INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 14, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CHMH Services PA LLC DBA Charlie Health was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #5 was hired on December 7, 2024 as a counselor and was still in the position as of the date of the inspection. The training was completed on January 9, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Compliance Managers met with the Compliance Operations Associate on 5/28/25 to develop a corrective action to address this finding. For corrective action, an enhancement has been implemented in the Clinical Training system to ensure timely completion of Emergency Preparedness & Fire Safety training. Effective May 28, 2025, due dates within the system have been adjusted so that this training must now be completed within seven days of an employee's start date.
Staff will receive notifications through automated alerts from Charlie Health's Clinical Training system. Compliance will be verified by confirming the training completion date on each employee's transcript. The Learning and Development team is responsible for implementing and maintaining these corrective actions and ensuring ongoing compliance.
These changes are now live and intended to support staff readiness and organizational safety compliance.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies.
Employee #5 was hired on December 7, 2024 as a counselor and was still in the position as of the date of the inspection. The training was completed on January 9, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Compliance Managers met with the Compliance Operations Associate on 5/28/25 to develop a corrective action to address this finding. For corrective action, an enhancement has been implemented in the Clinical Training system to ensure timely completion of Emergency Preparedness & Fire Safety training. Effective May 28, 2025, due dates within the system have been adjusted so that this training must now be completed within seven days of an employee's start date.
Staff will receive notifications through automated alerts from Charlie Health's Clinical Training system. Compliance will be verified by confirming the training completion date on each employee's transcript. The Learning and Development team is responsible for implementing and maintaining these corrective actions and ensuring ongoing compliance.
These changes are now live and intended to support staff readiness and organizational safety compliance.
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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 May, 2024 through April, 2025 fire drill logs, the facility failed to document the number of persons in the facility at the time of the drill. The June 13, 2024 drill documented " 0 " participants, the November 5, 2024 drill documented " -1 " participants and the April 9, 2025 drill documented " 0 " participants.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Following a review of the Fire Drill Logs dated June 13, 2024, November 5, 2024, and April 9, 2025, it was identified that the formula used in the Number of Participants section in the online form contained errors that affected the accuracy of participant tracking.
As of May 30, 2025, the formula has been corrected and thoroughly tested to ensure accurate participant counts are generated upon completion of each Fire Drill Log. The Compliance Manager is responsible for completing the Fire Drill Logs and achieving compliance.
To support ongoing compliance, a quality review check will now be conducted by the Compliance Manager prior to each log submission. Additionally, the designated Leadership Team will be responsible for conducting fire drills, while the Compliance Manager will oversee the quality review process. All reviews will be documented in the internal compliance tracking system and monitored for a period of 6 months to ensure corrective actions are implemented and sustained.
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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.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in six out of seven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred. Additinally, a consent to release information to a family member occured in one out of seven records reviewed.
Client #1 was admitted on February 6, 2025 and discharged on May 6, 2025. No release of information for funding source.
Client #2 was admitted on January 21, 2025 and was still active at the time of the inspection. No release of information for funding source.
Client #3 was admitted on January 15, 2025 and discharged on May 10, 2025. A consent to release information form was signed on March 31, 2025. Facility staff confirmed billing had occurred prior to this date.
Client #4 was admitted on February 14, 2025 and discharged on May 10, 2025. No release of information for funding source.
Client #5 was admitted on December 5, 2024 and discharged on March 31, 2025. No release of information for funding source.
Client #7 was admitted on February 1, 2025 and discharged on March 5, 2025. No release of information for funding source. Additionally, no release of information for a family member who received correspondence regarding a client.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the April 24, 2024 licensing inspection.
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Plan of Correction
Compliance Managers met with the Director of Health Information Management and Health Information Manager on 5/30/25 to determine corrective action for the finding. The corrective action plan identified will consist of a manual, daily review of an existing report that reflects clients who are missing Releases of Information (ROI). This review will be conducted by the Release of Information Team. For any clients who have outstanding funding source ROIs, a direct, weekly follow-up will be implemented in addition to the automatic system reminders that are already in place, to request that the client sign the ROI. This direct touchpoint between client and Charlie Health staff will increase client response to the request. The Director of Health Information confirmed that the Standard Operating Procedure for the ROI follow-up process will be updated to reflect the corrective action plan above and the ROI Team will receive training regarding the updated process.
The Director of Health Information is responsible for implementation of this corrective action and the monitoring of the plan.
In addition to the process described above, the Director of Health Information reported that a more permanent, automated process to address this finding should be underway soon. With this automated process, any client missing the ROI for the funding source would automatically trigger a flag for the billing team that no contact with the funding source should occur until the signed ROI is obtained. This would ensure that no billing occurs without a completed ROI.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in three out of seven records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed by the fifth session. Additionally, the facility failed to ensure that the treatment plan was developed with the client in four out of seven records reviewed.
Client #1 was admitted on February 6, 2025 and discharged on May 6, 2025. The treatment plan was completed on February 19, 2025 without the client.
Client #3 was admitted on January 15, 2025 and discharged on May 10, 2025. The treatment plan was completed on February 24, 2025, past the fifth session.
Client #4 was admitted on February 14, 2025 and discharged on May 10, 2025. The treatment plan was completed on March 20, 2025 without the client and past the fifth session.
Client #5 was admitted on December 5, 2024 and discharged on March 31, 2025. The treatment plan was completed on February 10, 2025, past the fifth session.
Client #6 was admitted on December 5, 2024 and discharged on March 3, 2025. The treatment plan was completed on December 17, 2024 without the client.
Client #7 was admitted on February 1, 2025 and discharged on March 5, 2025. The treatment plan was completed on February 12, 2025 without the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Charlie Health acknowledges the importance of timely and collaborative treatment planning and has taken immediate steps to ensure compliance with both internal policies and regulatory standards.
Implementation of Clinical Dashboard (Effective 05/19/2025):
As of May 19, 2025, Clinical Supervisors now have access to a real-time Clinical Review Dashboard. This dashboard provides proactive alerts for upcoming and overdue clinical documentation tasks, including treatment plan due dates and review timelines. This tool allows Clinical Supervisors to regularly monitor completion status and initiate timely check-ins with the clinical team to ensure treatment plans are completed by the fifth session, as outlined in our policy.
Enhanced Primary Therapist Workflow: Charlie Health has updated the Primary Therapist's workflow to include a step for verifying whether the client has signed the treatment plan. If the treatment plan is not yet signed, therapists are instructed to review and obtain the client's signature at the beginning of the next scheduled session. This ensures client participation and compliance with treatment planning requirements.
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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 document treatment plan updates within the guidelines established by the facility's policy and procedure manual in three out of six applicable records reviewed. The facility's policy and procedures manual states the treatment plan updates must be completed every 30 days.
Client #1 was admitted on February 6, 2025 and discharged on May 6, 2025. A treatment plan update was completed on March 14, 2025 and an update was due no later than April 13, 2025; however, it was not completed until April 18, 2025.
Client #2 was admitted on January 21, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on January 29, 2025 and an update was due no later than February 28, 2025; however, it was not completed until March 10, 2025. Additionally, the next update was due no later than April 9, 2025; however, it was not completed until April 22, 2025.
Client #3 was admitted on January 15, 2025 and discharged on May 10, 2025. A comprehensive treatment plan was completed on February 24, 2025 and an update was due no later than March 26, 2025; however, it was not completed until April 3, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Charlie Health is committed to ensuring that treatment plans are reviewed and updated in accordance with best clinical practices and internal policies that support comprehensive, individualized care.
Policy Review and Revision:
Following an internal policy review, Charlie Health has revised its Treatment Plan Update Policy. Effective 06/04/2025, treatment plan updates will now be required every 90 days instead of every 30 days. This change is based on a clinical determination that a 90-day interval allows for more meaningful review of client progress, clearer goal adjustments, enhanced documentation quality, and allows time for clinical staff to meet internal guidelines.
Monitoring and Compliance: Compliance with the new 90-day treatment plan review schedule will be monitored for a period of 6 months, with results reported to Clinical Leadership. Any staff not in compliance will be re-educated and, if necessary, subject to corrective action to ensure full adherence going forward.
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709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of seven records reviewed. The facility's policy and procedures manual states that case consultations must be completed weekly. No case consultations were documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Charlie Health is committed to upholding clinical excellence by ensuring all PA SUD clients are regularly reviewed through structured case consultations, in alignment with our internal policies and regulatory expectations.
To address the identified deficiency, the following corrective actions have been implemented:
EMR-Integrated Workflow for Case Consultations
A recurring task is now embedded within the Electronic Medical Record (EMR) system, triggering a case consultation alert monthly for each PA SUD client.
This alert prompts the assigned Clinical Supervisor to complete a Case Consultation and the Case Consultation Smart Form embedded within our EMR, which captures the following required elements related to the Case Consultation:
-PA-SUD enrollment indicator
-Primary Therapist and Clinical Supervisor identifiers
-Key discussion (Consultation) points
-Action items and follow-up task
Policy and SOP Development
A formal Case Consultation Policy and a Standard Operating Procedure (SOP) have been developed to define clear expectations, frequency requirements, documentation standards, and accountability measures for staff.
These documents will guide consistent practice across all clinical teams and will be reviewed annually for updates.
Monitoring and Quality Assurance
A compliance dashboard has been created within the EMR to monitor consultation completion and flag overdue items.
The Clinical Quality Analyst will review dashboard data monthly and include consultation compliance in their regular audit reports submitted to leadership
Staff Training
The Clinical Operations Team will conduct mandatory training for all Clinical Supervisors and Primary Therapists serving PA SUD clients. Training will cover:
-The new EMR workflow
-Use of the Case Consultation Smart Form
-Adherence to the new SOP and policy
Implementation Timeline
Impacted staff will receive training on the associated policy and SOP updates and the case consultation workflow will be active as of July 21, 2025. The Clinical Director is responsible for implementation and monitoring of this corrective action.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in one out of two applicable records reviewed. The facility's policy and procedures manual stated that the follow up must be completed 30 days following discharge.
Client #6 was admitted on December 5, 2024 and discharged on February 27, 2025. A follow up was due no later than March 29, 2025; however, none was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Managers met with the Research Manager on 5/28/25 to determine appropriate corrective action to address the finding. A recent update to the Aftercare and Continuity of Care Policy was fully finalized and published on 5/19/25. The update revises the timeframes for follow-up. The new timeframes for follow-up are: at discharge and 3, 6, 9, and 12 months post discharge. The Research Manager confirmed that the Research Team is currently conducting follow-ups based on the updated policy language.
The Research Manager also confirmed the process for conducting follow-ups. When the team conducts the follow-up at discharge, attempts are made to connect with the client on the day of discharge. If these attempts are unsuccessful, regular attempts are made to follow-up for 45 days before they cease and the next follow-up is conducted at 3 months. At the 3, 6, 9, and 12 month follow-ups, attempts are made by the research team for 30 days.
In addition to the policy and process outlined above, the discharge follow-ups will be added to the internal audit process owned by the Regulatory Compliance team. The Research Manager is collaborating with the Engineering Team to create a report that will reflect all follow-up attempts and follow-up completion by client name. This will enable the Regulatory Compliance team to audit the compliance with the follow-up requirements based on Charlie Health policy. This will be built and implemented by June 30, 2025. The Research Manager is responsible for implementing the corrective action and ensuring ongoing compliance.
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