INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28, 2026 and July 29, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, MPower Wellness of Pennsylvania 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor met the educational qualifications for the position in one of three applicable personnel records reviewed.
Employee # 7 was hired as a counselor on January 20, 2026 and was still in this position at the time of inspection. The personnel record included documentation that the employee was currently attending a Master's degree program as of the date of the inspection. At the time of the inspection, there was no educational undergraduate credentials documented in the personnel record; therefore, the employee was unable to be verified as being qualified for the position.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility corrected this deficiency effective August 24, 2026. The undergraduate educational credentials of Employee #7 were obtained and reviewed by the Executive Director. The employee's undergraduate degree and transcripts were verified, and the employee was determined to meet the educational qualifications required for the Counselor position. Copies of the employee's undergraduate degree and transcripts have been uploaded to and maintained in the employee's personnel record.
To prevent recurrence of this deficiency, the facility will ensure that educational credentials are obtained and reviewed as part of the qualification verification process for employees hired into clinical positions. The Executive Director will verify that documentation supporting the employee's required educational qualifications, including applicable degrees and/or transcripts, is maintained in the employee's personnel record.
The Executive Director will monitor compliance through periodic review of clinical personnel records to ensure documentation supporting the educational qualifications for each employee's assigned position is present and readily available for review. Any missing credential documentation identified during these reviews will be obtained and added to the personnel record promptly.
Corrective Action Date: August 24, 2026
Person Responsible for Implementation and Ongoing Compliance: Executive Director |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on the review of personnel records, the facility failed to ensure that a counselor assistant, with a high school diploma, counseled clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment; then, during the next 9 months of employment, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor in one of one applicable personnel record reviewed.
Employee # 9 was hired as a counselor assistant on February 2, 2026. The documentation in the personnel record showed the employee had a high school diploma. There was no documentation of direct observation and close supervision notes during the months of March 2026 and May 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility corrected this deficiency effective August 3, 2026. Employee #9 began receiving the required direct observation and close supervision by a qualified clinician in accordance with 28 Pa. Code § 704.9(c). Documentation of the required supervision and direct observation will be maintained in the employee's personnel record.
To prevent recurrence of this deficiency, the Executive Director will ensure that all employees hired into a Counselor Assistant position are reviewed at the time of hire to determine the applicable supervision requirements based upon the employee's educational qualifications. A supervision schedule will be established in accordance with § 704.9(c), and documentation of all required direct observation and/or close supervision will be maintained in the employee's personnel record.
The Executive Director will monitor compliance by periodically reviewing Counselor Assistant personnel records to verify that required supervision and direct observation are occurring and are appropriately documented throughout the applicable supervised period. Any missing documentation or lapse in required supervision identified through this review will be addressed immediately. |
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 the review of personnel records, the facility failed to ensure all staff persons received at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in three of five applicable personnel record reviewed.
Employee # 3 was hired as a counselor on July 21, 2025 and was due to have at least 4 hours of TB/STD training completed no later than July 21, 2026; however, there was documentation indicating only 1 hour of TB/STD training was completed as of the date of the inspection.
Employee # 4 was hired as a counselor on July 14, 2025 and was due to have at least 4 hours of TB/STD training completed no later than July 14, 2026; however, there was documentation indicating only 1 hour of TB/STD training was completed as of the date of the inspection.
Employee # 5 was hired as a counselor on July 23, 2025 and was due to have at least 4 hours of TB/STD training completed no later than July 23, 2026; however, there was documentation indicating only 1 hour of TB/STD training was completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has identified Employees #3, #4, and #5 as requiring additional tuberculosis, sexually transmitted diseases, and other health-related topics training to meet the requirements of 704.11(c)(1).
Employees #3, #4, and #5 will be registered for the next available Department-approved TB/STD and other health-related topics training. Employee #3 will complete the required training no later than December 31, 2026. Employee #4 will complete the required training no later than December 31, 2026. Employee #5 will complete the required training no later than December 31, 2026. Upon completion, documentation of the training will be maintained in each employee's personnel record and reflected in the facility's existing training tracking system.
To prevent recurrence, the facility will utilize its existing training tracking system to monitor mandatory staff training requirements, required training hours, and applicable completion deadlines. Staff requiring Department-approved training will be identified in advance of their regulatory deadlines and registered for an available Department-approved course. The Executive Director or designee will periodically review the training tracker to ensure required trainings are scheduled and completed within the applicable regulatory timeframes.
Corrective Action Completion Date: December 31, 2026 |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to ensure all staff were instructed in the use of the fire extinguisher upon staff employment in three of six applicable records reviewed.
Employee # 2 was hired as a counselor on August 11, 2025. The fire extinguisher training was not completed upon staff employment, as it was completed on July 9, 2026.
Employee # 6 was hired as a counselor on February 2, 2026. The fire extinguisher training was not completed upon staff employment, as it was completed on July 8, 2026.
Employee # 7 was hired as a counselor on January 20, 2026. The fire extinguisher training was not completed upon staff employment, as it was completed on February 13, 2026.
This is a repeat citation from the July 8, 2024 and August 8, 2025 annual licensing renewal inspections.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As of August 24, 2026, Employees #2, #6, and #7 have completed the required fire extinguisher training. Fire extinguisher training is currently included as part of the facility's new-hire training requirements; however, the identified employees did not complete the assigned training upon employment as required.
To prevent recurrence, the facility will reinforce the requirement that fire extinguisher training be completed upon employment. The Executive Director or designee will verify completion of the assigned fire extinguisher training for each newly hired employee as part of the onboarding process. New-hire training will not be considered complete until the fire extinguisher training has been completed and documented.
The facility will utilize its existing training tracking system to monitor completion and will follow up immediately with any newly hired employee who has outstanding required training to ensure compliance with 705.28(c)(4). |
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 the review of August 2025 through June 2026 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, there was no documentation indicating fire drills were conducted during the months of August 2025 and September 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that unannounced fire drills are conducted at least once each month as required. Moving forward, responsibility for conducting and documenting the monthly fire drill will be assigned to designated facility staff.
To prevent recurrence, the Executive Director or designee will review the fire drill log each month to verify that the required unannounced fire drill has been completed and properly documented. Any missing documentation will be addressed immediately to ensure that a fire drill is conducted during each calendar month. Completed fire drill documentation will be maintained at the facility and available for review during future licensing inspections. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies in three of six applicable records
Employee # 2 was hired as a counselor on August 11, 2025. The emergency preparedness training was not completed upon staff employment, as it was completed on July 8, 2026.
Employee # 6 was hired as a counselor on February 2, 2026. The emergency preparedness training was not completed upon staff employment, as it was completed on July 8, 2026.
Employee # 7 was hired as a counselor on January 20, 2026. The emergency preparedness training was not completed upon staff employment, as it was completed on February 16, 2026.
This is a repeat citation from the July 8, 2024 and August 8, 2025 annual licensing renewal inspections.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As of August 24, 2026, Employees #2, #6, and #7 have completed the required emergency preparedness training. Emergency preparedness training is currently included as part of the facility's new-hire training requirements; however, the identified employees did not complete the assigned training upon employment as required.
To prevent recurrence, the facility will reinforce the requirement that emergency preparedness training be completed upon employment. The Executive Director or designee will verify completion of the assigned emergency preparedness training for each newly hired employee as part of the onboarding process. New-hire training will not be considered complete until the required emergency preparedness training has been completed and documented.
The facility will utilize its existing training tracking system to monitor completion and will follow up immediately with any newly hired employee who has outstanding required training to ensure all personnel are trained to perform assigned tasks during emergencies. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on the review of the August 2025 through June 2026 fire drill logs, the facility failed to maintain a written fire drill record, which is to include documentation of the date, time, amount of time for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered, and whether a fire alarm or smoke detector was operative.
At the time of the inspection, the fire drill logs for the months of October 2025, March 2026, April 2026, and May 2026 were missing the length of time for evacuation and the exit route used. Additionally, the fire drill logs for the months of December 2025, January 2026, February 2026, and June 2026 were missing the exit route used.
This is a repeat citation from the July 8, 2024 and August 8, 2025 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will correct this deficiency by implementing a revised fire drill documentation process to ensure that all required information is recorded for each fire drill. Effective August 24, 2026, fire drill documentation will include the date and time of the drill, amount of time required for evacuation, exit route used, number of persons in the facility at the time of the drill, any problems encountered, and documentation indicating whether the fire alarm or smoke detector was operative.
To prevent recurrence of this deficiency, staff responsible for conducting and documenting fire drills will be instructed to complete all required elements of the fire drill record at the time each drill is conducted. The Executive Director or designee will review completed fire drill documentation to verify that all required information has been recorded, including the evacuation time and exit route used.
Because this was identified as a repeat deficiency, the Executive Director or designee will maintain ongoing oversight of the fire drill records and will review each completed fire drill log for completeness. If any required information is found to be missing, the documentation issue will be addressed promptly with the responsible staff member to ensure continued compliance.
Corrective Action Date: August 24, 2026
Person Responsible for Implementation and Ongoing Compliance: Executive Director or designee |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to ensure the completion of annual written individual staff performance evaluations, which are to be reviewed and signed by the employee, in three of three applicable personnel records reviewed.
Employee # 3 was hired as a counselor on July 21, 2025. The most recent individual performance evaluation was documented in the record, but the evaluation was not signed by the employee.
Employee # 4 was hired as a counselor on July 14, 2025. The most recent individual performance evaluation was documented in the record, but the evaluation was not signed by the employee.
Employee # 5 was hired as a counselor on July 23, 2025. The most recent individual performance evaluation was documented in the record, but the evaluation was not signed by the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility corrected this deficiency effective August 24, 2026. The annual written individual staff performance evaluations for Employees #3, #4, and #5 were reviewed and signed by the respective employees, and the completed evaluations are maintained in their personnel records.
To prevent recurrence of this deficiency, all annual staff performance evaluations will be reviewed with the employee and signed by the employee upon completion. The Executive Director or designee will ensure that the employee's signature is obtained before the evaluation is considered complete and that the signed evaluation is maintained in the employee's personnel record.
The Executive Director or designee will monitor compliance through periodic review of personnel records to ensure annual performance evaluations are completed, reviewed, and signed by the employee as required. Any incomplete or unsigned evaluations identified during these reviews will be addressed promptly.
Person Responsible for Implementation and Ongoing Compliance: Executive Director or designee |
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 client records, the facility failed to ensure a copy of a consent to release information form was offered to the client in eleven of fourteen client records reviewed.
Client # 1 was admitted into the partial hospitalization activity on July 17, 2026 and was active at the time of inspection. There was no documentation indicating a copy of the client-signed release of information form to the funding source was offered to the client.
Client # 2 was admitted into the partial hospitalization activity on December 23, 2025 and was discharged on January 29, 2026. There was no documentation indicating a copy of the client-signed release of information form to the funding source was offered to the client.
Client # 3 was admitted into the partial hospitalization activity on May 6, 2026 and was discharged on June 3, 2026. There was no documentation indicating a copy of the client-signed release of information form to the funding source was offered to the client.
Client # 5 was admitted into the partial hospitalization activity on December 18, 2025 and was discharged on December 29, 2025. There was no documentation indicating a copy of the client-signed release of information form to the funding source was offered to the client.
Client # 6 was admitted into the partial hospitalization activity on April 9, 2026 and was discharged on April 16, 2026. There was no documentation indicating a copy of the client-signed release of information form to the funding source was offered to the client.
Client # 7 was admitted into the partial hospitalization activity on May 26, 2026 and was discharged on June 16, 2026. There was no documentation indicating a copy of the client-signed release of information form to the funding source was offered to the client.
Client # 8 was admitted into the outpatient activity on July 13, 2026 and was active at the time of inspection. There was no documentation indicating a copy of the client-signed release of information form to the funding source was offered to the client.
Client # 9 was admitted into the outpatient activity on June 5, 2026 and was active at the time of inspection. There was no documentation indicating a copy of the client-signed release of information form to the funding source was offered to the client.
Client # 10 was admitted into the outpatient activity on April 7, 2026 and was active at the time of inspection. There was no documentation indicating a copy of the client-signed release of information form to the funding source was offered to the client.
Client # 11 was admitted into the outpatient activity on September 4, 2025 and was discharged on October 31, 2025. There was no documentation indicating a copy of the client-signed release of information form to the funding source was offered to the client.
Client # 13 was admitted into the outpatient activity on August 19, 2025 and was discharged on December 19, 2025. There was no documentation indicating a copy of the client-signed release of information form to the funding source was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of August 24, 2026, the facility has revised its Consent to Release Information form to include a checkbox documenting whether the client was offered a copy of the completed, client-signed release. This revision provides clear documentation within the client record that the required offer was made.
Moving forward, staff completing a Consent to Release Information form with a client will be required to indicate on the form that a copy was offered to the client and document whether the client accepted or declined the copy.
Staff will be educated on the revised form and the requirement to offer clients a copy of each completed release. The Executive Director or designee will monitor compliance through periodic client record reviews to ensure the appropriate documentation is completed and maintained in the client record. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five of five applicable records reviewed.
Client # 1 was admitted into the partial hospitalization activity on July 17, 2026 and was active at the time of inspection. The individual treatment plan was completed on July 23, 2026; however, the plan did not include documentation of the type of treatment and rehabilitation services the client was to receive.
Client # 2 was admitted into the partial hospitalization activity on December 23, 2025 and was discharged on January 29, 2026. The individual treatment and rehabilitation plan was completed on January 5, 2026; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services the client was to receive.
Client # 3 was admitted into the partial hospitalization activity on May 6, 2026 and was discharged on June 3, 2026. The individual treatment and rehabilitation plan was completed on May 8, 2026; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services the client was to receive.
Client # 4 was admitted into the partial hospitalization activity on October 24, 2025 and was discharged on November 24, 2025. The individual treatment and rehabilitation plan was completed on November 4, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services the client was to receive.
Client # 7 was admitted into the partial hospitalization activity on May 26, 2026 and was discharged on June 16, 2026. The individual treatment and rehabilitation plan was completed on May 28, 2026; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services the client was to receive.
This is a repeat citation from the July 13, 2023, July 8, 2024, and August 8, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of August 5, 2026, clinical staff have been provided training regarding the requirements of 709.82(a)(2), specifically that each individual treatment and rehabilitation plan must clearly document both the type and frequency of treatment and rehabilitation services the client is to receive. Staff were instructed that treatment plans must identify the specific services being provided, such as individual therapy, group therapy, case management, family services, medication management, and other applicable services, as well as the planned frequency of each service.
Moving forward, the facility will ensure that the type and frequency of all applicable treatment and rehabilitation services are clearly documented on each client's individual treatment and rehabilitation plan. The Executive Director or designee will monitor treatment plans through ongoing chart review to verify compliance. Any treatment plan identified as incomplete will be returned to the responsible clinician for prompt correction.
The facility will continue to reinforce this requirement with clinical staff to ensure sustained compliance with 709.82(a)(2) and prevent recurrence. |
709.83(a)(11) LICENSURE Client records
709.83. 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 maintain a complete client record on an individual, which is to include documentation of follow-up information, in four of six applicable records reviewed.
Client # 2 was admitted on December 23, 2025 and was discharged on January 29, 2026. There was no follow-up information documented in the record at the time of the inspection.
Client # 3 was admitted into the partial hospitalization activity on May 6, 2026 and was discharged on June 3, 2026. There was no follow-up information documented in the record at the time of the inspection.
Client # 5 was admitted into the partial hospitalization activity on December 18, 2025 and was discharged on December 29, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client # 7 was admitted into the partial hospitalization activity on May 26, 2026 and was discharged on June 16, 2026. There was no follow-up information documented in the record at the time of the inspection.
This is a repeat citation from the July 8, 2024 and August 8, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of August 24, 2026, the facility has updated its policies and procedures regarding client follow-up after discharge. The revised policy requires follow-up attempts to be completed at 7 days and 30 days following discharge.
Moving forward, designated staff will be responsible for completing the required follow-up attempts and documenting each attempt and its outcome in the client's record. Follow-up documentation will be completed regardless of whether contact with the former client is successful, including documentation of unsuccessful attempts to reach the client.
The Executive Director or designee will monitor compliance through periodic review of discharged client records to ensure that required follow-up attempts are completed and documented at the 7-day and 30-day intervals. Any identified deficiencies will be addressed with the responsible staff to ensure ongoing compliance with 709.83(a)(11 |
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 client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five of six applicable records reviewed.
Client # 8 was admitted into the outpatient activity on July 13, 2026 and was active at the time of inspection. The individual treatment plan was completed on July 27, 2026; however, the plan did not include documentation of the type of treatment and rehabilitation services the client was to receive.
Client # 10 was admitted into the outpatient activity on April 7, 2026 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on April 19, 2026; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services the client was to receive.
Client # 11 was admitted into the outpatient activity on September 4, 2025 and was discharged on October 31, 2025. The individual treatment and rehabilitation plan was completed on September 9, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services the client was to receive.
Client # 12 was admitted into the outpatient activity on September 3, 2025 and was discharged on December 5, 2025. The individual treatment and rehabilitation plan was completed on September 8, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services the client was to receive.
Client # 13 was admitted into the outpatient activity on August 19, 2025 and was discharged on December 19, 2025. The individual treatment and rehabilitation plan was completed on August 27, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services the client was to receive.
This is a repeat citation from the July 13, 2023, July 8, 2024, and August 8, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of August 5, 2026, clinical staff have been provided training regarding the requirements of 709.92(a)(2), specifically that each individual treatment and rehabilitation plan must clearly document both the type and frequency of treatment and rehabilitation services the client is to receive. Staff were instructed that treatment plans must identify the specific services being provided, such as individual therapy, group therapy, case management, family services, medication management, and other applicable services, as well as the planned frequency of each service.
Moving forward, the facility will ensure that the type and frequency of all applicable treatment and rehabilitation services are clearly documented on each client's individual treatment and rehabilitation plan. The Executive Director or designee will monitor treatment plans through ongoing chart review to verify compliance. Any treatment plan identified as incomplete will be returned to the responsible clinician for prompt correction.
The facility will continue to reinforce this requirement with clinical staff to ensure sustained compliance with 709.92(a)(2) and prevent recurrence.
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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 ensure treatment and rehabilitation plans were updated at least every 60 days in two of six applicable records reviewed.
Client # 10 was admitted into the outpatient activity on April 7, 2026 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on April 19, 2026, and the first update was due no later than June 19, 2026; however, the update was not completed until July 10, 2026.
Client # 13 was admitted into the outpatient activity on August 19, 2025 and was discharged on December 19, 2025..A treatment plan update was completed on September 9, 2025, and the next update was due no later than November 9 2025; however, the update was not completed until November 17, 2025.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
As of August 5, 2026, clinical staff have been provided training regarding the requirement that outpatient individual treatment and rehabilitation plans be reviewed and updated at least every 60 days.
Moving forward, clinical staff will be responsible for ensuring that treatment plan updates are completed within the required 60-day timeframe. Staff have been instructed to monitor treatment plan due dates and complete updates prior to the expiration of the applicable 60-day period.
The Executive Director or designee will monitor compliance through ongoing client record reviews to verify that treatment plan updates are being completed within the required timeframe. Any identified deficiencies will be addressed promptly with the responsible clinician to ensure continued compliance and prevent recurrence. |
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 client records and the facility's policy and procedure manual, the facility failed to maintain a complete client record on an individual, which is to include the documentation of case consultation notes, in four of four applicable client records reviewed.
The facility's policy and procedures manual stated that case consultations will be completed every 90 days following admission.
Client # 10 was admitted into the outpatient activity on April 7, 2026 and was active at the time of inspection. There were no case consultation notes documented in the record at the time of inspection.
Client # 12 was admitted into the outpatient activity on September 3, 2025 and was discharged on December 5, 2025. There were no case consultation notes documented in the record at the time of inspection.
Client # 13 was admitted into the outpatient activity on August 19, 2025 and was discharged on December 19, 2025. There were no case consultation notes documented in the record at the time of inspection.
Client # 14 was admitted into the outpatient activity on July 21, 2025 and was discharged on November 21, 2025. There were no case consultation notes documented in the record at the time of inspection.
This is a repeat citation from the August 8, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of August 5, 2026, the facility has added a Multidisciplinary Note to the EMR specifically for documenting case consultations. Clinical staff have been trained on the use of this note and on the requirement that case consultations be completed and documented in accordance with facility policy.
Moving forward, case consultations will be completed and documented at least every 90 days following admission for applicable outpatient clients. Staff will utilize the Multidisciplinary Note in the EMR to document the consultation and ensure that the required information is maintained as part of the client's clinical record.
The Executive Director or designee will monitor compliance through ongoing client record reviews to ensure case consultations are completed and documented within the required timeframe. Any identified deficiencies will be addressed promptly with the responsible staff to ensure ongoing compliance with 709.93(a)(8) and prevent recurrence. |
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 maintain a complete client record on an individual, which is to include documentation of follow-up information, in three of four applicable records reviewed.
Client # 11 was admitted into the outpatient activity on September 4, 2025 and was discharged on October 31, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client # 12 was admitted into the outpatient activity on September 3, 2025 and was discharged on December 5, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client # 13 was admitted into the outpatient activity on August 19, 2025 and was discharged on December 19, 2025. There was no follow-up information documented in the record at the time of the inspection.
This is a repeat citation from the July 8, 2024 and August 8, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of August 24, 2026, the facility has updated its policies and procedures regarding client follow-up after discharge. The revised policy requires follow-up attempts to be completed at 7 days and 30 days following discharge.
Moving forward, designated staff will be responsible for completing the required follow-up attempts and documenting each attempt and its outcome in the client's record. Follow-up documentation will be completed regardless of whether contact with the former client is successful, including documentation of unsuccessful attempts to reach the client.
The Executive Director or designee will monitor compliance through periodic review of discharged client records to ensure that required follow-up attempts are completed and documented at the 7-day and 30-day intervals. Any identified deficiencies will be addressed with the responsible staff to ensure ongoing compliance with 709.93(a)(11) and prevent recurrence. |
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 an administrative review and 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 failing to document the type and frequency of services in outpatient individual treatment plans was submitted and approved by the Department for the July 13, 2023, July 8, 2024, and August 8, 2025 annual licensing inspections. Not documenting the type and frequency of services was again found to be a deficiency in the July 29, 2026 licensing inspection.
A plan of correction for failing to document the type and frequency of services in partial hospitalization individual treatment plans was submitted and approved by the Department for the July 13, 2023, July 8, 2024, and August 8, 2025 annual licensing inspections. Not documenting the type and frequency of services was again found to be a deficiency in the July 29, 2026 licensing inspection.
A plan of correction for failing to document follow-up information in partial hospitalization client records was submitted and approved by the Department for the July 8, 2024 and August 8, 2025 annual licensing inspections. Not documenting follow-up information was again found to be a deficiency in the July 29, 2026 licensing inspection.
A plan of correction for failing to document follow-up information in outpatient client records was submitted and approved by the Department for the July 8, 2024 and August 8, 2025 annual licensing inspections. Not documenting follow-up information was again found to be a deficiency in the July 29, 2026 licensing inspection.
A plan of correction for failing to document the time it took for evacuation in fire drill records was submitted and approved by the Department for the July 8, 2024 and August 8, 2025 annual licensing inspections. Not documenting evacuation time was again found to be a deficiency in the July 29, 2026 licensing inspection.
A plan of correction for failing to complete staff fire extinguisher instruction within the required timeframe in employee records was submitted and approved by the Department for the July 8, 2024 and August 8, 2025 annual licensing inspections. Not completing staff fire extinguisher instruction timely was again found to be a deficiency in the July 29, 2026 licensing inspection.
A plan of correction for failing to complete staff emergency preparedness training within the required timeframe in employee records was submitted and approved by the Department for the July 8, 2024 and August 8, 2025 annual licensing inspections. Not completing staff emergency preparedness training timely was again found to be a deficiency in the July 29, 2026 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of August 24, 2026, the facility has reviewed the findings identified during the July 29, 2026 licensing inspection, including the deficiencies that were previously addressed through Department-approved plans of correction. The facility recognizes that previous corrective actions did not result in sustained compliance in the identified areas and has implemented additional oversight and monitoring measures to prevent recurrence.
Clinical staff have received training regarding the requirement to clearly document both the type and frequency of treatment and rehabilitation services on individual treatment plans. Compliance with this requirement will be monitored through ongoing client record reviews by the Executive Director or designee.
The facility has revised its discharge follow-up procedures to require documented follow-up attempts at 7 days and 30 days following discharge. Designated staff will complete and document these attempts, and discharged records will be periodically reviewed to verify compliance.
Fire extinguisher and emergency preparedness training are included in the facility's new-hire training requirements through Bayside CEU. The Executive Director or designee will verify completion of these required trainings during the onboarding process rather than relying solely on assignment of the training to the employee.
The facility will ensure that unannounced fire drills are conducted at least monthly and that all required information, including evacuation time, is documented on the fire drill record. The Executive Director or designee will review fire drill documentation to verify completion and accuracy.
In addition to the corrective actions associated with each individual deficiency, the Executive Director or designee will conduct ongoing compliance monitoring of the areas identified in the approved plans of correction. Any deficiency identified through internal monitoring will be addressed promptly with the responsible staff and corrective action taken prior to the applicable regulatory deadline.
These additional monitoring and accountability measures are being implemented to ensure that corrective actions are not only completed initially but are maintained on an ongoing basis and that the facility achieves sustained compliance with Department regulations and approved plans of correction.
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