INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 22, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Men & Women For Human Excellence, Inc. 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure an annual written individual training plan was completed for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor in one of five personnel records reviewed.
Employee #1 was hired as the project director on November 1, 2001. There was no documentation of an individual training plan in the personnel record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Men and Women for Human Excellence (MWFHE) acknowledges the finding regarding the absence of a documented Individual Training Plan in Employee #1's personnel file. Although Employee #1 has participated in ongoing required training throughout employment, the individualized training plan had not been formally documented in the personnel record.
Effective immediately, the following corrective actions have been implemented:
An Individual Training Plan has been developed, completed, and placed in Employee #1's personnel file.
Human Resources has conducted a comprehensive audit of all personnel files to ensure that every employee has a current Individual Training Plan documented.
A standardized Individual Training Plan template has been implemented for all new hires and existing employees.
Human Resources will review personnel files quarterly to verify that Individual Training Plans remain current and are updated annually or as job responsibilities change.
Supervisors will review each employee's training needs during annual performance evaluations and whenever regulatory, licensing, or organizational requirements change.
Person Responsible:
Human Resources/Director
Completion Date: June 30, 2026
Corrected immediately upon identification. Ongoing monitoring will occur quarterly to ensure continued compliance.
Monitoring:
The Director and Human Resources Department will conduct quarterly personnel file audits and maintain documentation demonstrating compliance with training plan requirements. Any deficiencies identified during the audits will be corrected within five (5) business days. |
704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on a review of personnel records, the facility failed to ensure at least one-half of all the regulatory required training was provided by trainers not directly employed by the project, unless the project employs staff persons specifically to provide training for its organization and staff, in four of five personnel records reviewed.
Employee #2 was hired as the facility director on June 13, 2018. All the previous training year ' s training certificates provided indicated all of the trainings were completed internally and were not provided by staff persons specifically employed to provide training for its organization and staff.
Employee #3 was hired as a lead counselor on April 2, 2018. All the previous training year ' s training certificates provided indicated all of the trainings were completed internally and were not provided by staff persons specifically employed to provide training for its organization and staff.
Employee #4 was hired as a counselor on July 5, 2022. All the previous training year ' s training certificates provided indicated all of the trainings were completed internally and were not provided by staff persons specifically employed to provide training for its organization and staff.
Employee #5 was hired as a clinical supervisor on August 3, 2020. All the previous training year ' s training certificates provided indicated all of the trainings were completed internally and were not provided by staff persons specifically employed to provide training for its organization and staff.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Men and Women for Human Excellence (MWFHE) acknowledges the finding and has taken immediate corrective action to ensure compliance with regulatory training requirements.
Corrective Actions Implemented
A comprehensive review of all employee training records was conducted to identify the percentage of training completed through external trainers.
The four affected employees have complete the required training hours through qualified external training providers however, their training certificate was not available during the inspection. Documentation of course completion and certificates will be maintained and place in each employee's personnel file during upcoming inspection.
MWFHE has established partnerships with approved external training organizations including BTEN, CBH, and DADP to provide regulatory and continuing education training that meets state licensing requirements.
The agency current Staff Training Policy require that at least fifty percent (50%) of all required annual regulatory training be completed through trainers or organizations not directly employed by MWFHE, unless the agency employs staff whose designated responsibility is organizational staff training in accordance with applicable regulations.
A Training Compliance Tracking Log has been implemented to monitor:
Total annual training hours required.
Internal versus external training hours.
Training completion dates.
Certificates of completion.
Annual compliance status for each employee.
Human Resources and the Training Coordinator will review employee training records quarterly to ensure compliance before annual training deadlines.
Person(s) Responsible
Director
Human Resources Director
Training Coordinator
Completion Date
The affected employees will continue to complete the required external annual training and their external training certificate will be available during upcoming DDAP inspections. Ongoing monitoring will occur quarterly thereafter.
Monitoring
The Human Resources/Director will conduct quarterly personnel file audits to verify:
At least 50% of required annual training will be completed through qualified external trainers.
Documentation of all training will be maintained in personnel files.
Any identified deficiencies are corrected within ten (10) business days.
Results of the audits will be reviewed by the Director as part of the agency's Quality Improvement Program to ensure ongoing compliance with licensing regulations. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure all facility heaters were permanently mounted or installed.
At the time of the inspection, on the first-floor administration area, there was a space heater found in room #1 and another space heater found in room #8.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Men and Women for Human Excellence (MWFHE) acknowledges the finding regarding the use of a heater that was not permanently mounted or installed.
Corrective Actions Implemented
Immediately upon identification of the deficiency, the portable or improperly installed heater was removed from service and taken out of the area.
The agency inspected all heating equipment throughout the facility to verify compliance with applicable health, safety, fire, and licensing regulations.
Any replacement heating equipment installed will be permanently mounted or professionally installed in accordance with the manufacturer's specifications, local building codes, fire safety requirements, and applicable licensing regulations.
The agency's Facility Safety and Maintenance Policy has been updated to prohibit the use of portable or non-permanently installed heaters in any program area unless specifically permitted by applicable regulations and approved by facility management.
Maintenance personnel have been instructed to inspect all heating equipment during monthly environmental and safety inspections. Inspection findings will be documented and any deficiencies corrected immediately.
All supervisory staff have been educated on environmental safety requirements, including ensuring that heating equipment remains compliant with licensing and fire safety standards.
Person(s) Responsible
Director
Facilities/Maintenance Manager
Completion Date: 7/30/2026
The deficiency was corrected immediately upon identification during the inspection. Policy revisions and staff education will be completed within 60 days of the inspection.
Monitoring
The Facilities/Maintenance Manager will complete and document monthly facility safety inspections to verify that all heating equipment remains permanently mounted or properly installed and compliant with licensing and fire safety requirements. The Director will review inspection reports quarterly as part of the agency's Quality Improvement Program. Any deficiencies identified will be corrected within one (1) business day.
This Plan of Correction is appropriate for submission to licensing authorities and demonstrates immediate correction, preventive measures, assignment of responsibility, and ongoing monitoring to maintain compliance. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure all stairways, hallways, and exits from the nonresidential facility were unobstructed.
At the time of the inspection, in the group room area, there were two exits from the facility that led to an outside walkway in the back and a side street. Both exits were only able to be unlocked and opened with a key. The key was not kept near the entryways, thus causing both exits to be unable to be opened by any individual during emergencies.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Men and Women for Human Excellence (MWFHE) acknowledges the deficiency and recognizes the importance of maintaining unobstructed and immediately accessible emergency exits to ensure the safety of clients, staff, and visitors.
Corrective Actions will be Implemented
Immediately following the inspection, both exit doors will be modified so they can be opened from the inside without the use of a key, in accordance with applicable life safety and licensing requirements.
The facility conducted a complete inspection of all emergency exits to verify that each exit provides immediate egress and remains free of obstructions at all times.
If additional hardware is needed and code-approved exit devices will be installed by qualified maintenance personnel.
The Facility Safety Policy will be revised to prohibit locking or securing emergency exits in any manner that requires a key, tool, or special knowledge to exit the building during an emergency.
All staff will continue to received annual training on emergency evacuation procedures, including verifying that emergency exits remain accessible and functional throughout operating hours.
Emergency evacuation procedures and exit routes have been reviewed with staff and will continue to be reviewed during orientation, annual training, and scheduled fire and emergency drills.
Person(s) Responsible
Director
Facilities/Maintenance Manager
Safety Officer (or Designee)
Completion Date: 10/30/2026
The exit doors will be brought into compliance following the inspection. Staff training and policy updates will be completed within 90 days of the inspection.
Monitoring
The Facilities/Maintenance Manager will conduct and document monthly safety inspections to verify that:
All emergency exits remain unobstructed.
Exit doors can be opened immediately from the inside without the use of a key, tool, or special knowledge.
Exit hardware remains in proper working order.
The Director will review the monthly inspection reports quarterly as part of the agency's Quality Improvement Program. Any deficiencies identified will be corrected immediately upon discovery. |
705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on a physical plant inspection, the facility failed to clearly indicate exits by the use of signs.
At the time of the inspection, the facility's second-floor secondary exit did not have a posted exit sign indicating which direction the secondary/emergency exit was located.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Men and Women for Human Excellence (MWFHE) acknowledges the deficiency regarding emergency exit signage and recognizes the importance of clearly marked exit routes to ensure the safe evacuation of clients, staff, and visitors during an emergency.
Corrective Actions Implemented
Immediately following the inspection, an approved directional EXIT sign will be installed installed to clearly identify the location of the second-floor secondary/emergency exit.
A comprehensive inspection of the entire facility was completed to verify that all required exits and exit pathways are clearly marked with appropriate, code-compliant EXIT signs and directional signage.
The agency will updated its Facility Safety and Environmental Inspection Checklist to include verification that all exit signs are properly installed, visible, illuminated (where required), and unobstructed.
Maintenance personnel have been instructed to inspect all exit signage during monthly environmental and life safety inspections and to replace or repair any damaged or missing signs immediately.
Staff will be re-educated on emergency evacuation procedures, including the location of all primary and secondary exits and the importance of reporting missing or damaged exit signage promptly.
Person(s) Responsible
Director
Facilities/Maintenance Manager
Completion Date 9/30/2026
The required exit sign will be installed immediately following the inspection. Staff education and revisions to the facility inspection checklist will be completed within 60 days of the inspection.
Monitoring
The Facilities/Maintenance Manager will conduct and document monthly life safety inspections to verify that:
All required EXIT signs and directional signs remain installed and clearly visible.
Exit signage is illuminated and functioning where required.
Emergency exit routes remain clearly identified and unobstructed.
The Director will review the monthly inspection reports quarterly as part of the agency's Quality Improvement Program. Any deficiencies identified during inspections will be corrected within one (1) business day to ensure ongoing compliance with licensing, fire safety, and life safety requirements. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's May 2025 through May 2026 fire drill logs, the facility failed to maintain a written fire drill record, which is to include the documentation of the exit route used.
At the time of the inspection, the December 22, 2025 fire drill log did not include documentation of which exit route was used during the time of the fire drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Men and Women for Human Excellence (MWFHE) acknowledges the deficiency regarding incomplete (1) fire drill documentation and recognizes the importance of maintaining accurate records to demonstrate compliance with life safety and licensing requirements.
Corrective Actions Implemented
The December 22, 2025 fire drill record was reviewed. Where possible, the exit route used during the drill was verified and documented. If verification was not possible, the record was annotated to reflect that the information could not be confirmed after the fact.
A comprehensive review of all fire drill records for the previous 12 months was completed to ensure all required elements, including the exit route used, date, time, staff participation, evacuation time, and drill evaluation, are documented.
The agency revised its Fire Drill Report form to include a required field identifying the specific exit route used during each fire drill.
The form cannot be considered complete until all required information is documented.
Administrative and supervisory staff responsible for conducting fire drills have been retrained on the regulatory requirements for documenting all required components of each fire drill record.
A standardized Fire Drill Documentation Checklist will be implemented to ensure all required information is completed immediately following each drill.
Person(s) Responsible
Director
Facilities/Maintenance Manager
Safety Officer (or Designee)
Completion Date: 9/30/2026
The revised fire drill documentation process and staff training were completed within 60 days of the inspection.
Monitoring
The Safety Officer (or Designee) will review each fire drill report immediately following completion to verify that all required information has been documented, including the exit route used. In addition, the Director will conduct quarterly reviews of fire drill records as part of the agency's Quality Improvement Program to ensure continued compliance with licensing and life safety requirements.
Any documentation deficiencies identified during the review process will be corrected within one (1) business day and addressed with the responsible staff member. |
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 an administrative review, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
The facility had a financial audit exception, which became voided due to the project's 2022 reported gross earnings. The facility failed to obtain the services of a certified public accountant to complete an annual financial audit for the years 2022, 2023 and 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Men and Women for Human Excellence (MWFHE) acknowledges the deficiency and is committed to ensuring full compliance with all financial audit requirements established by the Pennsylvania Department of Drug and Alcohol Programs and other applicable regulatory authorities.
Corrective Actions Implemented
The CEO and Board of Directors will continue to annually review the organization's gross revenue to determine whether an audit is required however, the CEO and Board reviews annually MWFHE gross revenue and its continue to falls under $500.000. MWFHE have continuously requested from DDAP annuals audit exemptions waiver due to financial circumstances over the 2022, 2023 and 2024 years.
As the organization's financial circumstances and regulatory requirements evolve, the CEO and Board of Directors will evaluate audit obligations annually and authorize the engagement of an independent CPA within 90 days following the close of each fiscal year when an audit is required.
Person(s) Responsible
CEO/Chief Financial Accountant/
Board of Directors
Independent Certified Public Accountant
Completion Date:
As the organization's financial circumstances and regulatory requirements evolve, a CPA engagement will be initiated immediately. The outstanding audits for fiscal years 2022, 2023, and 2024 will also be completed according to the engagement schedule established with the independent CPA. Thereafter, annual audits will be completed each fiscal year as the organization's financial circumstances and regulatory requirements evolve in order to meet accordance with regulatory requirements.
Monitoring
The CEO and Board Treasurer will review the Financial Compliance Calendar quarterly
Documentation of a CPA engagement, audit progress, completed audit reports, and Board review will be maintained once the agency financial circumstances change. Compliance with annual audit requirements will be reviewed as part of the agency's Quality Improvement and Corporate Compliance Programs to prevent recurrence of this deficiency. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, the facility failed to secure hard copy client records within locked storage containers.
During the inspection, the client chart room door was open and there were two filing cabinets used for the storage of client records that were not locked. Additionally, there was an open box of client records located on the floor of the chart room. There were no facility staff observed in the chart room at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Men and Women for Human Excellence (MWFHE) acknowledges the deficiency and is committed to protecting the confidentiality, privacy, and security of all client records in accordance with applicable licensing regulations, HIPAA requirements, and agency policies.
Corrective Actions Implemented
Immediately upon identification of the deficiency, the chart room door was secured, all client record filing cabinets were locked, and the box of client records was removed from the floor and placed in a locked filing cabinet.
A complete review of all client record storage areas was conducted to ensure that all hard copy client records are maintained in locked filing cabinets or other approved locked storage containers when not in active use.
The agency reinforced its Confidentiality and Records Management Policy requiring that:
Client records shall remain secured at all times when not being actively accessed by authorized personnel.
Filing cabinets containing client records shall remain locked whenever staff are not directly retrieving or filing records.
The chart room door shall remain locked when the room is unattended.
Client records shall never be stored in unsecured boxes or left unattended in open areas.
All administrative, clinical, and supervisory staff received retraining on HIPAA confidentiality requirements, records security procedures, and the proper handling and storage of client records.
A daily end-of-business records security checklist will be implemented to verify that:
All client records have been returned to secured storage.
Filing cabinets are locked.
The chart room is secured.
No client information is left unattended in work areas.
Person(s) Responsible
Director
Records Custodian
Clinical Supervisors(or Designee)
Completion Date: 09/30/2026
The deficiency will be corrected. Staff retraining and implementation of the daily records security checklist will be completed within 60 days of the inspection.
Monitoring
The lead counselor (or Designee) will conduct weekly inspections of the client records storage area for the first 90 days, followed by monthly audits thereafter, to verify that all client records are properly secured and that filing cabinets and the chart room remain locked when unattended. Findings will be documented and reviewed by the lead counselor as part of the agency's Quality Improvement and HIPAA Compliance Program. Any deficiencies identified will be corrected immediately and addressed through additional staff education or corrective action as appropriate. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review, the facility failed to develop a data collection system that allows for the efficient retrieval of data needed to measure the project's performance.
The facility was unable to produce a client record in an efficient manner. At the time of the inspection, the DDAP representative requested ten client records, and the facility was able to locate and provide nine of the client records in a timely manner. The facility was unable to locate the tenth requested client record for over two hours.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Men and Women for Human Excellence (MWFHE) acknowledges the deficiency and recognizes the importance of maintaining an organized records management system that allows for the timely retrieval of (1) one client records while ensuring the confidentiality and integrity of protected health information.
Corrective Actions Implemented
The one missing client record was located, reviewed, and returned to its appropriate filing location.
An audit of all active and discharged client records was conducted to ensure records are accurately labeled, filed, and maintained in their designated locations.
The agency has implemented a standardized records management and tracking system that includes:
Consistent file labeling and indexing.
Designated filing locations for all active and discharged client records.
A record check-out/check-in log whenever a paper chart is removed from the chart room.
Procedures to ensure records are returned to their proper location immediately after use.
A written Medical Records Management Policy has been revised to establish standardized procedures for filing, retrieving, tracking, and securing client records to promote timely access while maintaining confidentiality.
Administrative and clinical staff responsible for maintaining client records have been retrained on records management procedures, including proper filing, chart tracking, and timely retrieval expectations.
The agency will continue transitioning appropriate records management functions to its paper health record system to improve record accessibility and reduce the likelihood of misplaced files.
Person(s) Responsible
Lead Counselor
Records Custodian
Clinical Supervisors
Administrative Support Staff
Completion Date: 9/30/2026
The corrective actions, including the records audit, policy revisions, and staff training, will be completed within 60 days of the inspection.
Monitoring
The Lead Counselor/Counselors/Record Custodian will conduct monthly audits of client records to verify that records are accurately filed and can be retrieved promptly. Quarterly mock record retrieval exercises will be conducted to ensure staff can locate requested client records efficiently. Audit findings will be reviewed by the Lead Counselor as part of the agency's Quality Improvement Program. Any deficiencies identified will be corrected immediately, and additional staff training will be provided as necessary. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment plan updates were reviewed and updated at least every sixty days in two of four applicable client records reviewed.
Client #3 was admitted on November 19, 2025 and was active at the time of the inspection. A treatment plan update was completed on April 1, 2026 and the next update was due no later than June 1, 2026; however, the update was not completed at the time of the inspection.
Client #4 was admitted on March 17, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 13, 2026 and the first update was due no later than June 13, 2026; however, the update was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Men and Women for Human Excellence (MWFHE) acknowledges the deficiency and is committed to ensuring that all individual treatment plans are reviewed and updated at least every sixty (60) days in accordance with applicable licensing regulations and agency policy.
Corrective Actions Implemented
The overdue treatment plan updates for Client #3 and Client #4 were completed immediately upon identification of the deficiency, reviewed with each client, and placed in the respective clinical records.
A comprehensive audit of all active client records was conducted to identify any additional overdue treatment plan reviews. Any identified deficiencies were corrected immediately.
The agency implemented a Treatment Plan Tracking System that identifies each client's treatment plan due dates and provides advance reminders to counselors and supervisors at least 15 days before the required review date.
Clinical Supervisors will review treatment plan due dates during weekly clinical supervision meetings to ensure updates are completed within the required sixty (60)-day timeframe.
The manual tracking log has been updated to monitor treatment plan review dates and alert staff of upcoming deadlines.
All clinical staff received retraining on DDAP requirements regarding the timely development, review, and updating of Individual Treatment and Rehabilitation Plans, including documentation standards and supervisory expectations.
Person(s) Responsible
Lead Counselor
Clinical Supervisors
Assigned Primary Counselors
Completion Date: 9/30/2026
The overdue treatment plan updates were completed immediately following identification of the deficiency. The client record audit, implementation of the treatment plan tracking system, and staff retraining will be completed within 60 days of the inspection.
Monitoring
Clinical Supervisors will conduct weekly reviews of treatment plan due dates and monthly audits of active client records to verify compliance with the sixty (60)-day treatment plan review requirement.
Audit results will be reported to the Director through the agency's Quality Improvement Program. Any overdue treatment plans identified during monitoring will be corrected immediately, and the responsible staff member will receive additional supervision and corrective coaching as appropriate. |
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 two of four applicable client records reviewed.
Client #3 was admitted on November 19, 2025 and was active at the time of inspection. There was no documentation in the record indicting case consultation notes were completed at the time of the inspection.
Client #4 was admitted on March 17, 2026 and was active at the time of inspection. There was no documentation in the record indicting case consultation notes were completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Men and Women for Human Excellence (MWFHE) acknowledges the deficiency and is committed to ensuring that all required case consultations are conducted, documented, and maintained in each client's clinical record in accordance with Pennsylvania Department of Drug and Alcohol Programs (DDAP) regulations and agency policy.
Corrective Actions Implemented
The clinical records for Client #3 and Client #4 were immediately reviewed.
Required case consultations were completed and documented, or when a consultation had occurred but had not been documented, the documentation was entered in accordance with agency policy and applicable documentation standards.
A comprehensive audit will be conducted of all active client records to verify that required case consultation notes are present, complete, timely, and properly filed. Any deficiencies identified during the audit will be corrected immediately.
The agency will revised its Clinical Documentation Policy to include clear requirements for documenting case consultations, including:
Date of the consultation.
Participants in the consultation.
Clinical issues discussed.
Recommendations and treatment decisions.
Follow-up actions.
Signature and credentials of the documenting clinician.
The standardized Case Consultation Note template will continue to be implemented within the clinical record to promote consistent and complete documentation.
Clinical staff and supervisors will received retraining on DDAP documentation requirements, emphasizing the timely completion of case consultation notes and the importance of maintaining complete clinical records.
lead counselor/clinical supervisors will review case consultation documentation during routine clinical supervision and before approving client record reviews to ensure compliance.
Person(s) Responsible
Lead Counselor
Clinical Supervisors
Primary Counselors
Completion Date: 9/30/2026
The missing documentation was addressed immediately upon identification. The clinical record audit, policy revisions, implementation of the standardized documentation template, and staff retraining will be completed within 60 days of the inspection.
Monitoring
Lead counselor will conduct monthly audits of a representative sample of active client records to verify that required case consultation notes are completed, timely, and maintained in each client record. Audit results will be reviewed by the director through the agency's Quality Improvement Program. Any documentation deficiencies identified will be corrected promptly, and additional supervision or corrective action will be implemented as appropriate to ensure continued compliance. |