INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 12, 2026 to March 13, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Recovery Home LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
|
Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information contained in the client record in one of fourteen client records reviewed.
Client # 11 was admitted to the outpatient activity on August 7, 2025 and was discharged on September 30, 2025. The record did not include a client-signed consent to release information form to the funding source; however, there was evidence of billing during the treatment episode.
This is a repeat citation from the February 21, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Corrective Action Plan (0276)
Corrective Actions Implemented
Staff Training
All clinical and administrative staff have completed mandatory retraining on:
42 CFR Part 2 requirements
Proper completion of Release of Information (ROI) forms
Documentation standards prior to disclosure
Training Date: 3/24/2026
Ongoing training will be incorporated into:
New hire orientation
Annual compliance training
Process Improvement
Pre-Release Checklist
Staff must verify:
Signed ROI is present
All required elements are completed
Consent is current and valid
Supervisor Review
Any external disclosure requires supervisor or designee verification
Ongoing Monitoring
Monthly chart audits will be conducted for a minimum of 90 days, then quarterly thereafter.
Audits will specifically review:
Presence of ROI prior to disclosure
Proper completion of consent forms
Results will be reviewed in:
Quality assurance/performance improvement (QAPI) meetings
Responsible Staff
Compliance Officer/Designee
Executive Director
Completion Timeline
Staff training: Completed by 3/24/2026
Monitoring period: Ongoing (minimum 90 days)
Plan for Sustained Compliance
Recovery Home is committed to maintaining compliance with all confidentiality regulations. Through staff training, policy reinforcement, EMR safeguards, and ongoing audits, the facility will ensure that no information is disclosed without a valid, informed, and voluntary consent on file. |
709.28 (c) (6) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
|
Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent will expire on release of information forms in thirteen of thirteen client records reviewed.
In each client record reviewed, the release of information form to the funding sources did not include the date, event, or condition upon when the consent would expire.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Corrective Action Plan (0287)
Staff Training
All clinical and administrative staff completed mandatory training on:
42 CFR Part 2 consent requirements
Required elements of a valid ROI
Proper completion of expiration fields
Training Date: 3/24/2026
Ongoing education will be incorporated into:
New hire orientation
Annual compliance training
Process Improvement
The following safeguards have been implemented:
Mandatory Field Enforcement
ROI forms cannot be accepted or filed unless the expiration section is completed.
Staff must verify that all required fields?including expiration?are completed prior to:
Scanning into EMR
Uploading
Acting on the release
Compliance/ Executive Director will review ROI forms for completeness during:
Intake
Chart audits
Prior to external disclosures
Ongoing Monitoring
The facility will conduct monthly chart audits for 90 days, then quarterly thereafter.
Audits will specifically evaluate:
Presence of expiration date/event/condition on all ROI forms
Overall ROI compliance
Findings will be reviewed in:
Quality Assurance/Performance Improvement (QAPI) meetings
Responsible Staff
Compliance Officer/Executive Director
Completion Timeline
Staff training: Completed by 3/24/2026
Monitoring: Ongoing (minimum 90 days)
Plan for Sustained Compliance
Recovery Home has implemented standardized documentation, staff training, and ongoing monitoring to ensure that all Release of Information forms include a clearly defined expiration date, event, or condition in full compliance with 42 CFR Part 2 and DDAP standards. These corrective measures will prevent recurrence and ensure ongoing regulatory compliance. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project, in one of one applicable client records reviewed.
Client # 7 was admitted to the partial hospitalization activity on December 23, 2025 and was involuntarily discharged on January 21, 2026. There was no documentation, in the record, indicating the client received written notice of the involuntary termination from treatment at the project.
This is a repeat citation from the February 21, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Corrective Action Plan (0333)
Corrective Actions Implemented
Immediate Correction
The identified case was reviewed and:
A written involuntary discharge notification was completed (if clinically appropriate and feasible)
Documentation of discharge rationale and attempts to notify the client were updated in the record
A formal Involuntary Discharge Letter template has been implemented
Template is now required for all involuntary discharges and includes:
Client name and identifying information
Date of notice
Reason for discharge
Contact information for follow-up
Staff Training
All clinical and administrative staff completed mandatory training on:
DDAP discharge requirements
Client rights related to termination
Proper documentation of involuntary discharge
Training Date: 3/24/2026
Incorporated into:
New hire onboarding
Annual compliance training
The following safeguards have been implemented:
Discharge Checklist Requirement
All discharges must include:
Discharge summary
Level of care recommendation
Written notification (if involuntary)
Documentation Verification
Chart cannot be closed until required discharge documents are completed
Ongoing Monitoring
Monthly discharge record audits will be conducted for 90 days, then quarterly
Audits will ensure:
Written notification is present for all involuntary discharges
Documentation meets DDAP standards
Results reviewed in:
QAPI meetings
Responsible Staff
All staff
Completion Timeline
Staff training: Completed by Executive Director
Monitoring: Ongoing (minimum 90 days)
Plan for Sustained Compliance
Recovery Home has implemented standardized discharge procedures, staff training, and documentation safeguards to ensure that all involuntary discharges include written client notification in accordance with DDAP regulations. These measures will ensure consistent compliance and protection of client rights. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
|
Observations
Based on a review of client records, the facility failed to ensure the client was provided with an opportunity to request reconsideration of a decision terminating treatment in one of one applicable client records reviewed.
Client # 7 was admitted to the partial hospitalization activity on December 23, 2025 and was involuntarily discharged on January 21, 2026. There was no documentation, in the record, indicating the client was given an opportunity to request reconsideration of being involuntarily terminated from treatment at the project.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Corrective Action Plan (CAP)
Citation #: 0335
Corrective Actions Implemented
Standardized Documentation
A revised Involuntary Discharge Letter template has been implemented and now includes:
Reason for termination
Effective date
Referral recommendations
Client right to request reconsideration
Clear instructions for submitting an appeal (contact person, timeframe, process)
Staff Training
All clinical and administrative staff completed mandatory training on:
DDAP client rights requirements
Involuntary discharge procedures
Reconsideration/appeal process
Training Date: 3/24/2026
Training will be incorporated into:
New hire orientation
Annual compliance training
Process Improvement
The following safeguards have been implemented:
Discharge Documentation Checklist
Required for all involuntary discharges:
Written notification completed
Appeal/reconsideration rights included
Referral provided
Supervisor Approval Process
All involuntary discharges must be reviewed and approved by:
Compliance or Program Directo
Ongoing Monitoring
Monthly discharge audits will be conducted for 90 days, then quarterly
Audits will ensure:
Documentation of appeal/reconsideration rights
Compliance with discharge procedures
Results reviewed in:
Quality Assurance/Performance Improvement (QAPI) meetings
Responsible Staff
Compliance Officer/Designee
Completion Timeline
Staff training: Completed by 3/24/2026
Monitoring: Ongoing (minimum 90 days)
Plan for Sustained Compliance
Recovery Home has implemented standardized discharge procedures, policy updates, and staff training to ensure that all clients are informed of their right to request reconsideration of involuntary discharge decisions. These measures will ensure protection of client rights and ongoing compliance with DDAP regulations. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
|
Observations
Based on a review of client records, the facility failed to ensure all treatment and rehabilitation plans were reviewed and updated at least every thirty days in one of one applicable client records reviewed.
Client # 6 was admitted to the partial hospitalization activity on September 15, 2025 and was discharged on November 4, 2025. The individual treatment and rehabilitation plan was completed on September 15, 2025 and the next update was due no later than October 15, 2025; however, the update was not completed prior to discharge.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Corrective Action Plan (CAP)
Citation #: 1565
Corrective Actions Implemented
Staff Training
All clinical staff completed mandatory training on:
DDAP requirements for treatment plan reviews
Proper documentation of 30-day updates
Training Date: 3/24/2026
Ongoing training will be included in:
New hire orientation
Annual compliance training
4. Process Improvement
The following safeguards have been implemented:
Treatment Plan Tracking System
A tracking log (or EMR report) is now used to monitor:
Treatment plan due dates
Upcoming 30-day reviews
Supervisors review caseloads weekly to ensure no treatment plans are overdue
Accountability Measures
Clinicians are responsible for timely completion
Supervisors verify compliance
5. Ongoing Monitoring
Monthly chart audits will be conducted for 90 days, then quarterly thereafter
Audits will specifically review:
Timeliness of treatment plan reviews
Quality and completeness of updates
Results will be reviewed in:
QAPI meetings
Responsible Staff
Compliance Officer/Designee
Completion Timeline
Staff training: Completed by 3/24/2026
Monitoring: Ongoing (minimum 90 days)
Plan for Sustained Compliance
Recovery Home has implemented structured tracking, staff training, and supervisory oversight to ensure that all treatment plans are reviewed and updated every 30 days in compliance with DDAP regulations. These measures will prevent recurrence and support ongoing clinical and regulatory compliance. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
|
Observations
Based on a review of client records, the facility failed to ensure a client, in the partial hospitalization activity, was provided with individual counseling sessions at least twice weekly in four of six applicable client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on February 27, 2026 and was active at the time of inspection. The record of services and progress notes indicated there was only one individual counseling session during the week of March 1, 2026.
Client # 2 was admitted to the partial hospitalization activity on February 25, 2026 and was active at the time of inspection. The record of services and progress notes indicated there was only one individual counseling session during the week of March 1, 2026.
Client # 4 was admitted to the partial hospitalization activity on June 18, 2025 and was discharged on July 14, 2025. The record of services and progress notes indicated there was only one individual counseling session during the week of June 29, 2025.
Client # 5 was admitted to the partial hospitalization activity on November 11, 2025 and was discharged on December 3, 2025. The record of services and progress notes indicated there was only one individual counseling session during the week of November 16, 2025.
This is a repeat citation from the February 21, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Corrective Action Plan (CAP)
Citation #: 1571
Corrective Actions Implemented
Staff Training
All clinical staff completed mandatory training on:
DDAP PHP service requirements
Documentation standards for individual sessions
Scheduling expectations
Training Date:3/24/2026
Incorporated into:
New hire orientation
Annual compliance training
4. Process Improvement
The following safeguards have been implemented:
Weekly Scheduling Meeting
All PHP clients are pre-scheduled for 2 individual sessions per week
Supervision Oversight
Supervisors conduct weekly caseload reviews to ensure compliance with PHP requirements
Missed Session Protocol
If a session is missed:
It must be rescheduled within the same week when possible
Or clinically justified and documented
5. Ongoing Monitoring
Weekly PHP census and service delivery review will be conducted for 90 days, then ongoing
Monthly chart audits will ensure:
Two individual sessions per week are documented
Any exceptions are clinically justified
Findings reviewed in:
QAPI meetings
Responsible Staff
Compliance Officer/Designee
Completion Timeline
Staff training: Completed by Executive Director
Monitoring: Ongoing (minimum 90 days)
Plan for Sustained Compliance
Recovery Home has implemented structured scheduling, EMR tracking, staff training, and supervisory oversight to ensure that all PHP clients consistently receive a minimum of two individual counseling sessions per week in accordance with DDAP regulations. These measures will prevent recurrence and ensure ongoing compliance. |
709.83(a)(6) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(6) Aftercare plans, if applicable.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of an aftercare plan, in one of one applicable client records reviewed.
Client # 7 was admitted to the partial hospitalization activity on December 23, 2025 and was discharged on January 21, 2026. There was no aftercare plan documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Corrective Action Plan (CAP)
Citation #: 1605
Corrective Actions Implemented
Standardized Documentation
A standardized Aftercare Plan template has been implemented and is now required for all discharges.
Template includes:
Level of care recommendations
Appointment/referral information
Medication follow-up (if applicable)
Recovery support recommendations
Staff Training
All clinical staff completed mandatory training on:
DDAP discharge and aftercare requirements
Proper documentation of aftercare plans
Importance of continuity of care
Training Date: 3/24/2026
Incorporated into:
New hire orientation
Annual compliance training
Process Improvement
The following safeguards have been implemented:
All discharges must include:
Discharge summary
Aftercare plan
Referrals/recommendations
Client education/documentation
Supervisor Review
Discharge documentation must be reviewed and approved by:
Program Director
6. Ongoing Monitoring
Monthly discharge chart audits will be conducted for 90 days, then quarterly thereafter
Audits will ensure:
Presence of aftercare plan in all discharged client records
Completeness and quality of documentation
Results reviewed in:
QAPI meetings
Responsible Staff
Compliance Officer
Completion Timeline
Staff training: Completed by Executive Director
Monitoring: Ongoing (minimum 90 days)
Plan for Sustained Compliance
Recovery Home has implemented standardized discharge procedures, staff training, EMR safeguards, and ongoing monitoring to ensure that all client records include a complete and documented aftercare plan in compliance with DDAP regulations. These measures will support continuity of care and prevent recurrence. |
709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in three of four applicable client records reviewed.
Client # 4 was admitted to the partial hospitalization activity on June 18, 2025 and was discharged on July 14, 2025. There was no follow-up information documented in the record as of the date of the inspection.
Client # 5 was admitted to the partial hospitalization activity on November 11, 2025 and was discharged on December 3, 2025. There was no follow-up information documented in the record as of the date of the inspection.
Client # 6 was admitted to the partial hospitalization activity on September 15, 2025 and was discharged on November 4, 2025. There was no follow-up information documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Corrective Action Plan (CAP)
Citation #: 1615
Corrective Actions Implemented
Standardized Documentation
A Follow-Up Documentation Section has been added to the Aftercare/Discharge Plan template.
Required elements now include:
Date/time of follow-up appointment (if scheduled)
Provider or agency name
Type of service (IOP, OP, MAT, psychiatry, etc.)
Client instructions for follow-up
Staff Training
All clinical staff completed training on:
DDAP requirements for complete discharge documentation
Importance of documenting follow-up care for continuity and safety
Training Date: 3/24/2026
Incorporated into onboarding and annual compliance training.
5. Process Improvement
The following safeguards have been implemented:
Discharge Checklist (Required)
All discharges must include:
Aftercare plan
Follow-up information
Referrals and recommendations
Discharge summary
Supervisor Review Requirement
All discharge documentation must be reviewed and approved by: Executive Director
6. Ongoing Monitoring
Monthly chart audits will be conducted for 90 days, then quarterly thereafter
Audits will specifically monitor:
Presence of follow-up documentation in all discharge records
Completeness and accuracy of follow-up details
Findings will be reviewed in:
QAPI/QA meetings
Responsible Staff
Compliance Officer: Executive Director
Completion Timeline
Staff training: Completed by Executive Director
Monitoring: Ongoing (minimum 90 days)
Plan for Sustained Compliance
Recovery Home has implemented standardized discharge templates, staff training, EMR prompts, and ongoing auditing to ensure all client records include complete follow-up documentation in compliance with DDAP regulations. These measures will support continuity of care and prevent recurrence of this deficiency. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to ensure all treatment and rehabilitation plans were reviewed and updated at least every sixty days in four of four applicable client records reviewed.
Client # 9 was admitted to the outpatient activity on November 17, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on November 17, 2025 and the first update was due no later than January 17, 2026; however, the update was completed on February 17, 2026.
Client # 10 was admitted to the outpatient activity on December 24, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on December 24, 2025 and the first update was due no later than February 24, 2026; however, the update was not completed as of the date of the inspection.
Client # 12 was admitted to the outpatient activity on April 21, 2025 and was discharged on October 29, 2025. The individual treatment and rehabilitation plan was completed on May 13, 2025 and the first update was due no later than July 13, 2025; however, the update was not completed prior to discharge.
Client # 14 was admitted to the outpatient activity on June 3, 2025 and was discharged on November 3, 2025. The individual treatment and rehabilitation plan was completed on June 2, 2025 and the first update was due no later than August 2, 2025; however, the update was completed on October 30, 2025.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Corrective Action Plan (CAP)
Facility Name: Recovery Home
Citation #: 1883
Corrective Actions Implemented
1. Immediate Correction
All identified client records were reviewed and updated, and treatment plans were completed or brought into compliance.
A retrospective audit of all active charts was conducted to ensure no additional deficiencies exist.
2. Staff Training
All clinical staff were trained on:
DDAP requirements for 60-day treatment plan reviews
Importance of timely updates for medical necessity and continuity of care
Proper documentation procedures within EMR
Training Date: 3/30/2026
Incorporated into onboarding and annual compliance training
3. Compliance officer Oversight
Compliance officer will:
Conduct weekly chart reviews to ensure compliance
Review treatment plans during supervision sessions
Address deficiencies immediately with corrective feedback
4. Ongoing Quality Assurance Monitoring
The facility will conduct:
Weekly internal audits for 90 days
Monthly QA reviews thereafter
Audits will specifically track:
Timeliness of treatment plan updates
Accuracy and completeness of documentation
Responsible Staff
Compliance Officer
Completion Timeline
Immediate corrections: Completed
Staff training: Completed by 3/30/2026
Monitoring period: Ongoing (minimum 90 days)
Plan for Sustained Compliance
Recovery Home has implemented structured tracking systems, staff training, and supervisory oversight to ensure all treatment plans are reviewed and updated every 60 days in accordance with DDAP regulations. These measures will ensure ongoing compliance and prevent recurrence of this deficiency. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on the review of client records, the facility failed to ensure counseling services were being provided to the client according to the individual treatment and rehabilitation plan in two of five applicable client records reviewed.
Client # 11 was admitted to the outpatient activity on August 7, 2025 and was discharged on September 30, 2025. The treatment and rehabilitation plan, dated August 4, 2025, indicated the client was to receive three individual sessions per week. The record of services and progress notes in the record showed the only individual sessions provided to the client were on August 7, 2025, August 21, 2025, August 22, 2025 and September 30, 2025.
Client # 14 was admitted to the outpatient activity on June 3, 2025 and was discharged on November 3, 2025. The treatment and rehabilitation plan, dated June 2, 2025, indicated the client was to receive three individual or group sessions per week. The record of services and progress notes in the record showed there were no individual sessions provided to the client from July 10, 2025 to discharge and there were no group sessions from September 24, 2025 to discharge.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Corrective Action Plan (CAP)
Citation #: 1885
Corrective Actions Implemented
Staff Training
All clinical staff completed training on:
Importance of aligning treatment plan and service delivery
DDAP documentation expectations
How to update treatment plans when services change
Training Date: 3/24/2026
Added to onboarding and annual compliance training
Supervisory Oversight
Clinical Supervisors will:
Conduct weekly chart reviews to ensure services match treatment plans
Review service frequency during supervision sessions
Address discrepancies immediately
Ongoing Quality Assurance Monitoring
The facility will implement:
Weekly audits for 90 days, then monthly thereafter
Audits will monitor:
Consistency between treatment plans and services delivered
Documentation accuracy
Timely updates when services change
Responsible Staff
Compliance Officer
Completion Timeline
Staff training: Completed by Executive
Monitoring: Ongoing (minimum 90 days)
Plan for Sustained Compliance
Recovery Home has implemented standardized procedures, staff training, EMR workflow improvements, and supervisory oversight to ensure all counseling services are delivered in accordance with individualized treatment plans. These measures will ensure ongoing compliance with DDAP regulations and prevent recurrence. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
|
Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to maintain a complete client record, which is to include documentation of case consultation notes, in three of three applicable client records reviewed.
The facility policy and procedure manual stated that case consultation notes will be completed quarterly.
Client # 9 was admitted to the outpatient activity on November 17, 2025 and was active at the time of inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 12 was admitted to the outpatient activity on April 21, 2025 and was discharged on October 29, 2025. There were no case consultation notes documented in the record at the time of the inspection.
Client # 14 was admitted to the outpatient activity on June 3, 2025 and was discharged on November 3, 2025. There were no case consultation notes documented in the record at the time of the inspection.
This is a repeat citation from the February 21, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Corrective Action Plan (CAP)
Facility Name: Recovery Home
Citation #: 1905
Corrective Actions Implemented
1. Immediate Correction
The identified client records were reviewed and updated, and case consultation notes were completed where clinically appropriate.
A retrospective audit of all active charts was conducted to ensure compliance with consultation documentation requirements.
2. Policy & Procedure Reinforcement
The facility reviewed and reinforced its Case Consultation Policy, clarifying:
Case consultation notes must be completed at minimum quarterly
Documentation must include:
Date of consultation
Participants (e.g., therapist, supervisor, medical staff)
Clinical summary and recommendations
Any changes to treatment planning
3. Tracking & Monitoring System
A Case Consultation Tracking Log has been implemented to monitor:
Last consultation date
Next due date (quarterly)
Responsibility assigned to:
Primary Therapist (completion)
4. Staff Training
All clinical staff were trained on: 3/30/2026
DDAP requirements for complete client records
Internal policy requiring quarterly case consultation notes
Proper documentation standards
Training Date: 3/30/2026
Incorporated into onboarding and annual compliance training
5. Supervisory Oversight
Supervisors will:
Conduct monthly chart reviews to ensure consultation notes are completed
Review consultation documentation during supervision
Address deficiencies immediately with corrective action
6. Ongoing Quality Assurance Monitoring
The facility will conduct:
Monthly audits for 90 days, then quarterly thereafter
Audits will monitor:
Completion of quarterly case consultation notes
Documentation quality and timeliness
Responsible Staff
Compliance Officer/Executive Director
Completion Timeline
Immediate corrective actions: Completed
Staff training: Completed by 3/30/2026
Monitoring: Ongoing (minimum 90 days)
Plan for Sustained Compliance
Recovery Home has implemented standardized templates, tracking systems, staff training, and supervisory oversight to ensure all required case consultation notes are completed quarterly in accordance with facility policy and DDAP regulations. These measures will ensure complete client records and prevent recurrence of this deficiency. |
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.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in three of three applicable client records reviewed.
Client # 12 was admitted to the outpatient activity on April 21, 2025 and was discharged on October 29, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client # 13 was admitted to the outpatient activity on July 1, 2025 and was discharged on August 21, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client # 14 was admitted to the outpatient activity on June 3, 2025 and was discharged on November 3, 2025. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Corrective Action Plan (CAP)
Citation #1911
Corrective Actions Implemented
Staff Training
All clinical staff completed training on:
DDAP requirements for complete discharge documentation
Importance of documenting follow-up for continuity of care and patient safety
Proper use of updated EMR templates and discharge workflow
Training Date: 3/24/2026
Added to onboarding and annual compliance training
Discharge Checklist Implementation
A mandatory Discharge Checklist has been implemented requiring:
Aftercare plan completion
Follow-up information documented
Referrals provided
Discharge summary completed
Supervisory Oversight
Supervisors will:
Review all discharge documentation prior to chart closure
Ensure follow-up information is complete and accurate
Address deficiencies immediately
Ongoing Quality Assurance Monitoring
The facility will conduct:
Weekly discharge chart audits for 90 days, then monthly thereafter
Audits will monitor:
Presence of follow-up documentation
Completeness and accuracy of discharge planning
Responsible Staff
Compliance Officer
Completion Timeline
Staff training: Completed by Executive Director
Monitoring: Ongoing (minimum 90 days)
Plan for Sustained Compliance
Recovery Home has implemented standardized discharge templates, staff training, supervisory review, and ongoing auditing to ensure all client records include complete follow-up documentation in accordance with DDAP regulations. These measures will support continuity of care and prevent recurrence of this deficiency |