INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7-8, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mpower Wellness of Pennsylvania was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and review of personnel records, the facility failed to ensure that a written individual training plan for each employee, appropriate to that employee ' s skill level, with input from both the employee and the supervisor.
Employee was #1 was hired as the project director/facility director on March 10, 2025, and was still in the position at the time of the inspection. The initial individual training plan was due no later than April 10, 2025, however, it was not completed until August 05, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director, in collaboration with the Human Resources Manager, will be responsible for ensuring that all new hires, including administrative and clinical staff, have an individualized training plan developed and signed by both the employee and their supervisor. MPower Wellness will implement a revised onboarding protocol requiring that all individual training plans be developed and finalized within 30 days of hire. The process will include input from both the employee and their supervisor to ensure appropriateness to skill level and job function. All staff who previously had not completed an individual training plan have now a completed plan in their personnel file. Moving forward, all newly hired staff will have a completed training plan no later than 30 days post-hire and a onboarding checklist will be used to ensure continued compliance. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 fire drill logs from August 2024 through July 2025, the facility failed to maintain a written fire drill record that included the amount of time it took for evacuation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will be responsible for ensuring that all fire drill logs are completed accurately and in full. The designated staff member conducting the drill will be responsible for recording all required elements at the time of the drill. The Facility Director will review drill logs monthly to confirm compliance. MPower Wellness will revise the fire drill procedure to ensure that the amount of time for evacuation is always documented. Corrective actions include: Updating the Fire Drill Record Form to highlight required fields, including evacuation time. Training staff who conduct drills on how to properly measure and record evacuation times. Adding monthly compliance checks of fire drill logs by the Facility Director. Revised fire drill form and staff training will be completed by September 30, 2025. Monthly compliance reviews will begin with the October 2025 fire drill. |
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 in eight of eight applicable records reviewed.
Employee #1 was hired on March 10, 2025 as the Project Director/Facility Director and was still in the position as of the date of the inspection. The training was not completed until August 05, 2025.
Employee #3 was hired on July 14, 2025, as a counselor and was still in the position as of the date of the inspection. The training was not completed until August 05, 2025.
Employee #4 was hired on July 21, 2025, as a counselor and was still in the position as of the date of the inspection. The training was not completed until August 05, 2025.
Employee #5 was hired on July 23, 2025, as a counselor and was still in the position as of the date of the inspection. The training was not completed until August 05, 2025.
Employee #6 was hired on July 07, 2025, as a counselor and was in the position as of the date of the inspection. The training was not completed until August 05, 2025.
Employee #7 was hired on July 07, 2025, as a counselor and was still in the position as of the date of the inspection. The training was not completed until August 05, 2025.
Employee #8 was hired on December 2, 2024, as a group facilitator and was still in the position as of the date of the inspection. The training was not completed until August 05, 2025.
Employee #9 was hired on February 06, 2025, as a group facilitator and was still in the position as of the date of the inspection. The training was not completed until August 05, 2025.
This is a repeat citation from the July 08, 2024 licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director will oversee compliance with fire extinguisher training requirements and will ensure all staff complete fire extinguisher training during orientation. MPower Wellness will ensure all staff receive fire extinguisher training, covering fire classifications, proper extinguisher use (PASS method), and assigned roles during fire drills, prior to assuming independent duties.Updating the new-hire onboarding checklist to make fire extinguisher training mandatory within the first week of employment, Requiring staff to demonstrate knowledge of extinguisher use and fire drill roles during initial orientation, Conducting semi-annual refresher trainings for all staff on all shifts, Maintaining signed training logs in personnel files and Tracking completion in a centralized electronic training database. These measures will be implemented by September 30, 2025. All new hires will complete fire extinguisher training within the first week of employment starting September 30, 2025. Semi-annual refresher trainings will begin October 2025 and recur every April and October thereafter. |
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 tasks during emergencies in eight of eight applicable records reviewed.
Employee #1 was hired on March 10, 2025, as Project Director/Facility Director on March 10, 2025 and was still in the position as of the date of the inspection. The training was not completed until August 05, 2025.
Employee #3 was hired on July 14, 2025, as a counselor and was still in the position as of the date of the inspection. The training was not completed until August 05, 2025.
Employee #4 was hired on July 21, 2025, as a counselor and was still in the position as of the date of the inspection. The training was not completed until August 05, 2025.
Employee #5 was hired on July 23, 2025, as a counselor and was still in the position as of the date of the inspection. The training was not completed until August 05, 2025.
Employee #6 was hired on July 07, 2025, as a counselor and was still in the position as of the date of the inspection. The training was not completed until August 05, 2025.
Employee #7 was hired on July 07, 2025, as a counselor and was still in the position as of the date of the inspection. The training was not completed until August 05, 2025.
Employee #8 was hired on December 2, 2024, as a group facilitator and was still in the position as of the date of the inspection. The training was not completed until August 05, 2025.
Employee #9 was hired on February 06 2024, as a group facilitator and was still in the position as of the date of the inspection. The training was not completed until August 05, 2025.
This is a repeat citation from the July 08, 2024, licensing inspection.
These findings have been reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director will oversee compliance. The HR/Training Coordinator will ensure all staff complete emergency preparedness training during orientation. Supervisors will confirm ongoing compliance. The Compliance Manager will audit training records quarterly. MPower Wellness will ensure all staff receive emergency preparedness training, covering assigned roles during fire drills and other emergencies, prior to assuming independent duties. Corrective measures include: Updating the new-hire onboarding checklist to make emergency preparedness training mandatory within the first week of employment, Requiring staff to demonstrate knowledge of assigned emergency roles during initial orientation, Conducting semi-annual refresher trainings for all staff on all shifts, Maintaining signed training logs in personnel files, Tracking completion in a centralized electronic training database. These measures will be implemented by September 30, 2025. All new hires will complete training within the first week of employment starting September 30, 2025. Semi-annual refresher trainings will begin October 2025 and recur every April and October thereafter. |
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 an informed and voluntary consent from the client for the disclosure of information in six of the fourteen records reviewed. There was no consent to release information forms for the funding source.
Client #2 was admitted to the outpatient program on August 13, 2024, and discharged October 17, 2024. The record did not contain documentation of an informed and voluntary consent from the client for the disclosure of the information to funding source. Facility staff confirmed billing had occurred.
Client #6 was admitted to the outpatient program on August 12, 2024, and discharged on September 12, 2024. The record did not contain documentation of an informed and voluntary consent from the client for disclosure of information to the funding source. Facility staff confirmed billing had occurred.
Client #7 was admitted to the outpatient program on July 29, 2024, and discharged on August 28, 2024. The record did not contain documentation of an informed and voluntary consent from the client for disclosure of information to the funding source. Facility staff confirmed billing had occurred.
Client #8 was admitted to the partial hospitalization program on September 30, 2024, and discharged on November 9, 2024. The record did not contain documentation of an informed and voluntary consent from the client for disclosure of information to the funding source. Facility staff confirmed billing had occurred.
Client #9 was admitted to the partial hospitalization on July 22, 2024, and discharged on October 15, 2024. The record did not contain documentation of an informed and voluntary consent from the client for disclosure of information to the funding source. Facility staff confirmed billing had occurred.
Client #11 was admitted to the partial hospitalization on September 13, 2024, and discharged on October 18, 2024. The record did not contain documentation of an informed and voluntary consent from the client for disclosure of information to the funding source. Facility staff confirmed billing had occurred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The MPower Wellness Clinical Director and Compliance Manager will ensure that all clients sign an informed and voluntary consent-to-release form for the funding source at admission, prior to billing. For the six cited records, corrective actions include: Notifying staff of the oversight and provide training of the new procedure. Verifying that no current client is without a valid consent on file. All active client records were reviewed by September 1, 2025, to confirm consents are on file. The intake packet has been revised to make the consent-to-release form for funding sources a mandatory, non-skippable step. Staff training on confidentiality and consent requirements will be completed by September 30, 2025. Supervisors will review all new admissions within 72 hours to verify that the consent-to-release is signed and filed. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in twelve out of fourteen records reviewed.
Client #1 was admitted to the outpatient program on April 14, 2025, and was still active at the time of the inspection. There was no documentation that a copy of consent to release information forms, that were signed and dated April 14, 2025, for a hospital and the emergency contract were offered to the client.
Client #2 was admitted to the outpatient program on August 13, 2024, and discharged on October 17, 2024. There was no documentation that consent to release information forms, that were signed and dated July 29, 2024, for a family member, a hospital, a lab, and an outside facility were offered to the client.
Client #3 was admitted to the outpatient program on February 04, 2025, and discharged May 16, 2025. There was no documentation that consent to release information forms, that were signed and dated February 04, 2025, for a family member, a lab, the emergency contact, the funder, and a hospital were offered to the client.
Client #5 was admitted to the outpatient program on December 5, 2024, and discharged on March 17, 2025. There was no documentation that consent to release information forms, signed and dated December 05, 2024, for a hospital, a lab, the funder, a family member and a friend were offered to the client.
Client #6 was admitted to the outpatient program on August 12, 2024, and discharged on September 12, 2024. There was no documentation that consent to release information forms, that were signed and dated August 8, 2024, to a hospital, a lawyer, a lab, and a family member were offered to the client.
Client #7 was admitted to the outpatient program on July 29, 2024, and discharged on August 28, 2024. There was no documentation that consent to release information forms, that were signed and dated July 29, 2024, to a hospital, a lab and a family member were offered to the client.
Client # 8 was admitted to the partial hospitalization program on September 30, 2024, and discharged on November 9, 2024. There was no documentation that consent to release information forms, that were signed and dated September 30, 2024, for a hospital, a lab, a family member, county probation, a physician, and an outside facility were offered to the client.
Client #9 was admitted to the partial hospitalization program on July 22, 2024, and discharged on October 15, 2024. There was no documentation that consent to release information forms, that were signed and dated July 22, 2024, a lab, an outside facility, and a hospital were offered to the client.
Client #10 was admitted to the partial hospitalization program July 22, 2025, and was still active at the time of the inspection. There was no documentation that consent to release information forms, that were signed and dated July 22, 2025, to a hospital, a lab, the funder, and a family member were offered to the client.
Client #11 was admitted to the partial hospitalization program on September 13, 2024, and discharged on October 18, 2024. There was no documentation that consent to release information forms, that were signed and dated September 12, 2024, to a hospital, a lab, and the funder were offered to the client.
Client #13 was admitted to the partial hospitalization program on May 27, 2025, and discharged on June 27, 2025. There was no documentation that consent to release information forms, that were signed and dated May 27, 2025, to a hospital, the lab, an emergency contact and the funder were offered to the client.
Client #14 was admitted to the partial hospitalization program on October 9, 2024, and discharged on October 18, 2024. There was no documentation that consent to release information forms, that were signed and dated October 8, 2024, to a hospital, a lab, the funder, and a family member were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will be responsible for ensuring compliance with this regulation. The Intake Coordinator and primary counselors are responsible for offering copies of all signed consents to clients at admission and maintaining the signed documentation in the client record. MPower Wellness will revise its intake and consent procedures to ensure that: All clients are offered a copy of each signed consent form at the time of signing. The client record contains written documentation confirming that the copy was offered. Staff document client acceptance or refusal of the copy in the record. All intake and clinical staff will be informed of this oversight, trained on compliance of this regulation and all client charts audited for compliance by September 30, 2025. All current clients have completed the updated consent form. Ongoing monthly chart audits will ensure continued compliance. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in six of seven records reviewed.
Client #8 was admitted on September 30, 2024, and was discharged on November 9, 2024. The individual treatment and rehabilitation plan was completed on September 30, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #9 was admitted on July 22, 2024, and discharged October 15, 2024. The individual treatment and rehabilitation plan was completed July 22, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #10 was admitted on July 22, 2025, and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 30, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #11 was admitted on September 13, 2024, and discharged on October 18, 2024. The individual treatment and rehabilitation plan was completed on July 30, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #13 was admitted on May 27, 2025, and discharged on June 27, 2025. The individual treatment and rehabilitation plan was completed on May 27, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #14 was admitted on October 9, 2024, and discharged on October 18, 2024. The individual treatment and rehabilitation plan was completed on October 9, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
This is a repeat citation from the July 13, 2023, and July 08, 2024 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will be directly responsible for ensuring that all treatment plans include clearly documented type and frequency of services. Primary counselors are accountable for developing and updating treatment plans with this information, and supervisors will review for compliance. MPower Wellness will implement a multi-step corrective process to ensure treatment plans are complete: Revise the treatment plan template to include mandatory fields for type and frequency that cannot be skipped, Provide mandatory refresher training for all clinical staff on treatment planning requirements, focusing on how to properly document type and frequency, Require supervisory review and approval of all initial and updated treatment plans before they are finalized. Conduct random quarterly audits of at least 10% of active client records to verify compliance. Template revision will be completed and in use by September 30, 2025. Staff training will be conducted by September 30, 2025, with annual refreshers each August there will begin by September 30, 2025. Monthly audits will begin September 30, 2025 and continue to be monitored quarterly for 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.
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Observations
Based on a review of partial hospitalization client records, the facility failed to provide counseling to a client on a regular and scheduled basis to include individual counseling, at least twice weekly in six of seven records reviewed.
Client #8 was admitted on September 30, 2024, and discharged to a lower level of care November 09, 2024. The record only contained one individual counseling session during the weeks of October 13, 2024 through October 19, 2024, October 20, 2024 through October 26, 2024, and October 27, 2024 through November 2, 2024.
Client #9 was admitted on July 22, 2024, and discharged on October 15, 2024. The record only contained one individual session for the weeks of July 28, 2024 through August 3, 2024, August 4, 2024 through August 10, 2024, August 11, 2024 through August 17, 2024, August 18, 2024 through 24, 2024, August 25, 2024 through August 31, 2024, September 1, 2024 through September 7, 2024, September 8, 2024 through September 14, 2024, September 15, 2024 through September 21, 2024, September 22, 2024 through 28, 2024, September 29, 2024 through October 05, 2024, and October 06, 2024 through October 12, 2024.
Client #10 was admitted on July 22, 2025, and still active at the time of the inspection. The record only contained one individual session for the week of July 27, 2025, through August 2, 2025.
Client #11 was admitted on September 13, 2024, and discharged on October 18, 2024. The record only contained one individual session for the weeks of September 15, 2024 through September 21, 2024, September 22, 2024 through September 28, 2024, September 29, 2024 through October 05, 2024, and October 06, 2024, through October 12, 2024.
Client #13 was admitted on May 27, 2025, and discharged on June 27, 2025. The record only contained one individual session for the weeks of June 01, 2025, through June 07, 2025, June 8, 2025, through June 14, 2025, and June 15, 2025 through June 21, 2025.
Client #14 was admitted on October 9, 2024, and discharged on October 18, 2024. The record only contained one individual session for the weeks of October 13, 2024 through October 19, 2024.
This is a repeat citation from the July 08, 2024 licensing inspection.
These findings were reviewed with licensing staff during the licensing process.
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Plan of Correction
The Clinical Director will ensure adequate coverage to meet the individual counseling frequency requirement. The Compliance Manager will audit records to confirm compliance. MPower Wellness will ensure that every client in the Partial Hospitalization Program receives and has documented a minimum of two individual counseling sessions per week. Corrective measures include: Implementing a session completion checklist requiring counselors to confirm that both sessions were provided each week. Partial Hospitalization Program client records will be audited weekly by Clinical Director to confirm compliance and address any recurring issues. Measures will be implemented by September 30, 2025.
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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.
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Observations
Based on a review of partial hospitalization client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in three of six applicable records reviewed.
Client #8 was admitted on September 30, 2024, and discharged on November 9, 2024. There was no documentation of follow-up information in the record.
Client #9 was admitted on July 22, 2024, and discharged October 15, 2024. There was no documentation of follow up information in the record.
Client #11 was admitted on September 13, 2024, and discharged on October 18, 2024. There was no documentation of follow up information in the record.
This is a repeat citation from the July 08, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MPower Wellness will ensure that all client records contain documented follow-up information post-discharge. The corrective process includes: Implementing a standardized follow-up protocol requiring at least one documented follow-up contact within 30 days of discharge. Revising the discharge checklist to include a mandatory "follow-up completed" step with date, method of contact, and outcome noted. Incorporating a structured "Follow-Up Form" into the EMR, which must be completed before the record is closed. In addition, all staff will be trained on revised follow-up protocol. All clients discharged after August 1, 2025, will be reviewed to ensure follow-up documentation is added by September 30, 2025. Moving forward, all follow-ups will be documented within 30 days of discharge. The EMR has been updated with a mandatory follow-up documentation form. Discharge cannot be finalized without completing the form. The discharge checklist now requires confirmation of follow-up attempts, including date, method, and outcome. The Clinical Director will review all discharges weekly to ensure follow-up has been scheduled and documented. All corrective measures including staff training, will be completed by September 30, 2025. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the outpatient client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client that included written documentation of the type and frequency of treatment and rehabilitation services in six out of seven records reviewed.
Client #1 was admitted on April 14, 2025, and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 14, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #3 was admitted on February 04, 2025, and discharged on May 16, 2025. The individual treatment and rehabilitation plan was completed on February 04, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #4 was admitted to a lower level of care on November 09, 2024, and discharged on May 22, 2025. The individual treatment and rehabilitation plan was completed on November 15, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #5 was admitted on December 05, 2024, and discharged on March 17, 2025. The individual treatment and rehabilitation plan was completed on December 5, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #6 was admitted on August 12, 2024, and discharged on September 12, 2024. The individual treatment and rehabilitation plan was completed on August 14, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #7 was admitted on July 29, 2024, and discharged on August 28, 2024. The individual treatment and rehabilitation plan was completed on July 29, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
This is a repeat citation from both the July 13, 2023 and July 18, 2024 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will be directly responsible for ensuring that all treatment plans include clearly documented type and frequency of services. Primary counselors are accountable for developing and updating treatment plans with this information, and supervisors will review for compliance. The Compliance Manager will oversee monitoring and reporting. MPower Wellness will implement a multi-step corrective process to ensure treatment plans are complete: Revise the treatment plan template to include mandatory fields for type and frequency that cannot be skipped, Provide mandatory refresher training for all clinical staff on treatment planning requirements, focusing on how to properly document type and frequency, Require supervisory review and approval of all initial and updated treatment plans before they are finalized. Conduct random monthly audits of at least 10% of active client records to verify compliance. Template revision will be completed and in use by September 30, 2025. Staff training will be conducted by September 30, 2025, with annual refreshers each August thereafter. Supervisory approval process will begin by September 30, 2025. Monthly audits will begin by September 30, 2025 and continue to be monitored monthly/quarterly for compliance. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of outpatient client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed before the end of the clinical staff member ' s shift, per facility policy, in six out of seven records reviewed.
Client #1 was admitted on April 14, 2025, and still active at the time of the inspection. The record contained progress notes for individual sessions occurring on April 29, 2025, May 16, 2025, June 13, 2025, June 26, 2025, July 01, 2025, July 16, 2025, and July 29, 2025, that were not completed until May 07, 2025, May 19, 2025, June 16, 2025, June 26, 2025, July 02, 2025, July 18, 2025, and July 31, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring April 15, 2025, May 06, 2025, May 16, 2025, May 22, 2025, June 12, 2025, June 17, 2025, and June 24, 2025, that were not completed until April 21, 2025, May 11, 2025, May 29, 2025, July 14, 2025, June 16, 2025, June 30, 2025, and June 30, 2025, 2025, respectively.
Client #2 was admitted on August 13, 2024, and discharged on October 17, 2024. The record contained a progress note for an individual session occurring on October 10, 2024, that was not completed until October 22, 2024.
Client #3 was admitted on February 04, 2025, and discharged on May 16, 2025. The record contained a progress note for an individual session occurring on May 09, 2025, that was not completed until May 13, 2025. Additionally, the record contained progress notes for group sessions occurring on February 04, 2025, February 04, 2025, February 11, 2025, 2025, February 13, 2025, February 18, 2025, February 20, 2025, February 24, 2025, February 25, 2025, February 27, 2025, March 04, 2025, March 25, 2025, and April 15, 2025, that were not completed until February 09, 2025, February18, 2025, February 17, 2025, February 20, 2025, February 24, 2025, February 26, 2025, March 03, 2025, March 06, 2025, March 10, 2025, March 31, 2025, April 21, 2025, and April 17, 2025, respectively.
Client #4 was admitted to a lower level of care on November 09, 2024, and discharged on May 22, 2025. The record contained progress notes for group sessions occurring on January 16, 2025, January 16, 2025, and February 04, 2025, that were not completed until January 23, 2025, January 23, 2025, and February 09, 2025, respectively.
Client #5 was admitted on December 05, 2024, and discharged on March 17, 2025. The record contained progress notes for individual sessions occurring on January 09, 2025, February 18, 2025, and February 27, 2025, that were not completed until January 12, 2025, February 20, 2025, and March 03, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on January 02, 2025, January 03, 2025, January 21, 2025, February 04, 2025, February 20, 2025, February 25, 2025, February 27, 2025, and March 06, 2025, that were not completed until January 06, 2025, 2025, January 27, 2025, February 09, 2025, February 24, 2025, February 27, 2025, February 25, 2025, March 03, 2025, and March 10, 2025, respectively.
Client #6 was admitted on August 12, 2024, and discharged on September 12, 2024. The record contained a progress note for a group session occurring on September 05, 2024, that was not completed until September 09, 2024.
This is a repeat citation from the July 08, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MPower Wellness will ensure all progress notes are completed and signed within the same shift in which the service occurred. The Clinical Director will be responsible for oversight. Clinical staff (counselors, therapists, and group facilitators) are responsible for completing progress notes by the end of their shift. Corrective measures include: Updating EMR settings to automatically track and flag late notes. Requiring clinical staff to complete notes before leaving their scheduled shift. Implementing supervisory spot-checks at the end of each day to confirm compliance. Conducting monthly compliance reports from the EMR to track timeliness of documentation. These corrective measures are scheduled to begin by 9/30/2025. |
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 outpatient client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 90 days following admission.
Client #1 was admitted on April 14, 2025, and was still active at the time of the inspection. A case consultation was due no later than July 14, 2025; however, none was completed.
Client #3 was admitted on February 04, 2025, and discharged on May 16, 2025. A case consultation was due not later than May 04, 2025; however, none was completed.
Client #4 was admitted to a lower level of care on November 09, 2024, and was discharged on May 22, 2025. A case consultation was due no later than February 09, 2025; however, none was completed.
Client #5 was admitted on December 05, 2024, and was discharged on March 17, 2025. A case consultation was due no later than March 05, 2023; however, none was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MPower Wellness will ensure that every client receives a case consultation every 90 days following admission. Corrective measures include: Revising the EMR system to generate automatic alerts 15 days prior to the 90-day deadline for each client. Updating "case consultation due date" tracking to the supervisory chart audit checklist. The Clinical Director will be responsible for oversight. Primary counselors will be responsible for ensuring that case consultations are scheduled and completed. Supervisors will review compliance during supervision meetings. The Compliance Manager will conduct regular monthly audits to confirm completion. These corrective action plan will by implemented by September 30, 2025. |
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 outpatient client records, the facility failed to document a complete client record client record on an individual which includes information relative to the client's involvement with the project to include follow-up information, in five of six applicable records reviewed.
Client #2 was admitted on August 13, 2024, and discharged on October 17, 2024. There was no documentation of follow-up information in the record.
Client #3 was admitted on February 04, 2025, and discharged on May 16, 2025. There was no documentation of follow-up information in the record.
Client #5 was admitted on December 05, 2024, and discharged on March 17, 2024. There was no documentation of follow-up information in the record.
Client #6 was admitted on August 12, 2024, and discharged on September 12, 2024. There was no documentation of follow-up information in the record.
Client #7 was admitted on July 29, 2024, and discharged on August 28, 2024. There was no documentation of follow-up information in the record.
This is a repeat citation from the July 08, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MPower Wellness will ensure that all client records contain documented follow-up information post-discharge. The corrective process includes: Implementing a standardized follow-up protocol requiring at least one documented follow-up contact within 30 days of discharge. Revising the discharge checklist to include a mandatory "follow-up completed" step with date, method of contact, and outcome noted. Incorporating a structured "Follow-Up Form" into the EMR, which must be completed before the record is closed. In addition, all staff will be trained on revised follow-up protocol. All clients discharged after August 1, 2025, will be reviewed to ensure follow-up documentation is added by September 30, 2025. Moving forward, all follow-ups will be documented within 30 days of discharge. The EMR has been updated with a mandatory follow-up documentation form. Discharge cannot be finalized without completing the form. The discharge checklist now requires confirmation of follow-up attempts, including date, method, and outcome. The Clinical Director will review all discharges weekly to ensure follow-up has been scheduled and documented. All corrective measures including staff training, will be completed by September 30, 2025. |
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 completing and documenting type and frequency in the outpatient individual treatment plan records was submitted and approved by the Department for the July 13, 2023, and July 08, 2024, annual licensing inspections. Completing and documenting type and frequency in individual treatment plan records was again found to be a deficiency in the August 07-08, 2025, licensing inspection.
A plan of correction for completing and documenting type and frequency in the partial hospitalization individual treatment plan records was submitted and approved by the Department for the July 13, 2023, and July 08, 2024, annual licensing inspection. Completing and documenting type and frequency in individual treatment plan records was again found to be a deficiency in the August 07-08, 2025, licensing inspection.
This information was discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will ensure plaans of correction are implemented and adhered to by the primary counselors. MPower Wellness will implement a multi-step corrective action process to ensure treatment plans are complete: Revise the treatment plan template to include mandatory fields for type and frequency that cannot be skipped, Provide mandatory refresher training for all clinical staff on treatment planning requirements, focusing on how to properly document type and frequency, Require supervisory review and approval of all initial and updated treatment plans before they are finalized. Conduct random monthly audits of at least 10% of active client records to verify compliance. All corrective action tasks will be implemented by September 30, 2025. |