 was admitted on January 23, 2025 and discharged on May 29, 2025. The client record did not contain a psychosocial evaluation.Client #7 was admitted on July 09, 2025 and discharged on October 08, 2025. The client record did not contain a psychosocial evaluation.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Director will meet with Counselor by 1/15/26 to ensure Counselor knows how to properly complete our psychosocial evaluation. Facility will be in compliance by 1/15/26. Quality Assurance Team will audit charts monthly to ensure psychosocial evaluations are being 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:
|
Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines, by the third individual counseling session, per facility policy in five out of seven client records reviewed. Client #1 was admitted on December 12, 2024 and discharged on October 08, 2025. Client #1 ' s third session was on January 7, 2025; however, there was no documentation that a treatment and rehabilitation plan was completed. Client #2 was admitted on March 24, 2025 and discharged on November 09, 2025. Client #2 ' s third session was on April 08, 2025; however, there was no documentation that a treatment and rehabilitation plan was completed. Client #4 was admitted on January 23, 2025, and discharged on May 29, 2025. Client #4 ' s third session was on March 11, 2025; however, the treatment and rehabilitation plan was not completed until March 20, 2025. Client #5 was admitted on January 10, 2025, and still active at the time of the inspection. Client #5 ' s third session was on February 03, 2025; however, the treatment and rehabilitation plan was not completed until February 13, 2025. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Director will meet with Counselor by 1/15/26 to enforce treatment plan timeliness policy. Facility will be in compliance by 1/15/26. A treatment plan has been added for the current client. Quality Assurance Team will audit charts for treatment plan timeliness to prevent recurance. |
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.
|
Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of three applicable records reviewed.Client #1 was admitted on December 12, 2024 and discharged on October 08, 2025. There was no documentation that any treatment plan updates were completed. Client #2 was admitted on March 24, 2025, and discharged on November 09, 2025. There was no documentation that any treatment plan updates were completed. Client #5 was admitted on January 10, 2025, and still active at the time of the inspection. A treatment plan was completed on February 13, 2025, and an update was due no later than April 13, 2025; however, it was not documented until June 16, 2025. Additionally, the next update was due no later than August 16, 2025; however, it was not documented until October 10, 2025.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Director will meet with Counselor by 1/15/26 to ensure Counselor understands that treatment plans need updated every 60 days. Facility will be in compliance by 1/15/26. The Quality Assurance Team will audit charts monthly to ensure policy adherence. Also, Director will review treatment plan updates during future Supervision meetings. A treatment plan update has been added for the current active client. |
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.
|
Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes within 14 days of admission, change in level of care, and discharge, per the facility's policy, in seven out of seven records reviewed. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Director will meet with the Counselor by 1/15/26 to ensure the Counselor understands our case consultation policy. Facility will be in compliance by 1/15/26. Case consultations will be added to Individual Supervision agenda. Quality Assurance Team will audit charts to mitigate against recurance. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, and the facility policies and procedures, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, prior to discharge, per facility policy, in six out of six applicable records reviewed. Client #1 was admitted on December 12, 2024, and discharged on October 08, 2025. There was no documentation of an aftercare plan being completed prior to discharge. Client #2 was admitted on March 24, 2025, and discharged on November 09, 2025. There was no documentation of an aftercare plan being completed prior to discharge. Client #3 was admitted on January 31, 2025, and discharged on May 10, 2025. There was no documentation of an aftercare plan being completed prior to discharge. Client #4 was admitted on January 23, 2025, and discharged on May 29, 2025. There was no documentation of an aftercare plan being completed prior to discharge. Client #6 was admitted on February 11, 2025, and discharged on April 11, 2025. There was no documentation of an aftercare plan being completed prior to discharge.Client #7 was admitted on July 09, 2025, and discharged on October 08, 2025. There was no documentation of an aftercare plan being completed prior to discharge. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Director will meet with Counselor by 1/15/26 to ensure Counselor knows our Aftercare Plan policy. Facility will be in compliance by 1/15/26. Quality Assurance Team will audit charts monthly to preven recurance. |
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.
|
Observations
Based on a review of client records, the facility failed to document a discharge summary within 30 days of the last session attended, per facility policy, in six out of six applicable records reviewed. Client #1 was admitted on December 12, 2024 and was discharged on October 8, 2025. Client #1 last attended on September 08, 2025. A discharge summary was due no later than October 08, 2025; however, none was completed. Client #2 was admitted on March 24, 2025, and was discharged on November 9, 2025. Client #2 last attended on October 09, 2025. A discharge summary was due no later than November 09, 2025; however, none was completed. Client #3 was admitted on January 31, 2025 and discharged on May 10, 2025. Client #3 last attended on April 10, 2025. A discharge summary was due no later than May 10, 2025; however, none was completed.Client #4 was admitted on January 23, 2025 and discharged on May 29, 2025. Client #4 last attended on April 29, 2025. A discharge summary was due no later than May 29, 2025; however, none was completed.Client #6 was admitted on February 11, 2025 and discharged on April 11, 2025. Client #5 last attended on March 11, 2025. A discharge summary was due no later than April 11, 2025; however, none was completed. Client #7 was admitted on July 09, 2025 and discharged on October 8, 2025. Client #7 last attended on September 08, 2025. A discharge summary was due no later than October 08, 2025; however, none was completed. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Director will meet with Counselor by 1/15/26 to ensure Counselor understands our Discharge Summary policy. Facility will be in compliance by 1/15/26. Quality Assurance Team will audit charts monthly to prevent recurance. |