INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CHMH Services PA LLC DBA Charlie Health 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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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 May, 2025 - May, 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 months of October, 2025 - April, 2026.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Corrective Action
The facility acknowledges the deficiency and has taken immediate action to ensure ongoing compliance with 705.28(d)(1), which requires nonresidential facilities to conduct unannounced fire drills at least once each month.
This matter was elevated to executive leadership, including the Chief Executive Officer (CEO), who approved the implementation of a dedicated fire drill oversight process. Effective June 2026, specific staff members have been designated responsibility for conducting, documenting, and maintaining records of all required unannounced monthly fire drills.
On June 12, 2026, the Compliance Manager met with the identified staff members to review Regulation 705.28(d)(1), the facility's fire safety responsibilities, and the requirements for conducting and documenting unannounced monthly fire drills. Staff received instruction regarding the purpose of the drills, documentation expectations, record retention requirements, and procedures for reporting any identified safety concerns.
Systemic Changes Implemented
To prevent recurrence, the facility has implemented the following measures:
Designated staff members have been assigned responsibility for conducting and documenting all monthly unannounced fire drills.
A shared fire drill tracking log has been established between the Compliance Department and the designated staff members to ensure drills are scheduled, completed, and documented timely.
The shared log will be reviewed monthly by the Compliance Manager to verify completion of all required drills, ensure documentation is accurate and complete, and identify any corrective actions or adjustments needed.
Monthly compliance monitoring has been incorporated into the facility's ongoing quality assurance process to ensure continued adherence to fire safety regulations.
Date of Compliance
The facility began implementing these corrective measures in June 2026. Unannounced monthly fire drills will be conducted and documented beginning June 2026 and will continue on an ongoing basis thereafter.
Monitoring
The Compliance Manager will conduct monthly reviews of the fire drill log and documentation to ensure compliance with Regulation 705.28(d)(1). Any missed drills or documentation deficiencies will be addressed immediately through corrective action and staff follow-up.
The facility believes these actions fully address the cited deficiency and will ensure sustained compliance with fire safety requirements moving forward. |
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 a consent to release information form prior to releasing information in two out of seven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #5 was admitted on November 17, 2025 and discharged on January 15, 2026.
Client #6 was admitted on January 10, 2026 and discharged on March 16, 2026.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the April 24, 2024 and May 15, 2025 licensing inspections.
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Plan of Correction
Charlie Health acknowledges this citation and recognizes the seriousness of the finding. Charlie Health further acknowledges that this is a repeat citation and has reviewed the deficiency with an extreme level of importance to ensure ongoing compliance with all requirements related to client consent and the release of protected health information.
Upon identification of the deficiency, Charlie Health conducted a review of the affected records and processes related to obtaining consent to release information prior to billing and information disclosure to funding sources.
As an immediate corrective action, Charlie Health has implemented an additional safeguard requiring the upload and review of Treatment, Payment, and Healthcare Operations (TPO) documentation in the client chart prior to the initiation of services. This measure serves to ensure appropriate authorization is documented before information is released for payment purposes. The TPO's are sent prior to service starting, which will ensure to be readily available in the client chart. All previous consent documentation will still be sent as per usual and requested to be signed by the client.
Additionally, on June 16, 2026, the Compliance Manager met with the Quality Review Team to review the citation, discuss root causes, and reinforce regulatory requirements regarding consent and information disclosure. Effective June 16, 2026, verification of TPO documentation and/or appropriate consent forms has been added to the Quality Review Team's monthly audit process. Monthly audits will include review of client records to confirm that appropriate authorization documentation is present prior to billing activities or release of information to funding sources.
The Compliance Manager will oversee ongoing monitoring of audit results and corrective actions. Any identified deficiencies will be addressed through additional staff education, corrective action, and follow-up monitoring to ensure sustained compliance.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the guidelines established by the facility's policy and procedure manual in three out of seven applicable records reviewed. The facility's policy and procedures manual states the treatment plan updates must be completed every 30 days.
Client #1 was admitted on February 26, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 3, 2026 and an update was due no later than April 3, 2026; however, it was not completed until May 1, 2026.
Client #3 was admitted on March 14, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 20, 2026 and an update was due no later than April 20, 2026; however, it was not completed until May 1, 2026.
Client #7 was admitted on January 12, 2026 and discharged on March 18, 2026. A comprehensive treatment plan was completed on January 20, 2026 and an update was due no later than February 20, 2026; however, it was not completed until February 22, 2026.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the May 15, 2025 licensing inspection.
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Plan of Correction
In response to the cited deficiency regarding treatment plan updates, the Compliance Manager met with the Quality Review Team on 06/16/2026 to discuss this repeat finding and conduct a review of current practices, regulatory requirements, and internal processes.
During this review, it was determined that while the facility's policy required treatment and rehabilitation plans to be reviewed and updated every 30 days, there were inconsistencies in maintaining compliance with this timeframe. To address the root cause and establish a more sustainable and compliant process, the facility has elected to revise its internal policy to require that treatment and rehabilitation plans be reviewed and updated at least every 60 days.
This change aligns with applicable regulatory requirements and provides a more realistic operational framework while maintaining the quality and effectiveness of treatment planning.
The revised policy has been reviewed with the appropriate operational teams and leadership staff. The updated policy will become effective immediately.
In addition, the Quality Team has updated its risk assessment and monitoring processes to specifically track compliance with treatment plan review and update timeframes. Ongoing audits will be conducted to ensure treatment and rehabilitation plans are completed within the required 60-day timeframe, and findings will be reviewed through the facility's quality and compliance oversight processes. Any identified variances will be addressed through targeted coaching, retraining, and corrective action as appropriate.
These corrective actions are intended to ensure sustained compliance with treatment planning requirements and prevent recurrence of this deficiency.
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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.
Plans of correction for release of information were submitted and approved by the Department for the April 24, 2024 and May 15, 2025 annual licensing inspections. Release of information for funding sources was again found to be to be a deficiency in the May 28, 2026 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Charlie Health acknowledges this citation and recognizes the seriousness of the finding. Charlie Health further acknowledges that this is a repeat citation and has reviewed the deficiency with an extreme level of importance to ensure ongoing compliance with all requirements related to client consent and the release of protected health information.
Upon identification of the deficiency, Charlie Health conducted a review of the affected records and processes related to obtaining consent to release information prior to billing and information disclosure to funding sources.
As an immediate corrective action, Charlie Health has implemented an additional safeguard requiring the upload and review of Treatment, Payment, and Healthcare Operations (TPO) documentation in the client chart prior to the initiation of services. This measure serves to ensure appropriate authorization is documented before information is released for payment purposes. The TPO's are sent prior to service starting, which will ensure to be readily available in the client chart.
Additionally, on June 16, 2026, the Compliance Manager met with the Quality Review Team to review the citation, discuss root causes, and reinforce regulatory requirements regarding consent and information disclosure. Effective June 16, 2026, verification of TPO documentation and/or appropriate consent forms has been added to the Quality Review Team's monthly audit process. Monthly audits will include review of client records to confirm that appropriate authorization documentation is present prior to billing activities or release of information to funding sources.
The Compliance Manager will oversee ongoing monitoring of audit results and corrective actions. Any identified deficiencies will be addressed through additional staff education, corrective action, and follow-up monitoring to ensure sustained compliance.
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