INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 24, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PHMC Pathways to Recovery 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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704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of personnel records, the facility failed to ensure each employee ' s individual training plan was based upon that employee's previous education, experience, current job functions, and performance in six of six personnel records reviewed.
In every personnel record reviewed, the individual training plans were identical and were not individualized based on each specific employee's previous education, experience, current job functions, and job performance.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All active staff at PTR will complete a new Individualized Staff Training Plan. Plans will be based upon employees' previous education, experience, current job functions, and performance, with input from both the employee and supervisor by 8/30/2025.
During staff orientation, within 30 days of hire, all new staff will complete the initial PTR Individual Staff Training Plan with their assigned supervisor. The Staff Training Plans will be Individualized: based upon employees' previous education, experience, current job functions, and performance, with input from both the employee and supervisor . Every year, during the month of January, all existing staff will complete the PTR Staff Training Plan annual update Plan with their assigned supervisor. Both staff and supervisor, prior to signing and dating the initial or annual update Staff Training Plans, will individualize the Staff Training Plan by adding information (e.g. goals, comments) specific to that staff member: based upon employees' previous education, experience, current job functions, and performance. A copy will be offered to the staff member, and the original will be reviewed by the Program Director for completeness prior to being placed in the staff's personnel file.
All staff and supervisors will be trained on this plan of correction by 8/30/2025.
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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 a review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of three applicable personnel records reviewed.
Employee # 4 was hired as a counselor on November 28, 2023 and was due to have both trainings completed no later than November 28, 2024. There was documentation the HIV/AIDS training was completed, but the TB/STD training was not completed at the time of the inspection.
This is a repeat citation from the June 25, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All active staff at PTR without completed Mandatory Communicable Disease Trainings on file at PTR within required timeframes as described by 704.11(c)(1) will complete those training courses by 9/30/2025.
During staff orientation, within 30 days of hire, all new staff will complete the initial PTR Individual Staff Training Plan with their assigned supervisor. Every year, during the month of January, all existing staff will complete the PTR Individual Staff Training Plan annual update Plan with their assigned supervisor. Supervisors will review the PA Code 704.11 DDAP Training requirements and timeframes with the staff members during their Training Plan development meeting. Supervisors will instruct staff members on how to sign up and complete the training courses, including 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics, and will develop a plan to complete those DDAP training courses. During regular supervision/staff meetings (e.g. monthly), supervisors will review staff compliance with meeting the DDAP training course completion requirements. Supervisors will review their assigned staff member's course completions with the program director during their regular supervisor staff meetings (e.g. monthly). During regular program director supervision meetings (e.g. monthly), the Program Director will review program staff training course completions with the Managing Director of Addiction Services. Compliance with staff training course completion requirements will be documented on staff supervision notes.
All staff and supervisors will be trained on this plan of corrective by 8/30/2025.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training in one of two applicable personnel record reviewed.
Employee # 3 was hired as a counselor on November 7, 2022. The personnel record documented 7.5 hours of annual training during the facility's January 1, 2024 through December 31, 2024 training year.
This is a repeat citation from the June 25, 2024 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All active Counselors will be instructed by their Supervisor(s) to review 704.11 training hour requirements by 8/30/2025 and will sign agreement to a plan to complete the required training hours for the current training year (calendar year 2025).
During staff orientation, within 30 days of hire, all new staff will complete the initial PTR Individual Staff Training Plan with their assigned supervisor. Every year, during the month of January, all existing staff , including the counselors , will complete the PTR Individual Staff Training Plan annual update Plan with their assigned supervisor. Supervisors will review the PA Code 704.11 DDAP Training requirements and timeframes with the staff members during their Training Plan development meeting. Supervisors will instruct staff members on how to sign up and complete the training courses, completing the required clock hours of annual training, and will develop a plan to complete the DDAP required training hours. During regular supervision/staff meetings (e.g. monthly), supervisors will review staff compliance with meeting the DDAP training course completion requirements. Supervisors will review their assigned staff member's course completions with the program director during their regular supervisor staff meetings (e.g. monthly). During regular program director supervision meetings (e.g. monthly), the Program Director will review program staff training course completions with the Managing Director of Addiction Services. Compliance with staff training course completion requirements will be documented on staff supervision notes.
All staff and supervisors will be trained on this plan of corrective by 8/30/2025.
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's July 2024 through April 2025 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
The facility's posted hours of operation are Monday, Wednesday and Friday from 8:30am to 5pm, Tuesday and Thursday from 8:30am to 7pm and Saturday from 8:30am to 12pm.
Every fire drill conducted during the reviewed period were completed during the weekdays and all between the hours of 9:17am and 3:20pm. There were no evening hours or Saturday fire drills conducted during the reviewed period.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that Fire drills are conducted on different days of the week, at different times of the day and on different staffing shifts. The Program Director or the Program Director's assigned designee will, at least monthly, conduct the unannounced fire drill and document the results of the unannounced fire drill in the agency fire drill log. During the licensing year, there will be conducted and documented fire drills that occur at each of the shifts posted, including: Monday, Wednesday and Friday from 8:30am to 5pm, Tuesday and Thursday from 8:30am to 7pm and Saturday from 8:30am to 12pm. The Program Director will review the fire drill logs at least monthly to ensure that the drills were conducted and that the documentation of the drills are complete according to the 705.28 (d) (6) regulation. Priority will be given during the current licensing year (2025-2026) to conduct evening and Saturday fire drills. The Program Director will review this plan of correction with all staff responsible for conducting and documenting fire drills at the PHMC Pathways to Recovery facility by 8/30/2025. |
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 complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 5 was admitted on November 1, 2024 and was discharged on January 3, 2025. The release of information form to the funding source was signed by the client on May 7, 2024 and expired on November 6, 2024. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form, signed by the client, documented in the record prior to any disclosures after November 6, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and/or the Program Director's designee will conduct a thorough review of all active client charts to ensure that current releases of information are in place and valid. In cases where releases have expired and there is an ongoing need to disclose information, assigned therapists will meet with the affected clients to complete updated consent forms. Additionally, the Program Director will provide training to all staff members on the requirements of § 709.28 (c), with a specific focus on obtaining informed and voluntary consent prior to any disclosures. Staff will be instructed, per requirements and agency policy, to verify that a valid release of information is on file before disclosing any client data. And when written information is released, staff must include a copy of the valid consent form alongside the disclosed material. All chart reviews, updates to consent documentation, and staff training will be completed by 8/30/2025. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information form in one of seven client records reviewed.
Client # 7 was admitted on December 17, 2024 and was discharged on March 6, 2025. The release of information form to the emergency contact was signed by the client on December 17, 2024; however, the name of the person, agency or organization to whom the disclosure would be made was not documented on the release form.
This is a repeat citation from the June 25, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will conduct an internal review of all active client file documentation of Consent for the Release of Information (ROI), including that documentation includes 709.28 (c) (1) required information: in writing and include, but not be limited to: (1) Name of the person, agency or organization to whom disclosure is made. Errors and incomplete documentation of Consent for ROI discovered during the internal review will be amended, signed, and dated, with consent from the client, by 8/30/2025.
The Project Director will train all staff responsible for obtaining and documenting clients' Consent for the Release of Information (ROI), on the 709.28 (c) (1) regulatory requirements . Staff training will occur by 8/30/2025.
Prior to disclosure of information, all staff will be responsible to obtain an informed and voluntary consent for Release of Information (ROI) from the client, documented in the official client record per PA Code 709.28 (c) Confidentiality requirements.
During the intake admission process, Consent for Release of Information will be discussed and completed for Emergency Contact, Insurers, Primary Care Physicians (PCP), Dentists, Medical Specialists , treatment providers, and any other involved disclosure parties. Prior to disclosure of information, staff will ensure that there is a complete and valid/ signed ROI on file in the client record for the 3rd party. If not, then the staff member will discuss the disclosure with the client, and obtain written documented consent prior to making the disclosure. Documentation of the consent and the disclosure will be placed in the official client record.
As part of the Individualized Staff Training Plan development, within 30 days of hire, supervisors will instruct every staff member assigned to them to complete a DDAP Approved Confidentiality Training Course within 365 days of hire, which includes information about obtaining Consent for Release of Information.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that complete and valid ROI documentation is present in the official client record, and that ROIs are in use during communications with outside parties. The Compliance Department will report any findings to the Program Director and Managing Director of Addiction Services for internal Plan of Correction.
During regular (e.g. monthly) Supervision, the Program Director will report on progress and completion of this Plan of Correction to the Managing Director of Addiction Services.
All staff and supervisors will be trained on this plan of corrective by 8/30/2025.
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709.30 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.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by the client that they have been notified of their client rights in three of seven client records reviewed.
Client # 1 was admitted on April 30, 2025 and was still active at the time of the inspection. There was no client-signed documentation, in the record, indicating they had been notified of their rights.
Client # 2 was admitted on May 7, 2025 and was still active at the time of the inspection. There was no client-signed documentation, in the record, indicating they had been notified of their rights.
Client # 5 was admitted on November 1, 2024 and was discharged on January 3, 2025. There was no client-signed documentation, in the record, indicating they had been notified of their rights.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director or Director's designee will conduct a review of all active client files' documentation of written acknowledgement by clients that they have been notified of Client Rights. Effective immediately , as of 7/23/2025, all existing and new clients will be prompted by admissions and counselor staff for written acknowledgement that they have been notified of those rights, and the documentation placed in their file, by 8/30/2025.
The Project Director will train all staff responsible for obtaining and documenting clients' written acknowledgement that they have been notified of their Client rights, on the 709.30 regulatory requirements . Staff training will occur by 8/30/2025.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that complete and valid Client Rights documentation is present in the official client record. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
During regular (e.g. monthly) Supervision, the Program Director will report on progress and completion of this Plan of Correction to the Managing Director of Addiction Services.
All staff and supervisors will be trained on this plan of corrective by 8/30/2025.
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709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, a psychosocial evaluation of the client in six of seven client records reviewed.
Client # 1 was admitted on April 30, 2025 and was still active at the time of the inspection. There was no psychosocial evaluation documented in the record at the time of the inspection.
Client # 2 was admitted on May 7, 2025 and was still active at the time of the inspection. There was no psychosocial evaluation documented in the record at the time of the inspection.
Client # 3 was admitted on May 2, 2025 and was still active at the time of the inspection. There was no psychosocial evaluation documented in the record at the time of the inspection.
Client # 5 was admitted on November 1, 2024 and was discharged on January 3, 2025. There was no psychosocial evaluation documented in the record at the time of the inspection.
Client # 6 was admitted on December 3, 2024 and was discharged on February 3, 2025. There was no psychosocial evaluation documented in the record at the time of the inspection.
Client # 7 was admitted on December 17, 2024 and was discharged on March 6, 2025. There was no psychosocial evaluation documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director or Director's designee will conduct a review of all active client files' documentation of a completed Psychosocial evaluation. Effective immediately , as of 7/23/2025, all existing and new clients will receive a completed Psychosocial evaluation, and the documentation placed in their file, by 8/30/2025.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that complete Psychosocial evaluation documentation is present in the official client record. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
During regular (e.g. monthly) Supervision, the Program Director will report on progress and completion of this Plan of Correction to the Managing Director of Addiction Services.
All staff and supervisors will be trained on this plan of corrective by the Program Director or the Program Director's designee by 8/30/2025.
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709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, a preliminary treatment and rehabilitation plan in two of two applicable client records reviewed.
Client # 5 was admitted on November 1, 2024 and was discharged on January 3, 2025. There was no documentation of a preliminary treatment and rehabilitation plan in the record at the time of the inspection.
Client # 7 was admitted on December 17, 2024 and was discharged on March 6, 2025. There was no documentation of a preliminary treatment and rehabilitation plan in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by the Program Director and Clinical Director on the requirements of 709.81(b)(7) LICENSURE Intake and admission regulation, by 8/30/2025. Staff participation in this training will be kept in staff training files.
The Clinical Director will review treatment plan completion and due-date status every morning on the Pathways to Recovery Treatment Plan tracker, which is kept in the Clinical Director's office, and will consult staff on a daily basis about treatment plan completions.
The Clinical Director will review treatment plan completion and due-date status at every (e.g. weekly) Clinical Team Meeting using the Pathways to Recovery Treatment Plan tracker, and will consult staff about treatment plan completions during that meeting.
The Clinical Director will review treatment plan completion and due-date status at every (e.g. weekly) Counselor and Intake Coordinator Individual staff meeting, using the Pathways to Recovery Treatment Plan tracker, and will consult staff about their treatment plan completions with clients during that meeting. Compliance with meeting due dates for Treatment Plans with clients on their caseload will be documented on the Counselor's Individual Staff Supervision Notes.
The Clinical Director will report Treatment Plan Completions to the Project Director during regular (e.g. monthly) Supervision meetings. Compliance with meeting due dates for Treatment Plans will be documented on The Clinical Director's Individual Staff Supervision Notes.
The Project Director will report Treatment Plan Completions to the PHMC Managing Director of Addiction Services Division during regular (e.g. monthly) Supervision meetings. Compliance with the Program's meeting due dates for Treatment Plans will be documented on The Program Director's Individual Staff Supervision Notes.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that treatment plans are completed in a timely manner and are present in the official client record. The Compliance Department will report any findings to the Program Director and Managing Director of Addiction Services for internal Plan of Correction.
During regular (e.g. quarterly) Board reporting, the Program Director , in cooperation with the Managing Director of Addiction Services, will report to the Board on progress and completion of these Plans of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2025.
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in three of six applicable client records reviewed.
Client # 4 was admitted on October 22, 2024 and was discharged on January 31, 2025. A treatment plan update was completed on December 4, 2024 and the next update was due no later than January 4, 2025; however, the update was not completed prior to discharge.
Client # 6 was admitted on December 3, 2024 and was discharged on February 3, 2025. A treatment plan update was completed on December 17, 2024 and the next update was due no later than January 17, 2025 however, the update was not completed prior to discharge.
Client # 7 was admitted on December 17, 2024 and was discharged on March 6, 2025. The individual treatment plan was completed on January 15, 2025 and the first update was due no later than February 15, 2025; however, the update was not completed prior to discharge.
This is a repeat citation from the July 14, 2022, June 27, 2023, and June 25, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by the Program Director and Clinical Director on the requirements of 709.82(b) Treatment and rehabilitation services by 8/30/2025. Staff participation in this training will be kept in staff training files.
The Clinical Director will review treatment plan completion and due-date status every morning on the Pathways to Recovery Treatment Plan tracker, which is kept in the Clinical Director's office, and will consult staff on a daily basis about treatment plan completions.
The Clinical Director will review treatment plan completion and due-date status at every (e.g. weekly) Clinical Team Meeting using the Pathways to Recovery Treatment Plan tracker, and will consult staff about treatment plan completions during that meeting.
The Clinical Director will review treatment plan completion and due-date status at every (e.g. weekly) Counselor and Intake Coordinator Individual staff meeting, using the Pathways to Recovery Treatment Plan tracker, and will consult staff about their treatment plan completions with clients during that meeting. Compliance with meeting due dates for Treatment Plans with clients on their caseload will be documented on the Counselor's Individual Staff Supervision Notes.
The Clinical Director will report Treatment Plan Completions to the Project Director during regular (e.g. monthly) Supervision meetings. Compliance with meeting due dates for Treatment Plans will be documented on The Clinical Director's Individual Staff Supervision Notes.
The Project Director will report Treatment Plan Completions to the PHMC Managing Director of Addiction Services Division during regular (e.g. monthly) Supervision meetings. Compliance with the Program's meeting due dates for Treatment Plans will be documented on The Program Director's Individual Staff Supervision Notes.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that treatment plans are completed in a timely manner and are present in the official client record. The Compliance Department will report any findings to the Program Director and Managing Director of Addiction Services for internal Plan of Correction.
During regular (e.g. quarterly) Board reporting, the Program Director , in cooperation with the Managing Director of Addiction Services, will report to the Board on progress and completion of these Plans of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2025.
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709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure counseling services were being provided according to the individual treatment and rehabilitation plan in six of six applicable client records reviewed.
Client # 1 was admitted on April 30, 2025 and was active at the time of the inspection. The individual treatment plan dated April 30, 2025 and the treatment plan updates, completed on May 19, 2025 and June 12, 2025, indicated the client was to receive 60 minutes or 2 individual counseling sessions per week. There were less than two individual sessions and less than 60 minutes documented in the record for each week from May 5, 2025 through June 23, 2025.
Client # 2 was admitted on May 7, 2025 and was active at the time of the inspection. The individual treatment plan dated May 7, 2025 and the treatment plan updates, completed on May 23, 2025 and June 18, 2025, indicated the client was to receive 2 individual counseling sessions per week. There were less than two individual sessions documented in the record for each week from May 12, 2025 through June 8, 2025 and the week of June 16, 2025 through June 22, 2025.
Client # 3 was admitted on May 2, 2025 and was active at the time of the inspection. The individual treatment plan dated May 2, 2025 and the treatment plan updates, completed on May 16, 2025 and June 13, 2025, indicated the client was to receive 2 individual counseling sessions per week. There were less than two individual sessions documented in the record for each week from May 5, 2025 through June 8, 2025 and the week of June 16, 2025 through June 22, 2025.
Client # 4 was admitted on October 22, 2024 and was discharged on January 31, 2025. The individual treatment plan dated October 22, 2024 and the treatment plan updates, completed on October 28, 2024, November 6, 2024, and December 4, 2024, indicated the client was to receive 2 individual counseling sessions per week. There were less than two individual counseling sessions documented in the record for each week within October 28, 2024 through November 10, 2024 and each week from November 25, 2025 through January 29, 2025.
Client # 6 was admitted on December 3, 2024 and was discharged on February 3, 2025. The individual treatment plan dated December 3, 2024 and the treatment plan update, completed on December 17, 2024, indicated the client was to receive 2 individual counseling sessions per week. There were less than two individual counseling sessions documented in the record for each week from December 9, 2024 through February 2, 2025.
Client # 7 was admitted on December 17, 2024 and was discharged on March 6, 2025. The individual treatment plan dated January 15, 2025 indicated that the client was to receive 60 minutes of individual counseling weekly. There was less than 60 minutes of individual counseling documented in the record for each week from December 23, 2024 through March 2, 2025.
This is a repeat citation from the June 27, 2023 and June 25, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by the Program Director and Clinical Director on the requirements of 709.82(c) Treatment and rehabilitation services by 8/30/2025. Staff participation in this training will be kept in staff training files.
The Clinical Director will review that counseling services are provided according to the individual treatment and rehabilitation plan using the Pathways to Recovery Client Registry Service (CRS) Electronic Health Record (EHR), at least weekly.
The Clinical Director will review counseling services completion status at every (e.g. weekly) Clinical Team Meeting with the counseling staff.
The Clinical Director will review counseling services completion and due-date status at every (e.g. weekly) Counselor and Intake Coordinator Individual staff meeting, using the CRS EHR. Compliance with meeting counseling services frequencies for clients on their caseload will be documented on the Counselor's Individual Staff Supervision Notes.
The Clinical Director will report counseling services completion to the Project Director during regular (e.g. monthly) Supervision meetings. Compliance with meeting frequencies for counseling services will be documented on The Clinical Director's Individual Staff Supervision Notes.
The Project Director will report counseling services completions to the PHMC Managing Director of Addiction Services Division during regular (e.g. monthly) Supervision meetings. Compliance with the Program's meeting due dates for counseling services will be documented on The Program Director's Individual Staff Supervision Notes.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that counseling services are completed in a timely manner according to the treatment plans and are present in the official client record. The Compliance Department will report any findings to the Program Director and Managing Director of Addiction Services for internal Plan of Correction.
During regular (e.g. quarterly) Board reporting, the Program Director , in cooperation with the Managing Director of Addiction Services, will report to the Board on progress and completion of these Plans of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2025.
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on review of client records, the facility failed to ensure clients admitted to the partial hospitalization program received individual counseling, at least twice weekly, in seven of seven client records reviewed.
Client # 1 was admitted on April 30, 2025 and was active at the time of the inspection. There were less than two individual sessions documented in the record for each week from May 5, 2025 through June 23, 2025.
Client # 2 was admitted on May 7, 2025 and was active at the time of the inspection. There were less than two individual sessions documented in the record for each week from May 12, 2025 through June 8, 2025 and during the week of June 16, 2025 through June 22, 2025.
Client # 3 was admitted on May 2, 2025 and was active at the time of the inspection. There were less than two individual sessions documented in the record for each week from May 5, 2025 through June 8, 2025 and during the week of June 16, 2025 through June 22, 2025.
Client # 4 was admitted on October 22, 2024 and was discharged on January 31, 2025. There were less than two individual sessions documented in the record for each week from October 28, 2024 through November 10, 2024 and during each week from November 25, 2025 through January 29, 2025.
Client # 5 was admitted on November 1, 2024 and was discharged on January 3, 2025. There were less than two individual sessions documented in the record for each week from November 4, 2024 through December 29, 2024.
Client # 6 was admitted on December 3, 2024 and was discharged on February 3, 2025. There were less than two individual sessions documented in the record for each week from December 9, 2024 through February 2, 2025.
Client # 7 was admitted on December 17, 2024 and was discharged on March 6, 2025. There were less than two individual sessions documented in the record for each week from December 23, 2024 through March 2, 2025.
This is a repeat citation from the July 14, 2022, June 27, 2023, and June 25, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by the Program Director and Clinical Director on the requirements of 709.82(d)(1) Treatment and rehabilitation services by 8/30/2025. Staff participation in this training will be kept in staff training files.
On at least a weekly basis, the Clinical Director will review that individual counseling services are provided to clients according to the 709.82(d)(1) , at least twice weekly, using the Pathways to Recovery Client Registry Service (CRS) Electronic Health Record (EHR).
The Clinical Director will review counseling services completion status at every (e.g. weekly) Clinical Team Meeting with the counseling staff.
The Clinical Director will review counseling services completion and due-date status at every (e.g. weekly) Counselor and Intake Coordinator Individual staff meeting, using the CRS EHR. Compliance with meeting counseling services frequencies for clients on their caseload will be documented on the Counselor's Individual Staff Supervision Notes.
The Clinical Director will report counseling services completion to the Project Director during regular (e.g. monthly) Supervision meetings. Compliance with meeting frequencies for counseling services will be documented on The Clinical Director's Individual Staff Supervision Notes.
The Project Director will report counseling services completions to the PHMC Managing Director of Addiction Services Division during regular (e.g. monthly) Supervision meetings. Compliance with the Program's meeting due dates for counseling services will be documented on The Program Director's Individual Staff Supervision Notes.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that counseling services are completed in a timely manner according to 709.82(d)(1) , at least twice weekly, with documentation present in the official client record. The Compliance Department will report any findings to the Program Director and Managing Director of Addiction Services for internal Plan of Correction.
During regular (e.g. quarterly) Board reporting, the Program Director , in cooperation with the Managing Director of Addiction Services, will report to the Board on progress and completion of these Plans of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2025.
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709.83(a)(6) 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of an aftercare plan, in three of four applicable client records reviewed.
Client #5 was admitted on November 1, 2024 and was discharged on January 3, 2025. There was no aftercare plan documented in the record at the time of the inspection.
Client #6 was admitted on December 3, 2024 and was discharged on February 3, 2025. There was no aftercare plan documented in the record at the time of the inspection.
Client #7 was admitted on December 17, 2024 and was discharged on March 6, 2025. There was no aftercare plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by the Program Director and Clinical Director on the requirements of 709.83(a)(6) LICENSURE Client records regulation, by 8/30/2025. Staff participation in this training will be kept in staff training files.
The Clinical Director will review Aftercare plan completion at the time of discharge, and will consult staff on a daily basis about aftercare plan completions.
The Clinical Director will review aftercare plan completion at every (e.g. weekly) Clinical Team Meeting, and will consult staff about aftercare plan completions during that meeting.
The Clinical Director will review aftercare plan completion at every (e.g. weekly) Counselor and Intake Coordinator Individual staff meeting, and will consult staff about their aftercare plan completions with clients during that meeting. Compliance with meeting requirements for Aftercare Plans with clients on their caseload will be documented on the Counselor's Individual Staff Supervision Notes.
The Clinical Director will report Aftercare Plan Completions to the Project Director during regular (e.g. monthly) Supervision meetings. Compliance with meeting requirements for Aftercare Plans will be documented on The Clinical Director's Individual Staff Supervision Notes.
The Project Director will report Aftercare Plan Completions to the PHMC Managing Director of Addiction Services Division during regular (e.g. monthly) Supervision meetings. Compliance with the Program's meeting requirements for Aftercare Plans will be documented on The Program Director's Individual Staff Supervision Notes.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that aftercare plans are completed in a timely manner and are present in the official client record. The Compliance Department will report any findings to the Program Director and Managing Director of Addiction Services for internal Plan of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2025.
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709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of a discharge summary, in three of four applicable client records reviewed.
Client #5 was admitted on November 1, 2024 and was discharged on January 3, 2025. There was no discharge summary documented in the record at the time of the inspection.
Client #6 was admitted on December 3, 2024 and was discharged on February 3, 2025. There was no discharge summary documented in the record at the time of the inspection.
Client #7 was admitted on December 17, 2024 and was discharged on March 6, 2025. There was no discharge summary documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by the Program Director and Clinical Director on the requirements of 709.83(a)(10) LICENSURE Client records regulation, by 8/30/2025. Staff participation in this training will be kept in staff training files.
The Clinical Director will review Discharge summary completion at the time of discharge, and will consult staff on a daily basis about discharge summary completions.
The Clinical Director will review discharge summary completion at every (e.g. weekly) Clinical Team Meeting, and will consult staff about discharge summary completions during that meeting.
The Clinical Director will review discharge summary completion at every (e.g. weekly) Counselor and Intake Coordinator Individual staff meeting, and will consult staff about their discharge summary completions with clients during that meeting. Compliance with meeting requirements for Discharge summaries with clients on their caseload will be documented on the Counselor's Individual Staff Supervision Notes.
The Clinical Director will report Discharge summary Completions to the Project Director during regular (e.g. monthly) Supervision meetings. Compliance with meeting requirements for Discharge summaries will be documented on The Clinical Director's Individual Staff Supervision Notes.
The Project Director will report Discharge summary Completions to the PHMC Managing Director of Addiction Services Division during regular (e.g. monthly) Supervision meetings. Compliance with the Program's meeting requirements for Discharge summaries will be documented on The Program Director's Individual Staff Supervision Notes.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that discharge summaries are completed in a timely manner and are present in the official client record. The Compliance Department will report any findings to the Program Director and Managing Director of Addiction Services for internal Plan of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2025.
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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, which is to include the documentation of follow-up information, in three of four applicable client records reviewed.
Client #4 was admitted on October 22, 2024 and was discharged on January 31, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client #5 was admitted on November 1, 2024 and was discharged on January 3, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client #6 was admitted on December 3, 2024 and was discharged on February 3, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client #7 was admitted on December 17, 2024 and was discharged on March 6, 2025. There was no follow-up information documented in the record at the time of the inspection.
This is a repeat citation from the June 27, 2023 and June 25, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All follow-up staff and counselor staff will be trained by the Program Director and Clinical Director on the requirements of 709.83(a)(11)Client Records by 8/30/2025. Staff participation in this training will be kept in staff training files.
The Clinical Director will review Client Discharges at every (e.g. weekly) Clinical Team Meeting using reports from the Pathways to Recovery Client Registry Service (CRS) Electronic Health Record (EHR), and will consult follow-up staff about individual following-up with those discharges at that meeting.
The Clinical Director will report follow-up information completion to the Project Director during regular (e.g. monthly) Supervision meetings. Compliance with meeting follow-up information will be documented on The Clinical Director's Individual Staff Supervision Notes.
The Project Director will report follow-up information completions to the PHMC Managing Director of Addiction Services Division during regular (e.g. monthly) Supervision meetings. Compliance with the Program's meeting due dates for follow-up information will be documented on The Program Director's Individual Staff Supervision Notes.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that follow-up information is completed in a timely manner according to 709.83(a)(11), with documentation present in the official client record. The Compliance Department will report any findings to the Program Director and Managing Director of Addiction Services for internal Plan of Correction.
During regular (e.g. quarterly) Board reporting, the Program Director , in cooperation with the Managing Director of Addiction Services, will report to the Board on progress and completion of these Plans of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2025.
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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 failing to ensure the completion of treatment plan updates within the regulatory timeframe were submitted and approved by the Department for the July 14, 2022, June 27, 2023, and June 25, 2024 annual licensing inspections. Failing to complete treatment plan updates within the regulatory timeframe was again found to be a deficiency in the June 24, 2025 licensing inspection.
Plans of correction for failing to ensure individual counseling services were provided to partial hospitalization clients at least twice a week were submitted and approved by the Department for the July 14, 2022, June 27, 2023 and June 25, 2024 annual licensing inspections. Failing to provide individual counseling services at least twice a week was again found to be a deficiency in the June 24, 2025 licensing inspection.
Plans of correction for failing to ensure counseling services were being provided according to the individual treatment and rehabilitation plan were submitted and approved by the Department for the June 27, 2023 and June 25, 2024 annual licensing inspections. Failing to ensure counseling services were being provided according to the individual treatment and rehabilitation plan was again found to be a deficiency in the June 24, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors responsible for implementing Department approved plans of correction will be trained by the Program Director on the requirements of 709.17(a)(3) by 8/30/2025. Staff participation in this training will be kept in staff training files.
Staff responsible for implementing Department approved plans of correction will report plans of correction implementation status to their Supervisors during regular (e.g. monthly) Supervision meetings. Compliance with meeting plans of correction implementation will be documented on Individual Staff Supervision Notes.
Supervisors will report plans of correction implementation status to the Project Director during regular (e.g. monthly) Supervision meetings. Compliance with meeting plans of correction implementation will be documented on The Supervisors' Individual Staff Supervision Notes.
The Project Director will report plan of correction implementation status to the PHMC Managing Director of Addiction Services Division during regular (e.g. monthly) Supervision meetings. Compliance with the Program's meeting plans of correction will be documented on The Program Director's Individual Staff Supervision Notes.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that plans of correction approved by the Department are being implemented according to 709.17(a)(3). The Compliance Department will report any findings to the Program Director and Managing Director of Addiction Services for internal Plan of Correction.
During regular (e.g. quarterly) Board reporting, the Program Director , in cooperation with the Managing Director of Addiction Services, will report to the Board on progress and completion of these Plans of Correction.
All staff and supervisors will be trained on this plan of corrective by 8/30/2025.
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