INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Step-By-Step Support 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one applicable client record.
Client #1 was admitted on October 14, 2025, and discharged on January 19, 2026.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction
Regulation: § 709.33 Notification of Termination
Corrective Action Taken:
The facility reviewed Client #1's record and confirmed that written notification of involuntary termination was not maintained in the client's file as required. A written termination notice has been developed and added to the facility's documentation procedures to ensure compliance with § 709.33.
Systemic Changes:
A standardized Involuntary Termination Notice form has been created and will be utilized for all involuntary discharges.
All clinical and administrative staff have been retrained regarding the requirements of § 709.33, including the requirement to provide written notification to clients and maintain a copy in the client record.
A discharge checklist has been implemented to ensure all required discharge documentation is completed prior to closing a client file.
The Clinical Director will conduct monthly chart audits for a period of six months to verify compliance with termination notification requirements.
Date of Compliance:
Compliance was achieved immediately upon identification of the deficiency and will be maintained through ongoing monitoring and staff oversight.
Responsible Person: The Director |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in three of three applicable records.
The facility's policy and procedures state an aftercare plan is to be completed for all successful discharges.
Client #2 was admitted on January 27, 2026, and successfully discharged on April 10, 2026.
Client #3 was admitted on November 18, 2025, and successfully discharged on February 27, 2026.
Client #4 was admitted on October 10, 2025, and successfully discharged on January 12, 2026.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Corrective Action Taken:
The records for Client #2, Client #3, and Client #4 were reviewed. Aftercare plans were completed and added to the client records to reflect discharge recommendations, community supports, recovery resources, and follow-up care recommendations.
Systemic Changes:
The Clinical Director reviewed the facility's discharge procedures with all clinical staff and reinforced the requirement that an aftercare plan must be completed and documented for every successful discharge prior to case closure. The discharge checklist was revised to include verification of a completed aftercare plan before a client record can be finalized.
Monitoring:
The Clinical Director or designee will conduct monthly audits of discharged client records for a period of six months to ensure aftercare plans are completed and maintained in accordance with facility policy and DDAP regulations. Any deficiencies identified will be addressed through staff supervision and corrective training.
Completion Date:
Immediately upon acceptance of this Plan of Correction and ongoing thereafter.
Responsible Person:
Program Director |