INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Wellspan Medical Group 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) 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 prior to releasing information in one out of seven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #3 was admitted on March 31, 2025 and was discharged on November 13, 2025.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Team members will be educated and review fully complete Releases of Information during an all staff meeting on 2/9/2026 by the Project Director or designee. The Releases of Information example from the staff meeting will also be sent electronically to all staff and placed electronically on our Teams channel on 2/2/2026. The Front Office Manager or designee will review the scheduled patients daily and all Substance Use Disorder Clients will be identified and consents prepared. The Treatment, Payment and Operations consent (contains release for payment) will be obtained at check in. New staff will be trained to the requirement during Onboarding by the Project Director or designee. Those staff who are responsible for the completion of Release of Information who may be on Paid Time Off or extended leave will be educated to requirements upon their return by the Project Director or designee prior to their next assigned shift. Monitoring will be completed for fully completed Releases of Information starting in February 2026 by the Grant Evaluator or designee. Monitoring results will be reported monthly to the Quality Management Council by the Project Director or designee until sustained compliance is obtained. The corrective action plan will be determined effective after 3 consecutive reporting periods of 100% compliance have been achieved. |
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 outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of six records reviewed.
Client #2 was admitted on September 4, 2025 and was discharged on December 4, 2025. A comprehensive treatment plan was completed on September 25, 2025 and an update was due no later than November 25, 2025; however, none was completed.
Client #3 was admitted on March 31, 2025 and was discharged on November 13, 2025. A comprehensive treatment plan was completed on April 10, 2025 and an update was due no later than June 10, 2025; however, it was not completed until August 4, 2025.
Client #5 was admitted on September 26, 2025 and was discharged on December 12, 2025. A treatment plan update was completed on September 26, 2025 and the next update was due no later than November 26, 2025; however, none was completed.
Client #6 was admitted on May 16, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 16, 2025 and an update was due no later than July 16, 2025; however, it was not completed until July 25, 2025. Additionally, the next update was due no later than September 25, 2025; however, it was not completed until October 3, 2025
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the December 9, 2024 licensing inspection.
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Plan of Correction
A tracking dashboard for Treatment Plan due dates will be created by 1/23/2026. The dashboard will be reviewed by all Substance Use Disorder Clinicians weekly. Clients whose Treatment Plans that need to be updated during the period will be identified and clinicians will schedule clients for Treatment Plan Updates and will Teams Message confirmation to leads when the updates are complete. Staff will be trained on the new process during Clinical Supervision on 2/3/2026. Those team members who are responsible for updating treatment plans who are on paid time off or extended leave will be educated to the requirement upon their return by the program manager or designee. New hires will be trained during Onboarding. If a clinician is out of the office, plans will be made for another clinician to cover. The Grant Evaluator or designee will check the Treatment Plan Update Status report that is managed for compliance monitoring. Monitoring results will be reported monthly to the Quality Management Council by the Project Director or designee. The corrective action plan will be determined effective after 3 consecutive reporting periods of 100% compliance have been achieved. |
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 three out of six applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 60 days in conjunction with the treatment plan update.
Client #2 was admitted on September 4, 2025 and was discharged on December 4, 2025. A case consultation was due no later than November 25, 2025; however, none was completed.
Client #3 was admitted on March 31, 2025 and was discharged on November 13, 2025. A case consultation was due no later than June 10, 2025; however, it was not completed until July 8, 2025.
Client #6 was admitted on May 16, 2025 and was still active at the time of the inspection. A case consultation was due no later than July 16, 2025; however, it was not completed until October 3, 2025.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the December 9, 2024 licensing inspection.
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Plan of Correction
A tracking dashboard for Case Consultation due dates will be created by 1/23/2026. The dashboard will be reviewed by all Substance Use Disorder Clinicians weekly. Clients whose Case Consultations that need to be updated during the period will be identified and presented during huddles, individual supervision, rounding or clinical supervision, before the due date. Clinicians will Teams Message confirmation to leads when the consults are complete. Staff will be trained on the new process during Clinical Supervision on 2/3/2026. Those team members responsble for case consultations who are on paid time off or extended leave will be educated to the requirement upon their return by the program manager or designee. New hires will be trained during Onboarding. If a clinician is out of the office, plans will be made for another clinician to cover. The Grant Evaluator or designee will check the Update Status report that she manages for compliance monitoring. Monitoring results will be reported monthly to the Quality Management Council by the Project Director or designee. The corrective action plan will be determined effective after 3 consecutive reporting periods of 100% compliance have been achieved. |