INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Caron Counseling Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.92(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 three of the seven records reviewed.
Client #1 was admitted on June 30, 2025 and a current client at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 7, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #4 was admitted on December 3, 2024 and was discharged on March 11, 2025. The individual treatment and rehabilitation plan was completed on December 11, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #6 was admitted on January 28, 2025 and discharged on August 13, 2025. The individual treatment and rehabilitation plan was completed on January 28, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
This is a repeat citation from the November 14, 2024 annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinical Supervisor re-educated clinicians on individual and treatment rehabilitation plan requirements, specifically that the plan must include written documentation of type and frequency of treatment and rehabilitation services. This education was provided during a clinical team meeting on 12/12/25. The Clinical Supervisor will increase the amount of monthly chart audits to ensure that individual and treatment rehabilitation plans include type and frequency of treatment and rehabilitation services. The Clinical Supervisor will report progress to the Quality Committee on a quarterly basis. |
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 the review of the review of intensive outpatient client records and the project ' s policies and procedure manual, the facility failed to review and update treatment and rehabilitation plans at least every 30 days, per the project ' s policies and procedures, in three of seven applicable records reviewed.
Client #3 was admitted on August 21, 2025 and was active at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on September 30, 2025, with the next update due no later than October 30, 2025; however, there were no updated treatment and rehabilitation plans documented in the client record until November 10, 2025.
Client #4 was admitted on December 3, 2024 and was discharged on March 11, 2025. A comprehensive treatment and rehabilitation plan was documented in the record on December 11, 2025, with the next update due no later than January 11, 2025; however, there were no updated treatment and rehabilitation plans documented in the client record.
Client #5 was admitted on May 8, 2025 and was discharged on September 26, 2025. An updated treatment and rehabilitation plan was documented in the record on June 24, 2025, with the next update due no later than July 24, 2025; however, there were no updated treatment and rehabilitation plans documented in the client record until August 11, 2025.
This is a repeat citation from the November 14, 2024 annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinical Supervisor re-educated clinicians on individual and treatment rehabilitation plan update requirements, specifically that plans must be reviewed and updated at least every 60 days. This education was provided during a clinical team meeting on 12/12/25. The Clinical Supervisor will increase the amount of monthly chart audits to ensure that individual and treatment rehabilitation plans are updated at least every 60 days. The Quality Analyst will do quarterly chart reviews and will report progress to leadership. |
709.93(a)(5) 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:
(5) Progress 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 ensure a complete client record included information relative to the client's involvement with the project to include progress notes entered within seventy-two hours of the date of service, per the facility's policy, in three of seven records reviewed.
Client #3 was admitted on August 21, 2025 and was active at the time of the inspection. The record contained progress notes for group counseling sessions occurring on September 8, 2025, September 23, 2025, October 13, 2025, October 14, 2025, November 18, 2025, and December 2, 2025, that were not documented in the record until September 12, 2025, September 28, 2025, October 17, 2025, October 18, 2025, November 22, 2025 and December 7, 2025, respectively.
Client #4 was admitted on December 3, 2024 and was discharged on March 11, 2025. The record contained a progress note for a group counseling session occurring on February 18, 2025, that was not documented in the record until February 25, 2025.
Client #6 was admitted on January 28, 2025 and discharged on August 13, 2025. The record contained progress notes for group counseling sessions occurring on June 3, 2025, July 7, 2025, and July 8, 2025, that were not documented in the record until June 8, 2025, and July 12, 2025, respectively.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinical Supervisor re-educated clinicians on progress note requirements, specifically that progress notes must be entered within seventy-two hours of the date of service. This education was provided during a clinical team meeting on 12/12/25. The Clinical Supervisor will complete monthly chart audits to ensure that progress notes are entered within seventy-two hours of the date of service. The Quality Analyst will do quarterly closed chart reviews and will report progress to leadership.
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