INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 23-24, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Armada Recovery PA - dba Blueview 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(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel files, the facility failed to provide a sufficient number of staff, so that at least one person trained in these skills is onsite during the project's hours of operation. At the time of the inspection, one staff person, with consistent hours onsite, was trained in CPR and first aid. The time period reviewed was January - October 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As part of the onboarding process, the Clinical Director and or the Owner will ensure all new employees obtain CPR and First Aid certification within the first month of being hired in the agency. The agency has ensured that at least one staff member is trained in CPR and First Aid. On November 7, the Clinical Director who is always present completed a CPR and First Aid Training, Certification has been emailed to the inspector, On November 19, 2025, another staff member also completed her training, proof of training has also been submitted to inspector
The Owner, Clinical Director and or Chief Compliance Officer will monitor staff's completion of CPR and First Aid. As part of onboarding, proof of CPR and First Aid training will be requested and staff will be provided the training link for completion. Employee files have been updated with the completed CPR and First Aid certificates. Training Link: https://nationalcprfoundation.com/courses/standard-cpr-aed-first-aid/
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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 a review of personnel files, the facility failed to instruct staff in the use of a fire extinguisher upon employment in three out of three applicable files. All trainings were completed on October 29, 2025.
Employee #2 was hired on April 7, 2025 as a Director and was still in that position at the time of the inspection.
Employee #3 was hired on June 30, 2025 as a counselor and was still in that position at the time of the inspection.
Employee #4 was hired on August 11, 2025 as a counselor and was still in that position at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Owner, Clinical Director and or Chief Compliance Officer as applicable will provide the training and on an annual basis staff will be required to review the training to ensure continued mastery of protocols to follow in the event of the need to utilize the fire extinguisher. Owner, Chief Compliance Officer and or Clinical director will monitor annual trainings.
Training on how to utilize fire extinguisher will be completed as part of the onboarding process for each new staff. Moving forward the agency will utilize the following training module in addition to current training at new staff onboarding to ensure that staff is adequately trained.
Training Link : https://emergency.yale.edu/sites/default/files/files/TMS-Fire-Extinguisher-Training.pdf
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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 a review of October 2024 - September 2025 fire drill logs, the facility failed to document a fire drill in July 2025. In addition, documentation for January, April and June 2025 showed that fire drills were announced.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Moving forward, agency will ensure all fire drills are completed on a monthly basis and will be unannounced. The leadership team will identify when fire drill will take place at weekly leadership meetings and staff and clients will subsequently given an unannounced fire drill as directed by leadership team. |
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 a review of personnel files, the facility failed to ensure all staff are trained to perform assigned tasks during emergencies in three out of three applicable files. All trainings were completed on October 29, 2025.
Employee #2 was hired on April 7, 2025 as a Director and was still in that position at the time of the inspection.
Employee #3 was hired on June 30, 2025 as a counselor and was still in that position at the time of the inspection.
Employee #4 was hired on August 11, 2025 as a counselor and was still in that position at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Moving forward, the agency will ensure all new employees are trained to perform assigned tasks during emergencies. Specifically, the fire and emergency training will be completed within the first week of hire into the organization and all employees will be required to complete an annual training on fire and emergencies as part of their yearly training requirements, training will be monitored during employee performance review by direct supervisor. Annual trainings will be administered and monitored annually as applicable by staff's immediate supervisor. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of October 2024 - September 2025 fire drill logs, the facility failed to set off a fire alarm or smoke detector during November and December 2024, January through June, August and September 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Due to the facility being located in a medical office building, the agency is unable to manipulate the smoke detector or set off fire alarms in the agency suites, to avoid causing a disruption to the other organizations in the shared office building. The organization however completes an unannounced monthly fire drill requiring that all staff and clients leave the building and gather at the designated meeting place outside of the medical office building. Attendance of clients present is taken, and all staff personnel are then accounted for to ensure no one is left in the building. A documentation of the monthly fire drill is completed by specified / assigned staff upon completion of the fire drill. A review of the completed monthly fire drill is reviewed and or completed by either the Owner, Clinical Director or Chief Compliance Officer. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the policy and procedures manual, the facility failed to document the project director having annually updated and signed the manual.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In accordance with DDAP regulations the Clinical Director has created a document titled Annual Policy and Procedures Manual Review Statement. The review of the manual dated for 10/15/2025 was documented on the newly created form, a yearly annual update will be reflected on the policy and a revised date will be indicated in the policy prior to the next annual inspection. Moving forward the annual review of policy manual will be completed and documented by the Clinical Director/ Project or Facility Director as applicable. The document is below. Blueview Recovery
Annual Policy & Procedures Manual Review Statement
Date: ______________________
This document serves as formal confirmation that the Policy and Procedures Manual for Blueview Recovery has undergone its annual review. The review was completed in accordance with organizational requirements to ensure that all policies, procedures, and operational guidelines remain accurate, current, and compliant with applicable laws, regulations, and industry standards.
As part of this annual update, the following actions were completed:
1. A full evaluation of all sections of the manual.
2. Revisions and updates to policies and procedures where necessary.
3. Verification that all information accurately reflects current organizational practices.
4. Approval of all changes by the appropriate governing authority or leadership body.
By signing below, the undersigned acknowledges that the manual has been reviewed, updated (as needed), and approved for organizational use for the current year.
Authorized Reviewer / Approver
Name: ___________________________________
Title: ____________________________________
Signature: _________________________________
Date: _____________________________________
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on the review of client records, the facility failed to obtain a consent to release information forms prior to releasing information in four out of fourteen records reviewed.
Client #3 was admitted on April 9, 2025 and discharged on August 11, 2025. On or about August 11, 2025, the facility contacted another treatment facility without a release of information form. In addition, the facility spoke about the client's aftercare plan. The release of information form for the family member did not include permission to discuss the aftercare plan.
Client #10 was admitted on May 7, 2025 and discharged on May 21, 2025. There was no consent to release information form for the funding source. Facility staff confirmed billing had occurred.
Client #11 was admitted on May 16, 2025 and discharged on September 5, 2025. On or about September 5, 2025, the facility contacted another treatment facility without a release of information form.
Client #13 was admitted on July 15, 2025 and discharged on September 10, 2025. On or about September 10, 2025, the facility contacted another treatment facility without a release of information form.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from September 11, 2024 and October 25, 2023 licensing inspections.
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Plan of Correction
The agency held an all staff meeting including clinical teams, business development teams and any personnel providing case management on behalf of clients within the agency to ensure that release of information is completed when a recommendation has been made by the clinical team, indicating the need for a higher level of care for any client. All staff is required to review client chart to ensure there is a release of information on file specifically indicating the name of facility the client would like to be referred to as well as the permissible disclosure and or information that can be disseminated to the agency the client is being referred to.
Moving forward no disclosure of aftercare planning will be communicated to family members without the release of information specifying that agency or representative can communicate with family member about aftercare planning and or lapse in insurance coverage to refer to a higher level of care. Clinical Director has requested that KIPU created a "Contact Note" within the EMR system to capture all communication with client outside of program and family members with consent on file. Clinical Director and or Chief Compliance Officer as applicable will monitor disclosures and review all contact notes on a monthly basis.
As part of the intake process, all clients are required to complete all intake paperwork inclusive of releases of information for the funding source, the intake staff has been trained on the required releases of information to be obtained from clients at admission inclusive of funding source. All staff have been trained on how to obtain and upload a non electronic release of information in the event an electronic release of information is not in the client's chart for the agency client is being discharged to post discharge.
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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 partial hospitalization client records, the facility failed to document treatment plan updates within the regulatory timeframe in five out of five applicable records reviewed.
Client #8 was admitted on July 7, 2025 and transferred to a lower level of care on August 20, 2025. A comprehensive treatment plan was completed on July 10, 2025 and an update was due no later than August 10, 2025; however, none was completed.
Client #9 was admitted on July 11, 2025 and transferred to a lower level of care on September 24, 2025. A comprehensive treatment plan was completed on July 25, 2025 and an update was due no later than August 25, 2025; however, none was completed.
Client #11 was admitted on May 16 2025 and discharged on September 5, 2025. A comprehensive treatment plan was completed on May 21, 2025 and an update was due no later than June 21, 2025; however, the update was completed on July 11, 2025.
Client #13 was admitted on July 15, 2025 and discharged on September 10, 2025. A comprehensive treatment plan was completed on July 18, 2025 and an update was due no later than September 18, 2025; however, none of completed.
Client #14 was admitted on August 5, 2025 and discharged on September 15, 2025. A comprehensive treatment plan was completed on August 5, 2025 and an update was due no later than September 15, 2025; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During weekly supervision, Clinical Director will review caseloads ensure treatment plan updates are completed for clients within their due dates. A monthly email indicating due dates for treatment plans will be sent to all clinicians. Clinical Director will complete chart audits on a monthly basis to ensure that PHP treatment plans are completed within 30 days and IOP treatment plans are completed within 60 days of when the master treatment plan was completed. Clinical staff were trained on EMR on how to locate treatment plan updates, clinical staff were also trained on the need for treatment plans for PHP at 30 days and IOP at 60 days. Clinical Director has also made a request from KIPU (EMR system) to affix an alert in the system a week prior to when a client will need a treatment plan update. Flags will be placed in the chart to reflect need for treatment plan update to ensure staff do not forget the need to complete a treatment plan update by due date. |
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 a review of partial hospitalization records, the facility failed to document individual counseling, at least twice weekly, in seven out of seven records reviewed. There were no individual sessions documented in the record.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the September 11, 2024 licensing inspection.
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Plan of Correction
During individual supervision, Clinicians will continue to meet with Clinical Director who reviews individual counseling sessions completed for the previous week with the clients on the Clinician's caseload. The Clinical Director has requested a new Clinical Progress Note to capture Individual Sessions from KIPU (EMR). The Clinical Director submitted a request with KIPU on November 10,2025, indicating that the clinical progress note currently utilized by the agency to document individual sessions does not meet state regulations and a new format outlining the content discussed in the session, interventions utilized, assessment of clinical presentation and plan for client going forward. The Individual Session Note is to include the goals and objective for the client, as well as a clickable option to signify specific goal and objective that is being addressed in the individual session. Clinical Director and Owner are responsible for continued monitoring of the deployment of the new form. In the interim all clinical staff are to utilize the Golden Thread Progress Note in the EMR System and not the Weekly Treatment Team Note previously utilized to capture individual counseling session. |
709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document case consultations in seven out of seven records reviewed. The facility's policy and procedures manual states case consultations should be completed upon admission and transfer to another level of care.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the September 11, 2024 licensing inspection.
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Plan of Correction
Clinical Director will document case consultation had with primary therapist who will be assigned to the client in partial hospitalization and or pertinent clinical staff on level of care at admission, as well as changes in levels of care from partial hospitalization to outpatient. The Clinical Director will be responsible for monitoring compliance of case consultation and documentation thereof. During weekly staff meeting, cases will be discussed and either the clinical director or primary therapist assigned to the client will document case consultation completed with Clinical Director and or Clinical Team. |
709.83(a)(8) 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:
(8) Record of services provided.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document a record of services in seven out of seven records reviewed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All client's clinical record will be kept in the KIPU EMR system, Client's progress in treatment will be documented in the electronic health record, all clients in PHP will be provided two individual counseling session weekly; all clients in the outpatient will be provided one individual session weekly. Primary therapist and Clinical Director as applicable will be responsible for providing individual sessions and documentation of client's progress in the client's chart in the electronic health record (KIPU). The Clinical Director will review the Clinical Progress Notes daily and at a minimum weekly during individual supervision with primary therapist. |
709.83(a)(9) 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:
(9) Progress notes.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document progress notes in seven out of seven records reviewed. There were no progress notes for individual sessions in the client records.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During individual supervision, Clinicians will continue to meet with Clinical Director who reviews individual counseling sessions completed for the previous week with the clients on the Clinician's caseload. The Clinical Director has requested a new Clinical Progress Note to capture Individual Sessions from KIPU (EMR). The Clinical Director submitted a request with KIPU on November 10,2025, indicating that the clinical progress note currently utilized by the agency to document individual sessions does not meet state regulations and a new format outlining the content discussed in the session, interventions utilized, assessment of clinical presentation and plan for client going forward. The Individual Session Note is to include the goals and objective for the client, as well as a clickable option to signify specific goal and objective that is being addressed in the individual session. Clinical Director and Owner are responsible for continued monitoring of the deployment of the new form. In the interim all clinical staff are to utilize the Golden Thread Progress Note in the EMR System and not the Weekly Treatment Team Note previously utilized to capture individual counseling session. |
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 partial hospitalization client records, the facility failed to document follow-up information in five out of five applicable records reviewed. The facility's policy and procedures manual states follow-up needs to be completed within seven days if referred to another facility and within 30 days for all other discharges.
Client #10 was admitted on May 7, 2025 and discharged on May 21, 2025.
Client #11 was admitted on May 16, 2025 and discharged on September 5, 2025.
Client #12 was admitted on May 28, 2025 and discharged on June 10, 2025.
Client #13 was admitted on July 15, 2025 and discharged on September 10, 2025. Client was referred to another treatment facility.
Client #14 was admitted on August 5, 2025 and discharged on September 15, 2025. Client was referred to another treatment facility.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On November 17, 2024, Clinical Director held an all staff inclusive of the clinical teams, business development and case management teams to provide training on the timelines of follow up and documentation follow up attempts in the "Contact Note" Section of each client's chart. Moving forward the agency will utilize the "Contact Note" to document all follow up or client re engagement efforts in the client's chart. On a quarterly basis the Clinical Director will complete a full audit of all client's chart, specifically to assess for issues with follow up and documentation thereof. Clinical Director will complete a refresher training on the timelines for completion of follow up calls and documentation. Since being informed by the state inspector of follow up timeless, Clinical Director has completed follow up calls and documented them in "Contact Note" section of clients who have been discharged from treatment and or referred to another agency. Clinical Director has instituted a system whereby a follow up of client's are to be completed within 48 hours of client discharge from care to ensure adequate linkage to resources provided and to ensure continuum of care. |
709.91(b)(7) LICENSURE Intake and admission
709.91. 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 outpatient client records, the facility failed to document a preliminary treatment plan in three out of five applicable records. The facility's policy and procedures manual states the preliminary treatment plan needs completed within three days of admission.
Client #1 was admitted on June 16, 2025 and discharged on August 27, 2025. The preliminary treatment plan was due on June 19, 2025; however, it was completed on June 23, 2025.
Client #3 was admitted on April 9, 2025 and discharged on August 11, 2025. The preliminary treatment plan was due on April 12, 2025; however, it was completed on June 23, 2025.
Client #4 was admitted on June 13, 2025 and discharged on July 9, 2025. There was no documentation of a preliminary treatment plan in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will be responsible for ensuring that initial treatment plans are completed as part of the Biopsychosocial Assessment, Clinical Director will review all new client's chart either on the same day as admission if Biopsychosocial Assessment is completed by Clinical Director to ensure Initial treatment plan has been completed and signed by the client and Clinical Director or by therapist completing the biopsychosocial assessment. If the biopsychosocial assessment was completed by any clinician other than the Clinical Director, the Clinical Director will review the client's chart within 48 hours of client's admission and ensure a an initial treatment plan has been documented and signed by both the client and the primary therapist or Clinical Director. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of four applicable records.
Client #1 was admitted on June 16, 2025 and discharged on August 27, 2025. A comprehensive treatment plan was completed on June 23, 2025 and an update was due no later than August 23, 2025; however, none was completed.
Client #2 was admitted on June 30, 2025 and discharged on September 16, 2025. A comprehensive treatment plan was completed on July 8, 2025 and an update was due no later than September 8, 2025; however, none was completed.
Client #3 was admitted on April 9, 2025 and discharged on August 11, 2025. A comprehensive treatment plan was completed on April 23, 2025 and an update was due no later than June 23, 2025; however, none was completed.
Client #5 was admitted on August 1, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on August 5, 2025 and an update was due on October 5, 2025; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On November 10, 2025, Clinical Director requested that a EMR System (KIPU) create a treatment plan update document with alert for when they are due in the system. On Nov 24, 2025, Clinical Director, Owner met with Kyle from KIPU (EMR) to discuss progress made on clinical documentation. A sample of the requested treatment plan update form was provided to KIPU requesting that Treatment Plan Updates include: Client information, Master Treatment Plan with Initial Goals and Objectives, Presenting Status since last review, Progress towards initial goals and objectives, New or Emerging Clinical Needs, Treatment Plan Revisions, Interventions to Continue, Modify, or Add, Risk Assessment Update and Client Engagement and Motivation. See sample of form provided to KIPU below.
PHP ? Treatment Plan Update Form
Client Information
- Client Name:
- Client ID:
- Date of Update:
- Primary Clinician/Therapist:
- Program Level: Partial Hospitalization Program (PHP)
- Date of Master Treatment Plan:
- Review Interval: 30 days
1. Master Treatment Plan ? Initial Goals &
Objectives
(Copy from original plan?these remain the foundation for assessing progress.)
Long-Term Goal(s):
1.
2.
Short-Term Objectives (From Master Treatment Plan):
1.
2.
3.
2. Presenting Status Since Last Review
(Clinical summary of current functioning during PHP.)
- Substance use since last review (type, frequency, amount):
- Cravings (severity, frequency):
- Withdrawal symptoms (if any):
- Medical/psychiatric concerns:
- Attendance/participation in PHP:
- Support system involvement:
- Medication adherence (MAT or psychotropic):
- Changes in legal, social, or occupational status:
3. Progress Toward Initial Goals &
Objectives
Objective 1:
- Progress:
- Evidence/Examples:
- Barriers:
- Clinician Interpretation:
Objective 2:
- Progress:
- Evidence/Examples:
- Barriers:
- Clinician Interpretation:
Objective 3:
- Progress:
- Evidence/Examples:
- Barriers:
- Clinician Interpretation:
(Add more if needed.)
4. New or Emerging Clinical Needs
(Identify anything not included in the master plan.)
- Co-occurring symptoms (anxiety, depression, trauma)
- Social/environmental stressors
- Medication needs or changes
- Relapse risk changes
- Safety concerns (harm to self/others, overdose risk)
5. Treatment Plan Revisions
Revised Goals (If applicable):
(Only update if long-term recovery targets have shifted.)
1.
2.
Revised or New Short-Term Objectives:
(Objectives should be measurable and PHP-appropriate.)
Objective # New/Updated Objective Target Date Status
1
2
3
6. Interventions to Continue, Modify, or Add
(Check all that apply and describe.)
A. Continue:
- □ Relapse-prevention skills training
- □ CBT for substance use
- □ Motivational interviewing
- □ Group therapy participation
- □ Co-occurring mental health treatment
- □ Medication-assisted treatment
- □ Psychoeducation on triggers/cravings
B. Modify:
- □ Increase individual session frequency
- □ Adjust coping skills focus
- □ Increase urine drug screens
- □ Expand family involvement
- □ Adjust psychoeducation topics
Descriptions:
C. Add:
- □ Trauma-focused therapy
- □ Psychiatric referral
- □ Higher level of care consideration
- □ Case management / housing support
- □ Additional groups (anger management, grief, etc.)
Descriptions:
7. Risk Assessment Update
- Relapse Risk: Low / Moderate / High
- Suicidal/Homicidal Ideation: Yes / No
- Overdose Risk Factors:
- Protective Factors:
- Safety Plan Updates (if any):
8. Client Engagement & Motivation
- Current Stage of Change:
□ Precontemplation
□ Contemplation
□ Preparation
□ Action
□ Maintenance
- Client insight into substance use patterns:
- Client motivation level (0?10):
- Barriers to engagement:
9. Client & Clinician Signatures
Client Signature: _____________________________ Date: _________
Clinician Signature: ___________________________ Date: _________
Supervisor : _______________________ Date: _________
The Primary Therapist is responsible for the completion of treatment plan updates, Clinical Director will monitor deployment of form by KIPU and completion of treatment plan updates within the 30 days for PHP and 60 days for Outpatient.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 outpatient client records, the facility failed to document counseling services according to the individual treatment plans in four out of four applicable records. There was no documentation of individual sessions in the client records.
Client #1 was admitted on June 16, 2025 and discharged on August 27, 2025. The comprehensive treatment plan dated June 23, 2025, indicated weekly individual sessions.
Client #2 was admitted on June 30, 2025 and discharged on September 16, 2025. The comprehensive treatment plan dated July 8, 2025 indicated individual sessions four times per month.
Client #3 was admitted on April 9, 2025 and discharged on August 11, 2025. The comprehensive treatment plan dated April 23, 2025 indicated weekly individual sessions.
Client #5 was admitted on August 1, 2025 and was still active at the time of the inspection. A comprehensive treatment plan dated August 5, 2025 indicated individual sessions four times per month.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director and or assigned Clinical Supervisor will review all treatment plans, treatment plan updates and ensure the frequency of the individual sessions as indicated in the treatment plan is being adhered to, during weekly supervision, the Clinical Director or Clinical Supervisor as applicable will address identified gaps in the adherence of treatment plan objectives. Primary therapist will document all missed session in the individual counseling session progress note as well as document rationale for client missing, attempts made to reach client and plan for a "catch up session", to make up for missed or cancelled session. Clinical Director will monitor adherence to treatment plan goals and objectives and provide feedback to primary therapist at a minimum during weekly individual supervision. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of outpatient client records, the facility failed to document a record of services in seven out of seven records reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The agency will have a complete client record of clients seen in the treatment center. All services rendered will be documented in the client's EMR in KIPU. On Nov 10, 2025, Clinical Director requested that KIPU create a running of of client services rendered for easy accessibility of clinical documentation. KIPU provided a way for Clinical Director to see the list of services rendered to client in the client's chart. Clinical Director is monitoring the progress of the deployment of this functionality in KIPU. |
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 outpatient client records, the facility failed to document progress notes in five out of five applicable records reviewed. In each client's record, a summary of weekly treatment services indicated individual therapy sessions but there were no corresponding progress notes.
Client #1 was admitted on June 16, 2025 and discharged on August 27, 2025.
Client #2 was admitted on June 30, 2025 and discharged on September 16, 2025.
Client #3 was admitted on April 9, 2025 and discharged on August 11, 2025.
Client #5 was admitted on August 1, 2025 and was still active at the time of the inspection.
Client #6 was admitted on July 7, 2025 and discharged on September 23, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During individual supervision, Clinicians will continue to meet with Clinical Director who reviews individual counseling sessions completed for the previous week with the clients on the Clinician's caseload. The Clinical Director has requested a new Clinical Progress Note to capture Individual Sessions from KIPU (EMR). The Clinical Director submitted a request with KIPU on November 10,2025, indicating that the clinical progress note currently utilized by the agency to document individual sessions does not meet state regulations and a new format outlining the content discussed in the session, interventions utilized, assessment of clinical presentation and plan for client going forward. The Individual Session Note is to include the goals and objective for the client, as well as a clickable option to signify specific goal and objective that is being addressed in the individual session. Clinical Director and Owner are responsible for continued monitoring of the deployment of the new form. In the interim all clinical staff are to utilize the Golden Thread Progress Note in the EMR System and not the Weekly Treatment Team Note previously utilized to capture individual counseling session. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of outpatient client records, the facility failed to document case consultations according to the facility's policy and procedures manual in seven out of seven records reviewed. The manual states case consultations need to be completed at time of admission and at change of level of care.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from September 11, 2024 and October 25, 2023 licensing inspection.
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Plan of Correction
Clinical Director will document case consultation had with primary therapist who will be assigned to the client in outpatient and or pertinent clinical staff on level of care at admission, as well as changes in levels of care from outpatient to include the need for aftercare planning. The Clinical Director will be responsible for monitoring compliance of case consultation and documentation thereof. During weekly staff meeting, cases will be discussed and either the clinical director or primary therapist assigned to the client will document case consultation completed with Clinical Director and or Clinical Team. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of outpatient client records, the facility failed to document an aftercare plan in one out of three applicable records reviewed.
Client #2 was admitted on June 30, 2025 and discharged on September 16, 2025. No documentation of an aftercare plan in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During weekly All Staff meeting (November 24, 2025), Clinical Director reviewed and reminded the clinical staff of the need to complete an aftercare plan in the EMR system (KIPU) with every client on their caseload during a discharge planning session, in the event a client leaves against medical advice the therapist, case manager or clinical director will complete a follow up with the client to provide resources and promptly complete such documentation in the EMR system (KIPU). Clinical Director is responsible for monitoring documentation of after care plan, as well as follow up calls once a client has been discharged. On November 25, 2025, a follow up email with specifics on where to locate the document and the importance of timely completion of the Aftercare Plan/ Discharge Form was discussed and was a sample was provided to all clinical staff. |
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 outpatient client records, the facility failed to document follow-up information in five out of five applicable records. The policy and procedures manual states follow-up needs to be completed in seven days for referrals and 30 days for all other discharges.
Client #1 was admitted on June 16, 2025 and discharged on August 27, 2025.
Client #2 was admitted on June 30, 2025 and discharged on September 16, 2025.
Client #3 was admitted on April 9, 2025 and discharged on August 11, 2025. Client was referred to a higher level of care.
Client #4 was admitted on June 13, 2025 and discharged on July 9, 2025.
Client #6 was admitted on July 7, 2025 and discharged on September 23, 2025. Client was referred to a higher level of care.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On November 17, 2024, Clinical Director held an all staff inclusive of the clinical teams, business development and case management teams to provide training on the timelines of follow up and documentation follow up attempts in the "Contact Note" Section of each client's chart. Moving forward the agency will utilize the "Contact Note" to document all follow up or client re engagement efforts in the client's chart. On a quarterly basis the Clinical Director will complete a full audit of all client's chart, specifically to assess for issues with follow up and documentation thereof. Clinical Director will complete a refresher training on the timelines for completion of follow up calls and documentation. Since being informed by the state inspector of follow up timeless, Clinical Director has completed follow up calls and documented them in "Contact Note" section of clients who have been discharged from treatment and or referred to another agency. Clinical Director has instituted a system whereby a follow up of client's are to be completed within 48 hours of client discharge from care to ensure adequate linkage to resources provided and to ensure continuum of care. |
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 case consultations and releases of information were submitted and approved by the Department for September 11, 2024 and October 25, 2023 annual licensing inspections. Case consultations and releases of information were again found to be a deficiency in the October 23-24, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon completion of all intake and biopsychosocial assessment, a documented case consultation meeting will be held with primary therapist assigned to the client and or other clinical staff members able to opine on the client's clinical presentation. Upon being informed by the inspector of the need for case consultation, subsequent intake assessments have had documentation of clinical case consultation meetings in client's chart. Additionally on Monday of each week all new and current clients are discussed in staff meeting and one a bi weekly basis, a treatment team meeting inclusive of the Medical Director, Nurse Practitioner, Clinical Director and Primary Clinician/ Therapist will meet starting December 2025 to discuss client progress and consult on clinical needs and presentation a documentation of those consultation meetings will be made available in a meeting binder separate from client's chart.
Agency will work with EMR system KIPU to ensure that Release of Information does not have pre checked boxes, allowing clients to adequately check of boxes they would like to be disclosed. Staff will also review client's ROI with client both at the time the ROI is completed as well as at the time of potential disclosure to ensure there are no inadvertent disclosures made without client's consent, in the event client is providing verbal consent on a disclosure not previously checked/ permitted, the staff will document in a contact note of client chart indicating client provided verbal consent.
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