INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 06, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Engagement, 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:
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Plan of Correction
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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 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the purpose of the disclosure in one out of seven records reviewed.
Client #4 was admitted on November 15, 2024, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to the funding source and probation were signed and dated November 15, 2024, that did not include the purpose of disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The requirement for the proper documentation of the purpose of the information disclosed in a confidential release will be reviewed by the Facility Director with the counselor who failed to properly complete that section on a 1:1 basis and with the treatment team during staff supervision.
This will occur on December 5, 2025.
To prevent this in the future The Facility Director / Clinical Director will conduct monthly reviews of charts to ensure the correct details are being used in the ROI's. If this is found to be done correctly by the end of the first quarter, the review then will then go back to the quarterly reviews that are usually done to ensure charts are correct.
The client #4 will have an updated ROI completed prior to 12/05/2025 to include the purpose of the disclosures.
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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 seven client records reviewed.
Client #4 was admitted on November 15, 2024, and was still active at the time of the inspection. A consent form signed and dated November 15, 2024, for the funding source and probation, did not have documentation that the client was offered a copy of the consent form.
Client #5 was admitted on March 05, 2025, and was still active at the time of the inspection. A consent form signed and dated March 05, 2025, for the funding source, did not have documentation that the client was offered a copy of the consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/21/2025 the clients mentioned completed and signed new consent to release information forms. These forms were completed correctly ensuring all pertinent information involving specific information to be disclosed was correct along with including the specific purpose for the disclosure. The forms were also documented to include offering a copy to the patient. On 11/28/2025 a training was conducted by the Facility Director with the clinical team on proper completion of authorization to release forms emphasizing confidentiality and DDAP 709.28 (c) (2), (3), and 709.28 (d). The Facility Director/Clinical Supervisor will conduct monthly record audits inspecting for proper completion of the authorization to release information forms.
The first review occured on 11/28/2025, this will continue through the end of January, on a monthly basis, to make sure the EMR maintains the change. If it does, the monthly review then will switch to a quarterly review. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to document written acknowledgements by the clients they were notified of their client rights in seven out of seven records reviewed.
The client ' s rights form signed by the clients did not include that clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
This is a repeat citation from September 25, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director & the Facility Director updated the clients rights in the EMR to include written acknowledgement by clients that the clients have the right to inspect their own records and that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental in if presented to the client. This updated client rights was communicated to any of the clients in services. To ensure the client rights continue to maintain the totality of the client rights information as noted above, inspection of the client rights materials will be verified in Monthly reviews completed by the facility director, to verify the updated EMR stays consistent. The next review will occur on 11/28/2025, this will continue through the end of January, on a monthly basis, to make sure the EMR maintains the change. If it does, the monthly review then will switch to a quarterly review. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document written acknowledgements by the clients they were notified of their client rights in seven out of seven records reviewed.
The client ' s rights form signed by the clients did not include that clients have the right to appeal a decision limiting access to their records to the director.
This is a repeat citation from September 25, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director & the Facility Director updated the clients rights in the EMR to show that clients have the right to appeal a decision limiting access to their records to the director.
This updated client rights was communicated to any of the clients in services. To ensure the client rights continue to maintain the totality of the client rights information as noted above, inspection of the client rights materials will be verified in Monthly reviews completed by the facility director, to verify the updated EMR stays consistent. The next review will occur on 11/28/2025, this will continue through the end of January, on a monthly basis, to make sure the EMR maintains the change. If it does, the monthly review then will switch to a quarterly review. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to document written acknowledgements by the clients they were notified of their client rights in seven out of seven records reviewed.
The client ' s rights form signed by the clients did not include that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
This is a repeat citation from September 25, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director & the Facility Director updated the clients rights in the EMR to show that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
This updated client rights was communicated to any of the clients in services. To ensure the client rights continue to maintain the totality of the client rights information as noted above, inspection of the client rights materials will be verified in Monthly reviews completed by the facility director, to verify the updated EMR stays consistent. The next review will occur on 11/28/2025, this will continue through the end of January, on a monthly basis, to make sure the EMR maintains the change. If it does, the monthly review then will switch to a quarterly review. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document written acknowledgements by the clients they were notified of their client rights in seven out of seven records reviewed.
The client ' s rights form signed by the clients did not include that clients have the right to submit rebuttal data or memoranda to their own records.
This is a repeat citation from September 25, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director & the Facility Director updated the clients rights in the EMR to show that clients have the right to submit rebuttal data or memoranda to their own records.
This updated client rights was communicated to any of the clients in services. To ensure the client rights continue to maintain the totality of the client rights information as noted above, inspection of the client rights materials will be verified in Monthly reviews completed by the facility director, to verify the updated EMR stays consistent. The next review will occur on 11/28/2025, this will continue through the end of January, on a monthly basis, to make sure the EMR maintains the change. If it does, the monthly review then will switch to a quarterly review. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within 30 days of admission, per facility policy, in four out of seven records reviewed.
Client #1 was admitted on November 18, 2024 and was discharged on November 05, 2025. A comprehensive treatment plan was due no later than December 18, 2024; however, there was no documentation of it being completed at the time of the inspection.
Client #2 was admitted on January 31, 2025 and was discharged on October 20, 2025. A comprehensive treatment plan was due no later than March 02, 2025; however, it was not completed until April 08, 2025.
Client #3 was admitted on November 22, 2024 and discharged on April 01, 2025. A comprehensive treatment plan was due no later than December 22, 2024; however, it was not completed until April 11, 2025.
Client #4 was admitted on November 15, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 15, 2024; however, there was no documentation it was completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Comprehensive treatment plan due dates was reviewed with staff (11/28/2025). The facility Director/Clinical Supervisor is monitoring new patients by completing chart reviews on all intake charts. Additionally, all clients that are active in treatment, have had their treatment plans reviewed to ensure they are developed in according to the facility's policy. The Facility Director/Clinical supervisor will monitor staff's case loads, to ensure comprehensive treatment plans are signed and completed within 30 days of admission. Facility Director/Clinical supervisor will discuss /remind staff in staff meetings and/or individual supervisions of any treatment plan signatures coming up to ensure placed completed with clients accordingly. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client. The plan should include written documentation of short and long term goals for treatment as formulated by both staff and the client in three of seven client records reviewed.
Client #5 was admitted on March 05, 2025 and was still active at the time of inspection. The individual treatment and rehabilitation plan was completed on March 05, 2025; however, the plan did not include documentation of the short and long term goals.
Client #6 was admitted on April 02, 2025 and was still active at the time of inspection. The individual treatment and rehabilitation plan was completed on April 10, 2025; however, the plan did not include documentation of the short and long term goals.
Client #7 was admitted on May 07, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 9, 2025; however, the plan did not include documentation of the short and long term goals.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director & the Facility Director completed a training on 11/21/2025 with staff on development of treatment plan goals, to include:
Short and long-term goals for treatment as formulated by both staff and client.
The corrected treatment plans will be reviewed by the facility Director/Clinical supervisor to ensure the correct details are included in the comprehensive treatment plans. Quarterly reviews completed by the facility director, to verify the updated tx plans stay consistent. The next review will occur on 11/28/2025. Any of the client in question that were still active at the time of this correction, have been updated, or are scheduled to be corrected by 12/05/2025.
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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 client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client that included written documentation of type and frequency of treatment and rehabilitation services in three out of seven client records reviewed.
Client #5 was admitted on March 05, 2025, and was still active at the time of the inspection. A comprehensive treatment plan was developed on March 05, 2025, with no type or frequency identified.
Client #6 was admitted on April 02, 2025, and was still active at the time of the inspection. A comprehensive treatment plan was developed on April 10, 2025, with no type or frequency identified.
Client #7 was admitted on May 07, 2025, and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 09, 2025, with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director & the Facility Director completed a training on 11/21/2025 with staff on development of treatment plan goals, to include written documentation of type and frequency of treatment and rehabilitation services.
The corrected treatment plans will be reviewed by the facility Director/Clinical supervisor to ensure the correct details are included in the comprehensive treatment plans. Quarterly reviews completed by the facility director, to verify the updated tx plans stay consistent. The next review will occur on 11/28/2025. Any of the clients in question that are still active at the time of this correction, have been updated, or are scheduled to be corrected by 11/28/2025.
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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 document a discharge summary within 5 days post discharge, per facility policy, in one out of three applicable records reviewed. The facility policy also indicates within 30 days of last appointment the record is closed and client discharged.
Client #1 was admitted on November 18, 2024, and was discharged on November 5, 2025. The client was apprehended on March 05, 2025, and did not return to treatment; the record was not closed until November 05, 2025. There was no documentation of a discharge summary being completed; the record should have been closed and client discharged on April 5, 2025, indicating the discharge summary would be completed by April 10, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Documented review of 709.93(a)(10) was completed with all counselors on 11/28/2025. To ensure ongoing compliance with 709.93(a)(10), a quarterly audit will be conducted by Facility Director/Clinical Supervisor to monitor the completion of discharge summaries. |