INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on September 2 - 3, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Care LLC dba Miners Medical 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 personnel records. The facility failed to ensure all staff persons received at least 6 hours of HIV/AIDS and at least 4 hours of tuberculous, sexually transmitted diseases and other health-related topics training, using a Department approved curriculum, within the regulatory time frames in one out of seven personnel records reviewed. Employee # 7 was hired on April 4, 2022, as an office manager and was still in the position at the time of the inspection. The HIV/AIDS and tuberculosis, sexually transmitted diseases, and other related health topics training were due no later than April 4, 2024; however, there is no documentation that the employee received the tuberculosis, sexually transmitted diseases, and other related health topics training as of the date of the inspection. The HIV/AIDS training was not completed until August 14, 2026. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director received training regarding ensuring that all staff complete TB/STD and AIDS/HIV training within the first 2 years of employment on 8/13/26.Executive Director will ensure that all non-clinical staff will be scheduled to receive TB/STD and AIDS/HIV training within the first 2 years of employment. All clinical staff will be scheduled to receive the above training within 1 year of employment. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from November 2025 - July 2026, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the month of October 2026.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Office Manager and ED received training on 9/15/26 outlining that fire drills are to be conducted monthly.Office manager will schedule and conduct unannounced fire drills on a monthly basis.
Executive Director will ensure that fire drills are conducted monthly. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from November 2025- July 2026, the facility failed to prepare alternative exit routes to be used during fire drills, as all drills utilized the same exit route in nine out of nine fire drill logs reviewed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Office Manager and ED received training on 9/15/26 outlining that fire drills include all alternative exit routes Office Manager and/or Executive Director will conduct fire drills monthly rotating where the mock fire is and monitor that all staff are familiar with all exit routes.. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative documents, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.The last documented sign-off from the project director was dated January 15, 2025, and the next one was due no later than January 15, 2026; however, the documentation provided was dated August 11, 2026, and signed by the compliance specialist. When the document was reviewed with the project director, their signature was also added on to the document. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will review and ensure policies are updated and issue a signed attestation to that effect by January 15, 2027.
The Project Director will review and ensure policies are updated and issue a signed attestation to that effect by January 15, 2027. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosure is made in one of eleven records reviewed.Client #7 was admitted on June 2, 2026, and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to an emergency contact signed by the client on June 2, 2026, that did not identify the name of the person to whom disclosure can be made. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in two of eleven records reviewed.Client #5 was admitted on April 7, 2026, and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to the funder signed by the client on April 7, 2026, that did not identify the specific information to be released. Client #8 was guest dosing at the facility from January 28, 2026, until they were admitted on February 5, 2026, and discharged on April 3, 2026. The record contained an informed and voluntary consent to release information to a drug and alcohol facility signed by the client on January 28, 2026, that did not identify the specific information to be released. This is a repeat citation from October 1, 2024, and October 2, 2025, licensing inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one out of eleven records reviewed.Client #8 was guest dosing at the facility from January 28, 2026, until they were admitted on February 5, 2026, and discharged on April 3, 2026. The record contained an informed and voluntary consent to release information to a drug and alcohol facility signed by the client on January 28, 2026, that did not identify the purpose of the disclosure. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Training on completing a consent to release information took place on 9/24/26 and included the purpose of the disclosure. Confidentiality training is also required for all staff upon hire and annually that reinforces confidentiality requirements.Counselors will complete the voluntary written consent form in its entirety, checking that all information, including the purpose of the disclosure.
Clinical Supervisor and Lead Counselor will conduct regular chart audits which include checking the consent forms to ensure that there are accurately completed, and regularly report findings to the Executive Director and Regional Clinical Director.
Executive Director and Regional Clinical Director will randomly check 10 charts quarterly to ensure quality and that consent forms are accurately completed.
The Director of Quality will randomly check 6 charts quarterly to ensure quality and that consent forms are accurately completed. |
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 the 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 two out of eleven client records reviewed. Client #5 was admitted on April 7, 2026, and was still active at the time of the inspection. There was no documentation that a copy of two informed and voluntary consent to release information forms for funding sources dated April 7, 2026, were offered to the client. Client #9 was admitted on January 14, 2026, and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for an emergency contact dated May 19, 2026, was offered to the client. This is a repeat citation from October 1, 2024, and October 2, 2025, licensing inspections. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Training on completing a consent to release information took place on 9/24/26 and included that prior to releasing any information regarding a patient, voluntary written informed consent must be obtained and a copy offered is documented by checking the box on the form. Confidentiality training is also required for all staff upon hire and annually that reinforces confidentiality requirements. When consent forms are being completed, Counselors will ensure that a copy of the form is offered to the patient and must be documented on the form whether the patient received or refused copy.
On 10/20/26, patient and counselor met and signed new consent form completely filled out and was offered and refused copy.
Clinical Supervisor and Lead Counselor will conduct regular chart audits which include checking the consent forms to ensure that there are accurately completed, and regularly report findings to the
Executive Director and Regional Clinical Director will randomly check 10 charts quarterly to ensure quality and that consent forms are accurately completed.
The Director of Quality will randomly check 6 charts quarterly to ensure quality and that consent forms are accurately completed. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
The facility failed to have a data collection and recordkeeping system developed that allowed for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.During the licensing process, the facility failed to provide employed medical staff hours needed to measure the project ' s performance. The facility ' s recordkeeping system did not consistently collect the days and hours worked for all employed medical staff.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director received information as to how to document the MD and NP hours on a bi-weekly basis using a specific template.ED will monitor the medical staff hours and keep a log using the time template.
The Assistant Regional Director will oversee the ED and conduct random checks quarterly to ensure that the system is properly in place. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of physician timesheets and the program ' s NTP Questionnaire, the facility failed to provide at least one hour of physician time a week onsite for every ten patients. During the week of June 8-14, 2025, the patient census was 551. The facility was required to provide at least 55.1 physician hours. There were only 49.35 physician hours documented. During the week of June 15-21, 2025, the patient census was 598. The facility was required to provide at least 59.8 physician hours. There were only 57.24 physician hours documented.During the week of July 13-19, 2025, the patient census was 553. The facility was required to provide at least 55.3 physician hours. There were only 53.33 physician hours documented.During the week of July 20-26, 2025, the patient census was 546. The facility was required to provide at least 54.6 physician hours. There were only 52.66 physician hours documented.During the week of July 27-August 2, 2025, the patient census was 538. The facility was required to provide at least 53.8 physician hours. There were only 42.44 physician hours documented.During the week of August 17-23, 2025, the patient census was 528. The facility was required to provide at least 52.8 physician hours. There were only 40.21 physician hours documented.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executives will review the regulation and assist in acquiring physician coverage to meet the regulatory requirement.Arrangements will be made for a physician to provide coverage onsite during 1week or more scheduled Clinic physician PTO.
Executive Director will review any physician coverage needed with Regional Director to ensure regulatory compliance. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to document that transferred patient files included admission date, medical and psychological summaries, dosage levels, urinalysis reports or summary, exceptions requests and current status of the patient, and contained written consent of the patient in one out of two applicable records reviewed. Patient #10 was admitted on July 2, 2019, and transferred to another treatment facility on February 18, 2026. There was no documentation in the patient record that the facility transferred patient records to the receiving facility. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff received training on 9/24/26 regarding documenting in the patient's record when the patient files were sent to the receiving facility.-LPN's will notify the transferring program of patient's initial dose and date and document the
notification in the EHR.
- Lead LPN will check to ensure that the notification process to transferring program is documented in the EHR.
- Staff member that sent the required documentation to the receiving clinic must document in the patients chart when the records are sent to the receiving clinic.
- ED and CS will randomly check 10 charts quarterly (including transfer/discharge charts to ensure quality and that the chart reflects that the transfer documents were sent to the receiving site.
- Director of Quality will also audit 6 charts quarterly (including transfer/discharge charts to ensure quality and that the chart reflects that the transfer documents were sent to the receiving site. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of patient records, the facility failed to document the results of an in-person initial intake physical examination within 14 days of a telehealth induction in two of two applicable patient records reviewed.Patient #5 was admitted on April 7, 2026, and was active at the time of the inspection. A telehealth induction was completed with the patient on April 7, 2026. An in-person physical examination was due no later than April 21, 2026; however, it was not completed until April 22, 2026. Patient #8 was admitted on February 5, 2026, and discharged on April 3, 2026. A telehealth induction was completed with the patient on February 5, 2026. An in person physical examination was due no later than February 19, 2026; however, it was not completed until February 25, 2026. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Medical staff received training on 9/23/26 regarding DDAP audit corrective action plan that included documentation requirements of patients initially seen through telehealth, an in-person intake physical needs to be completed within 14 days of admission. The use of power tools reports to check daily to ensure what documentation is due.
The Office Manager and Receptionist received training on ensuring that they schedule appts for new admissions to be seen by medical staff within 14 days of admission when the intake was completed via telehealth. Office Manager/Receptionist will schedule the appointment for the intake physical in the EHR for the next day that the provider is on-site and use the flag system to ensure that appointment is kept prior to the 14th day of admission.
Office Manager/Receptionist will document when and reason for reschedule or failure to keep appointment.
Office Manager/Receptionist will make the Provider aware of the Intake physical appointments and ensure that if rescheduled, that the physical is completed within 14 days.
Office Manager/ Receptionist is to make ED aware if there is an issue or concern that needs intervention to ensure that appointment is complete.
- ED and CS will randomly check 10 charts quarterly (including completion of intake physical.
- Director of Quality will also audit 6 charts quarterly (including transfer/discharge charts to ensure quality and that the chart reflects that the intake physical was complete within 14 days. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to document an annual physical examination based on the patient ' s admission date, per facility policy, in one out of three applicable records reviewed.Patient #4 was admitted on May 1, 2021, and still active at the time of the inspection. The annual physical examination was due no later than May 14, 2026; however, it was not completed until August 18, 2026. Patient #6 was admitted on January 12, 2023, and discharged on February 6, 2026. The annual physical examination was due no later than January 12, 2026; however, there is no documentation that one was completed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Medical staff received training on 9/23/26 regarding DDAP audit corrective action plan that included documentation requirements of the results of annual physical examination prior to the anniversary date. The use of power tools reports to check daily to ensure what documentation is due.
TOffice Manager/Receptionist will schedule the appointment for the annual physical in the EHR for the that the provider is on-site and use the flag system to ensure that appointment is kept prior to the anniversary date.
Office Manager/Receptionist will document when and reason for reschedule or failure to keep appointment.
Office Manager/Receptionist will make the Provider aware of the annual physical appointments and ensure that if rescheduled, that the physical is completed prior to the anniversary date.
Office Manager/ Receptionist is to make ED aware if there is an issue or concern that needs intervention to ensure that appointment is complete.
- ED and CS will randomly check 10 charts quarterly (including completion of intake physical.
- Director of Quality will also audit 6 charts quarterly (including transfer/discharge charts to ensure quality and that the chart reflects that the annual physical was completed prior to the anniversary date.he Office Manager and Receptionist received training on ensuring that they begin to schedule appts for annual physical exams to be seen by medical staff 2 months prior to patient anniversary date to ensure completion prior to the date. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure that the annual evaluation of each patient's status was completed by the patient's counselor and was reviewed, dated and signed by the medical director annually based on the patient ' s admission date, per facility policy, in two out of three applicable patient records reviewed. Patient #3 was admitted on March 15, 2021, and was still active at the time of the inspection. The annual evaluation was due no later than March 15, 2026; however, it was not completed until August 6, 2026. Patient #6 was admitted on January 12, 2023, and discharged on February 6, 2026. The annual evaluation was due no later than January 12, 2026; however, there was no documentation that one was completed. This is a repeat citation from October 2, 2025, licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/24/26, counselors
- received training on use of the spreadsheet tracking tool that clearly outlines tasks and deadlines in order to prioritize and schedule annual clinical evaluations ahead of time.
All counselors will:
Use the spreadsheet tracking tool to organize their schedule for annual clinical evaluations.
Clinical Supervisor and Lead Counselor:
Monitor at least weekly that spreadsheet tracking tool is being used properly by their supervisees. Check the EHR reports to ensure that annual clinical evaluations appointments are scheduled and documented, timely completion of annual clinical evaluations, and prompt follow up when deadlines are not met.
- Notify ED, QI Director, and Regional Clinical Director of progress in this area.
- Retrain on spreadsheet tracking tool when needed,
- Conduct 2 chart audits during supervision using IAuditor to ensure appropriate documentation and timeliness of annual clinical evaluations.
- Follow up with Counselors during individual and group supervision to ensure use of scheduler and timeliness of treatment plan updates and annual clinical evaluations, and appropriate chart documentation. Acknowledge progress in this area and resolve any identified barriers to timely completion of annual clinical evaluations.
ED, QI Director, and Regional Clinical Director:
- Monitor that the tracking system is in place and that the CS and LC are following up.
- Conduct 10 chart audits quarterly using IAuditor to ensure appropriate documentation and timeliness of annual clinical evaluations.
- Take progressive discipline steps when necessary to ensure timely completion of treatment plan updates and annual clinical evaluations. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation within seven days of admission, per facility policy, in three out of six applicable records reviewed. Client #2 was admitted on December 17, 2025, and was still active at the time of the inspection. A psychosocial evaluation was due no later than December 22, 2025; however, there was no documentation that one was completed. Client #8 was admitted on February 5, 2026, and discharged on April 3, 2026. A psychosocial evaluation was due no later than February 12, 2026; however, it was not completed until February 27, 2026. Client #9 was admitted on January 14, 2026, and was still active at the time of the inspection.A psychosocial evaluation was due no later than January 21, 2026; however, it was not completed until July 7, 2026. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors received training on 9/24/26 regarding the timeliness of psychosocial evaluation within 7 days of admission.
- Use of Methasoft Powertool report to track when psychosocial evaluation is due to ensure timely completion.
- accurate documentation of barriers to completing psychosocial evaluation (missed appointments, efforts to engage,...)
- use of scheduler/appointments/ flags to meet with patient.
- doCounselors will check Methasoft powertools daily to see what work is due and ensure completion by due date.
Clinical Supervisor and Lead Counselor will conduct regular chart audits during supervision which include checking the consent forms to ensure that there are accurately completed, and regularly report findings to the Executive Director and Regional Clinical Director.
Clinical Supervisor will conduct regular audit of all newly admitted patients to ensure that documentation is complete.
Executive Director and Regional Clinical Director will randomly check 10 charts quarterly to ensure quality and that consent forms are accurately completed.
The Director of Quality will randomly check 6 charts quarterly to ensure quality and that consent forms are accurately completed documentation of all outreach efforts. |
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.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in five out of eleven records reviewed.Client #2 was admitted on December 17, 2025, and was still active at the time of the inspection. The treatment plans dated January 8, February 25, April 23, June 8, and July 21, 2026, indicated one hour of group therapy per month and one individual session weekly. There was no documentation of the client receiving group therapy from January through August 2026. There was no documentation that the client received any individual sessions the weeks of January 11 - January 17, 2026, January 25, 2026 - January 31, 2026, February 15, 2026 - February 21, 2026, April 5, 2026 - April 11, 2026, April 12, 2026 - April 18, 2026, April 26, 2026 - May 2, 2026, May 31, 2026 - June 6, 2026, June 14, 2026 - June 20, 2026, June 21, 2026 - June 27, 2026, July 5, 2026 - July 11, 2026, July 12, 2026 - July 18, 2026, July 26, 2026 - August 1, 2026, August 9, 2026 - August 15, 2026, or August 23, 2026 - August 29, 2026. Client #5 was admitted on April 7, 2026, and was still active at the time of the inspection. The treatment plans dated June 11 and August 11, 2026, indicated one individual session a month. There was no documentation that the client received any individual sessions in August 2026. Client #6 was admitted on January 12, 2023, and discharged on February 6, 2026. The treatment plans dated November 5, 2025, and January 14, 2026, indicated one individual session a month. There was no documentation that the client received individual therapy in the months of December 2025 or January 2026. Client #9 was admitted on May 18, 2026, and was still active at the time of the inspection. The treatment plans dated April 8 and May 19, 2026, indicated one individual session a week. There was no documentation that the client received any individual sessions the weeks of May 3 -May 9, 2026, May 10- May 16, 2026, May 31, 2026 - June 6, 2026, June 17, 2026 - June 23, 2026 or June 28, 2026 - July 4, 2026. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/24/26, Counselors were trained on the use of Methasoft report to ensure that patients are scheduled for the amount of services that they are to receive.
Counselors were trained on completing the treatment plan which reflects prescribed units of service and to ensure that patients are seen as per type and frequency.
Prior to signing the treatment plan,
Clinical Supervisor and Lead Counselor will conduct regular chart audits which include checking that patients are being seen as per type and frequency on treatment plan, and regularly report findings to the Executive Director and Regional Clinical Director.
Executive Director and Regional Clinical Director will randomly check 10 charts quarterly to ensure that patients are being seen per treatment plan type and frequency.
The Director of Quality will randomly check 6 charts quarterly to ensure quality and that patients are seen per treatment plans type and frequency. |
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 the review of client records, the facility failed to document case consultations every ninety days for the first year and then annually thereafter, per facility policy, in five out seven applicable records reviewed. Client #2 was admitted on December 17, 2025, and was still active at the time of the inspection. Case consultations were due no later than March 17 and June 15, 2026; however, there was no documentation that they were completed. Client #5 was admitted on April 7, 2026, and was still active at the time of the inspection. A case consultation was due no later than July 6, 2026; however, there was no documentation that one was completed. Client # 6 was admitted on January 12, 2023, and discharged on February 6, 2026. A case consultation was due no later than January 12, 2026; however, there was no documentation that one was completed. Client #7 was admitted on June 2, 2026, and was still active at the time of the inspection. A case consultation was due no later than August 31, 2026; however, there was no documentation that one was completed. Client #9 was admitted on January 14, 2026, and was still active at the time of the inspection. A case consultation was due no later than April 14, 2026; however, it was not completed until May 6, 2026. This is a repeat citation from October 2, 2025, licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors received training on 9/24/26 that included:
- importance of documenting all consultations,
- retrained on use of the spreadsheet tracking tool that clearly outlines tasks and deadlines in order to prioritize and schedule case consultations ahead of time.
- Follow up with Counselors during individual and group supervision to ensure use of scheduler and timeliness of case consultations, and appropriate chart documentation. Acknowledge progress in this area and resolve any identified barriers to timely completion of case consultations. All counselors will:
Use the spreadsheet tracking tool to schedule case conferences.
Clinical Supervisor and Lead Counselor:
. Check the EHR reports to ensure that case consultations are scheduled and documented, timely completion of case consultations.
- Notify ED, QI Director, and Regional Clinical Director of progress in this area.
- Conduct 2 chart audits during supervision using IAuditor to ensure appropriate documentation and timeliness of case consultations.
- Follow up with Counselors during individual and group supervision to ensure use of scheduler and timeliness of case consultations, and appropriate chart documentation. Acknowledge progress in this area and resolve any identified barriers to timely completion of case consultations.
ED, QI Director, and Regional Clinical Director:
- Conduct 10 chart audits quarterly using IAuditor to ensure appropriate documentation and timeliness of case consultations.
- Take progressive discipline steps when necessary to ensure timely completion of case consultations. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including a discharge summary within seven days of discharge, per facility policy, in two of four applicable records reviewed. Client #6 was admitted January 12, 2023, and discharged on February 6, 2026. A discharge summary was due no later than February 13, 2026; however, it was not completed until August 31, 2026. Client #8 was admitted on February 5, 2026, and discharged on April 3, 2026. A discharge summary was due no later than April 10, 2026; however, there is no documentation that one was completed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors received training on 9/24/26 on documenting a discharge summary within 7 days of discharge. Counselors will complete the transition/discharge plan with patients as soon as any related topic is brought up in counseling. Counselors will notify their Supervisor when a patient is planning on transitioning and arrangements will be explored and made when appropriate. Counselors will check the AWOL list and attempt to contact any patient that is not attending as scheduled. COE staff will keep staff apprized of the status of those not attending treatment.Counselors will complete transition/discharge plan as soon as they are notified.
Counselors will complete discharge summary will be completed within 7 days of discharge.
Executive Director will check to ensure that there is a discharge summary completed prior to completing the discharge.
Clinical Supervisor and Executive Director will audit 10 charts per quarter including discharged charts to ensure that the discharge summary is completed within 7 days of discharge.
Director of Compliance will also audit 2 charts quarterly. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information for clients at seven, thirty and sixty days after discharge per the facility policy, in three out of four applicable records reviewed. Client #6 was admitted on January 12, 2023, and discharged on February 6, 2026. There were no follow ups documented in the record. Client #8 was admitted on February 5, 2026, and discharged on April 3, 2026. There were no follow ups documented in the record.Client #10 was admitted on July 2, 2019, and discharged on February 18, 2026. There were no follow ups documented in the record.This is a repeat citation from October 2, 2025, licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/24/26, Counselors were re-trained on use of the scheduler in the EHR which automatically schedules follow-up contacts at 3 days of discharge (for administrative discharges), 7 days, 30 days and 60 days post discharge
- Counselors will document all attempts to contact clients at 3/7/30/and 60 days post discharge.
- Supervisor and Lead Counselor will ensure that outreach contact is conducted and documented on a timely basis during supervision and check discharged patient charts ( 3 per quarter) and will coach and counsel when needed. |
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 obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed was submitted and approved by the Department for October 1, 2024, and October 2, 2025, annual licensing inspections. Completing and obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed was again found to be a deficiency in the September 2 - 3, 2026 licensing inspection.A plan of correction for completing and documenting that a copy of a client consent was offered to the client and a copy maintained in the client record was submitted and approved by the Department for October 1, 2024, and October 2, 2025, annual licensing inspections. Completing and documenting that a copy of a client consent was offered to the client and a copy maintained in the client record was again found to be a deficiency in the September 2 - 3, 2026, licensing inspection.A plan of correction for completing and documenting an annual physical examination within the regulatory timeframe was submitted and approved by the Department for October 1, 2024, and October 2, 2025, annual licensing inspections. Completing and documenting an annual physical examination annually based on patient admission date was again found to be a deficiency in the September 2 - 3, 2026, licensing inspection.This is a repeat citation from October 2, 2025, licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director, the Clinical Supervisor, Lead Counselor, and Office Manager will all focus on the areas identified with deficiencies to ensure that these deficiencies do not recur. Clinical Supervisor and Lead Counselor will check at least 2 charts during each supervision to ensure that all deficient areas are correct. Executive Director and Clinical Supervisor will review corrective action plan in staff meetings quarterly. Executive Director, Regional Director and Quality Director will conduct quarterly audits to ensure that deficiencies have not recurred. |