INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Auberle 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of applicable staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in one of five staff records.Staff #7 was hired as a case aide on July 24, 2023 and was still in this position at the time of the inspection. HIV/AIDS and TB/STD trainings were to be completed by July 24, 2025. There was no documentation that the TB/STD training was 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
HIV/AIDS and TB/STD trainings will be added to the agency's Paycom training management system. Paycom will generate automatic reminders, alert managers and supervisors as training deadlines approach, and flag incomplete trainings. All new employees hired on or after February 6, 2026, will be enrolled in in-person or virtual TB/STD training within 90 days of hire. Completion of both HIV/AIDS and TB/STD trainings will be reviewed at a minimum during each employee's annual performance evaluation. All current employees who are past due for required training will register for the applicable training no later than February 20, 2026, and will provide proof of enrollment to their supervisor. |
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.
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Observations
Based on applicable client records reviewed, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights in four of seven records.Client #1 was admitted on June 19, 2025 and was still active at the time of the inspection.Client #2 was admitted on November 18, 2025 and was still active at the time of the inspection.Client #4 was admitted on July 11, 2025 and was discharged July 17, 2025.Client #6 was admitted on August 15, 2025 and was discharged November 24, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients receive information regarding their rights through the Client Handbook, which is provided upon admission to the Family Healing Center. Clients are required to complete a written acknowledgment of receipt of their rights within 72 hours of arrival in the electronic health record. This acknowledgment is completed in collaboration with a clinician, a member of the supervisory team, or support staff. All active clients who have not already completed the handbook acknowledgment will do so no later than February 27, 2026. The Client Rights policy will be updated by February 11, 2026, and staff will be informed of this update through a team meeting and follow-up email communication. Compliance will be monitored through ongoing client chart audits to ensure consistent documentation of client rights acknowledgment.
The Clinical Supervisor will conduct weekly chart audits for 60 days to ensure compliance with client rights acknowledgment requirements. After the initial 60-day period, the Program Director will conduct monthly audits for an additional three months. Findings will be reviewed during supervision and corrective action will be implemented immediately if deficiencies are identified. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by a physician in four of six records. Client #1 was admitted on June 19, 2025 and was still active at the time of the inspection.A medication was prescribed to be taken once daily and documented on the medication form to be taken at 8:00am. After a review of the facility medication administration records, there was no documentation of the medication being given on:November 2, 2025; November 3, 2025; November 4, 2025; November 5, 2025; November 7, 2025; November 14, 2025; November 25, 2025; December 9, 2025; December 16, 2025; December 26, 2025; and December 30, 2025. A medication was prescribed to be taken twice daily and documented on the medication form to be taken at 8:00am and 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00am on:November 2, 2025; November 3, 2025; November 4, 2025; November 5, 2025; November 7, 2025; November 14, 2025; November 15, 2025; November 25, 2025; November 27, 2025; December 9, 2025; December 16, 2025; December 26, 2025; and December 30, 2025.After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00pm on:November 3, 2025; November 21, 2025; December 2, 2025; and December 16, 2025.A medication was prescribed to be taken twice daily and documented on the medication form to be taken at 8:00am and 8:00pm. This medication was discontinued on December 12, 2025. After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00am on:November 3, 2025; November 4, 2025; November 5, 2025; November 7, 2025; November 14, 2025; November 15, 2025; November 25, 2025; November 26, 2025; and December 9, 2025. After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00pm on:November 3, 2025; November 21, 2025; and December 2, 2025.A medication was prescribed on December 12, 2025 to be taken three times daily and documented on the medication form to be taken at 8:00am, 4:00pm, and 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00am on:December 16, 2025; December 26, 2025; and December 30, 2025. After a review of the facility medication administration records, there was no documentation of the medication being given at 4:00pm on:December 12, 2025; December 13, 2025; December 14, 2025; December 16, 2025; December 21, 2025; and December 27, 2025.Client #2 was admitted on November 18, 2025 and was still active at the time of the inspection. The client record had MAR sheets uploaded to the electronic health record. A MAR uploaded to the client record did not indicate the month and other client identifying information; however, the MAR was saved as December 2025 and included medication dose history.A medication was prescribed to be taken daily every morning and documented on the medication form to be taken at 8:00am. After a review of the facility medication administration records, there was no documentation of the medication being given on:November 24, 2025; November 25, 2025; November 26, 2025; and November 30, 2025.This medication was listed on the November MAR, however, the following MAR did not continue the medication or document the reason the medication was not carried over.A medication was prescribed to be taken once daily at bedtime and documented on the medication form to be taken at 8:00pm. After a review of the facility medication administration records, there was no documentation of this medication being given on:December 11, 2025; December 12, 2025; and December 18, 2025.A medication was prescribed to be taken once daily every morning and documented on the medication form to be taken at 8:00am. After a review of the facility medication administration records, there was no documentation of the medication being given on:November 24, 2025; November 25, 2025; December 14, 2025; December 15, 2025; and December 16, 2025.The dosage of this medication was updated on December 18, 2025. After a review of the facility medication administration records, there was no documentation of this medication being given on: December 18 through 31, 2025.A medication was prescribed to be taken once daily in the evening and documented on the medication form to be taken at 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given on:November 27, 2025; December 11, 2025; and December 12, 2025.A medication was prescribed to be taken once daily in the evening and documented on the medication form to be taken at 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given on:December 11, 2025; and December 12, 2025.A medication was prescribed to be taken once daily in the evening and documented on the medication form to be taken at 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given on:November 24, 2025; November 26, 2025; December 11, 2025; and December 12, 2025.A medication was prescribed to be taken once daily in the evening and documented on the medication form to be taken at 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given on:November 24, 2025.This medication was documented on the November 2025 MAR; however, the following MAR did not include this medication or the reason it was not continued.A medication was to be taken in the morning, the afternoon, and the evening, and documented on the medication form to be taken at 8:00am, 2:00pm, and 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00am on:November 24, 2025; November 25, 2025; December 3, 2025; December 7, 2025; December 8, 2025; December 11 through 14, 2025; December 22, 2025; December 25 through 28, 2025; December 30, 2025; and December 31, 2025. After a review of the facility medication administration records, there was no documentation of the medication being given at 2:00pm on:November 25, 2025; December 5, 2025; and December 21, 2025.After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00pm on:November 24, 2025; November 25, 2025; December 1, 2025; December 4, 2025; December 5, 2025; December 8, 2025; December 9, 2025; December 12, 2025; December 27, 2025; and December 31, 2025.A medication was prescribed on December 13, 2025 for two weeks. The medication was to be taken once daily for two weeks and documented on the medication form to be taken at 8:00am. After a review of the facility medication administration records, there was no documentation of the medication being given on:December 14, 2025 and December 25, 2025.A medication was prescribed on December 28, 2025 to be taken once daily. The medication documented on the medication form to be taken at 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given on:December 30, 2025 and December 31, 2025.Client #3 was admitted on November 19, 2025 and was still active at the time of the inspection.A medication was prescribed to be taken daily and documented on the medication form to be taken at 8:00am. After a review of the facility medication administration records, there was no documentation of the medication being given on:November 24, 2025; November 25, 2025; November 26, 2025; November 28, 2025; November 29, 2025; December 1 through 20, 2025; December 22 through 24, 2025; and December 26 through 31, 2025.A medication was prescribed to be taken once daily and documented on the medication form to be taken at 8:00am. After a review of the facility medication administration records, there was no documentation of the medication being given on:December 1, 2025 and December 10, 2025.A medication was prescribed to be taken every eight hours and documented on the medication form to be taken at 8:00am and 4:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00am on:November 27 through 30, 2025 and December 1 through 31, 2025. After a review of the facility medication administration records, there was no documentation of the medication being given at 4:00pm on:November 24, 2025; November 27 through 30, 2025; and December 1 through 30, 2025.A medication was prescribed to be taken every eight hours and documented on the medication form to be taken at 8:00am and 4:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00am on:November 27 through 30, 2025 and December 1 through 17, 2025. After a review of the facility medication administration records, there was no documentation of the medication being given at 4:00pm on:November 24, 2025; November 27 through 30, 2025; December 1 through 16, 2025; December 21, 2025; and December 26, 2025.A medication was prescribed to be taken every eight hours and documented on the medication form to be taken at 8:00am and 4:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00am on:December 1, 2025; December 7 - 9, 2025; and December 11 - 31, 2025. After a review of the facility medication administration records, there was no documentation of the medication being given at 4:00pm on:November 25, 2025; November 27, 2025; December 3, 2025; December 4, 2025; and December 6 through 31, 2025.A medication was prescribed to be taken once daily and documented on the medication form to be taken at 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given on:November 24, 2025; November 26, 2025; December 2, 2025; December 4 through 8, 2025; and December 10 through 31, 2025.A medication prescribed on November 22, 2025 was to be taken three times a day and documented on the medication form to be taken at 8:00am, 4:00pm, and 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00am on:December 1, 2025; and December 10 through 17, 2025. After a review of the facility medication administration records, there was no documentation of the medication being given at 4:00pm on:November 24, 2025; November 25, 2025; December 5, 2025; December 8, 2025; and December 10 through 17, 2025.After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00pm on:November 24, 2025; November 26, 2025; December 2, 2025; December 5, 2025; December 8, 2025; and December 10 through 17, 2025.Additionally, this medication was documented on the MAR to be changed to "This is now a PRN," however, there was no date as to when this change occurred. The PRN sheet documents the dates the medication was given, but does not indicate the time of day the medication was given. A medication was listed on the December 2025 medication form for a prescription drop. However, this medication did not include when it was prescribed, the dosage, the frequency, or any documentation of it being provided.Client #7 was admitted on December 18, 2025 and was still active at the time of the inspection.A medication was prescribed to be taken four times a day and documented on the medication form to be taken at 8:00am, 12:00pm, 4:00pm, and 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00am on:December 24, 2025 and December 26, 2025.After a review of the facility medication administration records, there was no documentation of the medication being given at 12:00pm on:December 23, 2025 and December 26, 2025.After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00pm on:December 22, 2025; December 23, 2025; and December 26, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has transitioned to a new pharmacy that will provide pre-filled Medication Administration Records (MARs) beginning - March 2026. To support this change, the facility will implement mandatory training on medication administration documentation for all staff who are state-approved to administer medications. This training is required to ensure accurate and compliant documentation in the MAR and will be held on February 24 and February 26 for all currently medication-trained staff. Beginning March 1, any staff certified in medication administration must complete this documentation training prior to administering medications within the facility. Ongoing compliance will be supported through annual refresher trainings for all medication-authorized staff on documentation standards.
The Facility Director will conduct weekly MAR audits for 60 days following training implementation to ensure medications are documented as prescribed. After the initial 60-day period, monthly MAR audits will be conducted for an additional three months. Audit results will be reviewed in supervision and corrective action will be implemented immediately if deficiencies are identified. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on applicable client records reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one records.Client #4 was admitted on July 11, 2025 and discharged on July 17, 2025. There was no documentation in the client record notifying the client, in writing, of termination from the project.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Involuntary Discharge Policy will be updated by February 9, 2026, to include procedures for providing written notification of a decision to involuntarily terminate services. An involuntary discharge letter template has been developed. The discharge letter will be mailed within 7 days of an involuntary discharge. If the client does not have a mailing address on file, at least one documented attempt will be made within 7 days to obtain a mailing address from the client. If this attempt is unsuccessful, the effort will be documented in the client's chart through a memo-to-chart. The completed discharge letter will be uploaded to the client's document library in the electronic health record.
The Facility Director will review 100% of all involuntary discharges for 90 days to ensure written notification is completed, mailed within 7 days, and uploaded to the electronic health record. Following the initial 90-day period, quarterly audits will be conducted by the Clinical Supervisor for one year. Any deficiencies identified will result in immediate corrective coaching and documentation review with the responsible staff member. |
709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on applicable client records reviewed, the facility failed to ensure that there was documentation of intake procedures that included the disclosure of criteria for admission, treatment, completion, and discharge in four of seven records.Client #1 was admitted on June 19, 2025 and was still active at the time of the inspection.Client #2 was admitted on November 18, 2025 and was still active at the time of the inspection.Client #4 was admitted on July 11, 2025 and was discharged July 17, 2025.Client #6 was admitted on August 15, 2025 and was discharged November 24, 2025.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 22, 2025 and January 18, 2024 annual licensing inspections.
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Plan of Correction
Clients receive information regarding the criteria for admission, treatment, completion, and discharge through the Client Handbook, which is provided at the time of admission to the Family Healing Center. Clients are required to complete a written acknowledgment of receipt of this information within 72 hours of arrival in the electronic health record. This acknowledgment is completed with a clinician, a member of the supervisory team, or support staff. All active clients who have not already completed the handbook acknowledgment will do so no later than February 25, 2026. The relevant policy will be updated by February 11, 2026, and staff will be notified of this update through a team meeting and follow-up email communication. Ongoing compliance will be monitored through routine client chart audits to ensure consistent documentation of disclosure and acknowledgment.
The Clinical Supervisor will conduct weekly chart audits for 60 days to verify that intake documentation includes disclosure of criteria for admission, treatment, completion, and discharge, and that written acknowledgment is completed within 72 hours. Following the initial 60-day period, the Program Director will conduct monthly audits for an additional three months. Audit findings will be reviewed during supervision, and corrective action will be implemented immediately if deficiencies are identified. |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on applicable client records reviewed, the facility failed to ensure that there was documentation of client orientation to the project, which included a familiarization with project policies in four of seven records.Client #1 was admitted on June 19, 2025 and was still active at the time of the inspection.Client #2 was admitted on November 18, 2025 and was still active at the time of the inspection.Client #4 was admitted on July 11, 2025 and was discharged July 17, 2025.Client #6 was admitted on August 15, 2025 and was discharged November 24, 2025.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 22, 2025 annual licensing inspection.
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Plan of Correction
Clients receive information regarding on program policies through the Client Handbook, which is provided upon admission to the Family Healing Center. Clients are required to complete a written acknowledgment of receipt of their rights within 72 hours of arrival in the electronic health record. This acknowledgment is completed in collaboration with a clinician, a member of the supervisory team, or support staff. All active clients who have not already completed the handbook acknowledgment will do so no later than February 25, 2026. The Client Handbook Policy will be updated by February 11, 2026, and staff will be informed of this update through a team meeting and follow-up email communication. Compliance will be monitored through ongoing client chart audits to ensure consistent documentation of client rights acknowledgment.
The Clinical Supervisor will conduct weekly chart audits for 60 days to verify that client orientation includes documentation of familiarization with project policies and written acknowledgment within 72 hours. Following the initial 60-day period, the Program Director will conduct monthly audits for an additional three months. Any deficiencies identified will result in immediate corrective coaching and review with the responsible staff member. |
709.51(b)(2)(ii) LICENSURE Hours of Operation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(ii) Hours of operation.
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Observations
Based on applicable client records reviewed, the facility failed to ensure that there was documentation of client orientation to the project, which included a familiarization with hours of operation in four of seven records.Client #1 was admitted on June 19, 2025 and was still active at the time of the inspection.Client #2 was admitted on November 18, 2025 and was still active at the time of the inspection.Client #4 was admitted on July 11, 2025 and was discharged July 17, 2025.Client #6 was admitted on August 15, 2025 and was discharged November 24, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients receive information regarding the facility hours of Operation through the Client Handbook, which is provided at the time of admission to the Family Healing Center. Clients are required to complete a written acknowledgment of receipt of this information within 72 hours of arrival in the electronic health record. This acknowledgment is completed with a clinician, a member of the supervisory team, or support staff. All active clients who have not already completed the handbook acknowledgment will do so no later than February 25, 2026. The Client Handbook Policy will be updated by February 11, 2026, and staff will be notified of this update through a team meeting and follow-up email communication. Ongoing compliance will be monitored through routine client chart audits to ensure consistent documentation of disclosure and acknowledgment.
The Clinical Supervisor will conduct weekly chart audits for 60 days to verify that documentation of client orientation includes familiarization with facility hours of operation and written acknowledgment within 72 hours of admission. Following the initial 60-day period, the Facility Director will conduct monthly audits for an additional three months. Any deficiencies identified will result in immediate corrective coaching and review with the responsible staff member to ensure compliance. |
709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on applicable client records reviewed, the facility failed to ensure that there was documentation of client orientation to the project, which included a familiarization with the fee schedule in four of seven records.Client #1 was admitted on June 19, 2025 and was still active at the time of the inspection.Client #2 was admitted on November 18, 2025 and was still active at the time of the inspection.Client #4 was admitted on July 11, 2025 and was discharged July 17, 2025.Client #6 was admitted on August 15, 2025 and was discharged November 24, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients receive information regarding the facility fee schedule through the Client Handbook, which is provided at the time of admission to the Family Healing Center. Clients are required to complete a written acknowledgment of receipt of this information within 72 hours of arrival in the electronic health record. This acknowledgment is completed with a clinician, a member of the supervisory team, or support staff. All active clients who have not already completed the handbook acknowledgment will do so no later than February 25, 2026. The Client Handbook Policy will be updated by February 11, 2026, and staff will be notified of this update through a team meeting and follow-up email communication. Ongoing compliance will be monitored through routine client chart audits to ensure consistent documentation of disclosure and acknowledgment.
The Clinical Supervisor will conduct weekly chart audits for 60 days to verify documentation that clients were oriented to the facility fee schedule and that written acknowledgment was completed within 72 hours of admission. Following the initial 60-day period, the Facility Director will conduct monthly audits for an additional three months. Any deficiencies identified will result in immediate corrective coaching and documentation review with the responsible staff member to ensure compliance. |
709.51(b)(2)(iv) LICENSURE Services Provided
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iv) Services provided.
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Observations
Based on applicable client records reviewed, the facility failed to ensure that there was documentation of client orientation to the project, which included a familiarization with services provided in four of seven records.Client #1 was admitted on June 19, 2025 and was still active at the time of the inspection.Client #2 was admitted on November 18, 2025 and was still active at the time of the inspection.Client #4 was admitted on July 11, 2025 and was discharged July 17, 2025.Client #6 was admitted on August 15, 2025 and was discharged November 24, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients receive information regarding the services provided at the facility through the Client Handbook, which is provided at the time of admission to the Family Healing Center. Clients are required to complete a written acknowledgment of receipt of this information within 72 hours of arrival in the electronic health record. This acknowledgment is completed with a clinician, a member of the supervisory team, or support staff. All active clients who have not already completed the handbook acknowledgment will do so no later than February 25, 2026. The Client Handbook Policy will be updated by February 20, 2026, and staff will be notified of this update through a team meeting and follow-up email communication. Ongoing compliance will be monitored through routine client chart audits to ensure consistent documentation of disclosure and acknowledgment.
The Facility Director is responsible for ensuring implementation of the revised policy and communicating the updated expectations to staff through a team meeting and follow-up email communication.
The Clinical Supervisor will conduct weekly chart audits for 60 days to verify documentation that clients were oriented to services provided at the facility and that written acknowledgment was completed within 72 hours of admission. Following the initial 60-day period, the Facility Director will conduct monthly audits for an additional three months. Any deficiencies identified will result in immediate corrective coaching and documentation review with the responsible staff member to ensure compliance. |
709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on applicable client records reviewed, the facility failed to ensure that there was documentation of intake procedures that included the consent to treatment in four of seven records.Client #2 was admitted on November 18, 2025 and was still active at the time of the inspection. There was no documentation of the consent to treatment in this record.Client #4 was admitted on July 11, 2025 and was discharged July 17, 2025. There was no documentation of the consent to treatment in this record.Client #6 was admitted on August 15, 2025 and was discharged November 24, 2025. There was no documentation of the consent to treatment in this record.Client #7 was admitted on December 18, 2025 and was still active at the time of the inspection.The consent to treatment was not signed by the client until January 10, 2026. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients will be required to sign a Consent to Treatment within 24 hours of admission to the Family Healing Center. The Intake Procedure will be updated by February 11, 2026, to reflect this requirement. The Facility Director is responsible for updating and implementing the revised Intake Procedure and ensuring all staff are informed of the updated requirement through a team meeting and follow-up email communication.
The electronic health record intake workflow will be modified to include a required Consent to Treatment field, prompting completion prior to closing the intake documentation. Any client who has not signed a Consent to Treatment will do so no later than February 13, 2026.
February 13, 2026, upon completion of all outstanding consents and implementation of the revised procedure.
The Clinical Supervisor will review all new admissions weekly for 60 days to verify that the Consent to Treatment is signed within 24 hours of admission. Following the initial 60-day period, the Facility Director will conduct monthly audits for an additional three months. Audit findings will be reviewed during supervision. Any deficiencies identified will result in immediate corrective coaching and re-training of the responsible staff member to ensure sustained compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of applicable client records, the facility failed to document a psychosocial evaluation in five of seven records. The facility ' s policy states the psychosocial evaluation must be completed within seven days of admission to drug and alcohol program.Client #1 was admitted on June 19, 2025 and was still active at the time of the inspection.A psychosocial evaluation was due to be completed no later than June 26, 2025; however, this was not completed until January 20, 2026.Client #2 was admitted on November 18, 2025 and was still active at the time of the inspection.A psychosocial evaluation was due to be completed no later than November 25, 2025; however, this was not completed at the time of the inspection.. Client #3 was admitted on November 19, 2025 and was still active at the time of the inspection. A psychosocial evaluation was due to be completed no later than November 26, 2025; however, this was not completed until January 20, 2026.Client #6 was admitted on August 15, 2025 and was discharged November 24, 2025.A psychosocial evaluation was due to be completed no later than August 22, 2025; however, this was not completed prior to discharge.Client #7 was admitted on December 18, 2025 and was still active at the time of the inspection. A psychosocial evaluation was due to be completed no later than December 25, 2025; however, this was not completed until January 10, 2026.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical staff will be retrained on psychosocial evaluation documentation requirements, including the expectation that psychosocial evaluations are completed within seven days of admission to the drug and alcohol program. All clinical staff will complete this retraining no later than February 20, 2026. All active clients who do not currently have a documented psychosocial evaluation will have one completed no later than February 27, 2026. Ongoing compliance will be monitored through routine chart audits and supervisory review to ensure psychosocial evaluations are completed and documented within the required timeframe. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan within the facility ' s policy timeframe in six of seven applicable records. The facility ' s policy and procedure manual states the preliminary treatment plan must be completed within twenty-four hours following admission.Client #1 was admitted on June 19, 2025 and was still active at the time of the inspection. A preliminary treatment plan was due on June 20, 2025; however, it was not completed at the time of the inspection.Client #2 was admitted on November 18, 2025 and was still active at the time of the inspection. A preliminary treatment plan was due on November 19, 2025; however, it was not completed at the time of the inspection.Client #3 was admitted on November 19, 2025 and was still active at the time of the inspection. A preliminary treatment plan was due on November 20, 2025; however, it was not completed until November 30, 2025.Client #4 was admitted on July 11, 2025 and was discharged July 17, 2025. A preliminary treatment plan was due on June 20, 2025; however, it was not completed prior to discharge.Client #6 was admitted on August 15, 2025 and was discharged November 24, 2025.A preliminary treatment plan was due on June 20, 2025; however, it was not completed prior to discharge.Client #7 was admitted on December 18, 2025 and was still active at the time of the inspection. A preliminary treatment plan was due on December 19, 2025; however, it was not completed at the time of the inspection.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Preliminary Treatment Plan policy will be updated to require completion of the preliminary treatment plan within 72 hours of a client's admission to the facility. If the preliminary treatment plan is not completed within this timeframe, the reason will be clearly documented in the client's chart. This policy update will be completed by February 11, 2026. The Program Director is responsible for updating and implementing the revised policy.
The preliminary treatment plan template was updated in the electronic health record by February 9, 2026, to ensure it is clearly labeled, easily accessible, and consistently used. All clinical staff will be trained on the updated requirement and documentation expectations no later than February 20, 2026. Any active client without a completed preliminary treatment plan will have one completed immediately to ensure compliance.
February 20, 2026, upon completion of staff training and verification of compliance for all active clients.
The Clinical Supervisor will review 100% of new admissions weekly for 60 days to ensure the preliminary treatment plan is completed within 72 hours of admission and appropriately documented. Following the initial 60-day period, the Facility Director will conduct monthly audits for an additional three months. Audit findings will be reviewed in supervision meetings. Any deficiencies identified will result in immediate corrective coaching, documentation review, and retraining of the responsible staff member to prevent recurrence. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 in four of six applicable records. The facility ' s policy and procedure manual states the comprehensive treatment plan must be completed within seven days following admission.Client #1 was admitted on June 19, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than June 26, 2025; however, it was not completed until July 1, 2025.Client #2 was admitted on November 18, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than November 25, 2025; however, it was not completed until December 6, 2025.Client #3 was admitted on November 19, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than November 26, 2025; however, it was not completed until December 6, 2025.Client #7 was admitted on December 18, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 25, 2025; however, it was not completed until December 31, 2025. These findings were reviewed with the facility staff during the licensing process. This is a repeat citation from the January 22, 2025 annual licensing inspection.
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Plan of Correction
The treatment plan policy will be updated to require that the comprehensive treatment and rehabilitation plan be completed by the second individual session with the client's assigned clinician. This policy update will be completed by February 11. Clinical staff will be trained on this updated requirement no later than February 27, including expectations for timely completion and documentation. Compliance will be monitored through routine chart audits and supervisory review. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in five of five applicable records. The facility policy and procedure manual indicate a case consultation to occur every thirty days. Client #1 was admitted on June 19, 2025 and was still active at the time of the inspection. A case consultation was due to occur no later than July 19, 2025; however, there were no case consultations documented at the time of the inspection.Client #2 was admitted on November 18, 2025 and was still active at the time of the inspection. A case consultation was due to occur no later than December 18, 2025; however, there were no case consultations documented at the time of the inspection.Client #3 was admitted on November 19, 2025 and was still active at the time of the inspection. A case consultation was due to occur no later than December 19, 2025; however, there were no case consultations documented at the time of the inspection.Client #6 was admitted on August 15, 2025 and was discharged November 24, 2025.A case consultation was due to occur no later than September 15, 2025; however, there were no case consultations documented prior to discharge.Client #7 was admitted on December 18, 2025 and was still active at the time of the inspection. A case consultation was due to occur no later than January 18, 2026; however, this was not completed at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will revise its case consultation policy to require that case consultations occur at a minimum of every 90 days. This policy update will be completed by February 11. All clinical staff will be informed of the revised requirement and documentation expectations. All active clients who do not currently have a documented case consultation will have one completed no later than February 13, 2026. Ongoing compliance will be monitored through routine chart audits to ensure case consultation notes are completed within the required timeframe and appropriately documented in the client record. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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.
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Observations
Based on applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual in two of three records. The policy and procedure manual indicates a discharge summary be completed within seven days of discharge.Client #4 was admitted on July 11, 2025 and was discharged July 17, 2025. The discharge summary was due to be completed no later than July 24, 2025; however, this was not completed at the time of the inspection.Client #6 was admitted on August 15, 2025 and was discharged November 24, 2025.The discharge summary was due to be completed no later than December 1, 2025; however, this was not completed until January 7, 2026.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff will be retrained on discharge summary documentation requirements, including the expectation that discharge summaries are completed within seven days of discharge, as outlined in facility policy by Feb 27 2026. All clients discharged within the previous 30 days who do not yet have a completed discharge summary will have one completed and uploaded to the electronic health record. Ongoing compliance will be monitored through routine chart audits and supervisory review to ensure discharge summaries are completed timely and consistently documented for all future discharges. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.A plan of correction for documentation of intake procedures that included the disclosure of criteria for admission, treatment, completion, and discharge was submitted and approved by the Department for the January 22, 2025 and January 18, 2024 annual licensing inspections. Documentation of intake procedures was again found to be a deficiency in the January 21, 2026 annual licensing inspection.This was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility acknowledges that previously approved Plans of Correction were not consistently implemented and monitored to ensure sustained compliance. To address this deficiency, the facility is establishing a structured oversight process for all Department-approved Plans of Correction. A centralized compliance tracking system will be implemented and maintained by the Facility Director, which will include each approved Plan of Correction, assigned responsible individuals, implementation timelines, monitoring methods, and required audit frequency. All management and supervisory staff will receive mandatory training on all currently approved Plans of Correction, including their specific responsibilities for implementation, documentation expectations, and required monitoring procedures. This training will be completed no later than March 01, 2026, and supervisors will sign written attestations confirming their understanding and responsibility for compliant implementation within their scope of oversight.
Ongoing monitoring will include monthly reviews of all active Plans of Correction conducted by the Facility Director to verify implementation. The Director of Behavioral Health Operations will review compliance tracking documentation monthly, and the Chief Operating Officer will conduct quarterly executive oversight reviews to ensure sustained compliance. Compliance with approved Plans of Correction will be a standing agenda item at monthly leadership meetings. A The Facility Director maintains primary responsibility for implementation and monitoring, and the Chief Operating Officer maintains executive oversight to ensure continued adherence to all approved Plans of Correction. |