INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection, methadone and buprenorphine monitoring inspection conducted on May 20-21, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, BGI of Brandywine, Inc. 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)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the personnel records, the facility failed to provide a written individual training plan for each employee appropriate to that employee's skill level during the month of January per, facility policy, in twelve out of twenty-one employee records reviewed.
Employee #1 was hired on June 1, 2025, as the project director and was still in the position as of the date of the inspection. There was no documented individual training plan.
Employee #2 was hired on June 1, 2025, as the facility director and was still in the position as of the date of the inspection. The individual training plan was due in January; however, it was not completed until May 15, 2026.
Employee# 3 was hired on September 20, 2025, as a clinical supervisor and was still in the position as of the date of the inspection. The individual training plan was due in January; however, it was not completed until May 6, 2026.
Employee # 4 was hired on September 15, 2025, as a clinical supervisor and was still in the position as the time of the inspection. The individual training plan was due in January; however, it was not completed until May 6, 2026.
Employee # 5 was hired on October 6, 2025, and is still in the position at the time of the inspection. The individual training plan was due in January; however, it was not completed until May 7, 2026.
Employee #6 was hired on April 6, 2026, as a counselor and is still in the position at the time of the inspection. The individual training plan was due in January; however, it was not completed until May 15, 2026, and there was no documentation it was developed with input from the employee and the supervisor.
Employee #7 was hired on March 17, 2026, as a counselor and is still in the position at the time of the inspection. The individual training plan was due in January; however, it was not completed until May 11, 2026.
Employee #8 was hired on June 11, 2025, as a counselor and is still in the position at the time of the inspection. The individual training plan was due in January; however, it was not completed until May 14, 2026.
Employee # 9 was hired on January 26, 2026, as a counselor and is still in the position at the time of the inspection. The individual training plan was due in January; however, it was not completed until May 7, 2026.
Employee # 10 was hired on February 9, 2026, as a counselor and is still in the position at the time of the inspection. The individual training plan was due in January; however, it was not completed until May 14, 2026.
Employee # 13 was hired on August 3, 2022, as a counselor and is still in the position at the time of the inspection. The individual training plan was due in January; however, it was not completed until May 14, 2026.
Employee # 14 was hired on June 12, 2024, as a counselor and is still in the position at the time of the inspection. The individual training plan was due in January; however, it was not completed until May 6, 2026.
This is a repeat citation from May 22, 2024, and May 29- May 1, 2025, licensing inspections.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All missing training plans have been completed and added to the employee file. The organization has provided refresher training to all managers to ensure timely completion of annual trainings plans, to be submitted to HR no later than 1/31 of each year. The Organization has implemented a compliance monitoring schedule which includes quarterly audits of HR files for all new hires. Audit findings will be submitted to the Risk/Quality Committee in the month following completion of the scheduled audit. The Director of HR is responsible for implementation of these corrective actions. |
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 at least 6 hours pf HIV/AIDS and at least 4 hours of tuberculous, sexually transmitted diseases and other health-related topics training, using a Department approved curriculum, within the required time frames in seven out of twenty-one personnel records reviewed.
Employee #15 was hired on June 21, 2023, in the maintenance department and is still in the position at the time of the inspection. The HIV/AIDS and tuberculosis, sexually transmitted diseases, and other related health topics training were due no later than June 21, 2025; however, both trainings were not completed as of the date of the inspection.
Employee #16 was hired on August 24, 2023, in dietary and is still in the position at the time of the inspection. The HIV/AIDS and tuberculosis, sexually transmitted diseases, and other related health topics training were due no later than August 24, 2025; however, both trainings were not completed as of the date of the inspection.
Employee #17 was hired on September 13, 2023, in admissions and is still in the position at the time of the inspection. The HIV/AIDS and tuberculosis, sexually transmitted diseases, and other related health topics training were due no later than September 13, 2025; however, both trainings were not completed as of the date of the inspection.
Employee #18 was hired on August 30, 2023, as a case manager and is still in the position at the time of the inspection. The HIV/AIDS and tuberculosis, sexually transmitted diseases, and other related health topics training were due no later than August 30, 2025; however, both trainings were not completed as of the date of the inspection.
Employee #19 was hired on March 27, 2024, as a BHA and is still in the position at the time of the inspection. The HIV/AIDS and tuberculosis, sexually transmitted diseases, and other related health topics training were due no later than March 27, 2026; however, both trainings were not completed as of the date of the inspection.
Employee #20 was hired on March 29, 2023, as a driver and is still in the position at the time of the inspection. The HIV/AIDS and tuberculosis, sexually transmitted diseases, and other related health topics training were due no later than March 29, 2025; however, both trainings were not completed as of the date of the inspection.
Employee #21 was hired on August 10, 2023, as a driver and is still in the position at the time of the inspection. The HIV/AIDS and tuberculosis, sexually transmitted diseases, and other related health topics training were due no later than August 10, 2025; however, both trainings were not completed as of the date of the inspection.
This is a repeat citation from April 20- May 1, 2025, licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The organization has adopted a training curriculum that captures all elements of PA 704.11(c). All staff currently out of compliance will have this training completed by 7/15/2026. This training has also been incorporated into the Organizations standard New Hire Orientation curriculum to ensure compliance moving forward. The Organization has implemented a compliance monitoring schedule which includes quarterly audits of HR files for all new hires. Audit findings will be submitted to the Risk/Quality Committee in the month following completion of the scheduled audit. The Director of HR is responsible for implementation of these corrective actions |
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 the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Employee #13 was hired on August 3, 2022, as a counselor and was still in the position as of the date of the inspection. The facility's training year that was reviewed was from January 1, 2025, through December 31, 2025. Employee #13 ' s record only document 10 hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization has revised its Annual Training Plan for clinical staff to capture the training requirements of this standard. Managers will be trained on use and monitoring of the new Annual Training Plan by 7/15/2026. The Organization has implemented a compliance monitoring schedule which includes quarterly audits of HR files for all new hires. Audit findings will be submitted to the Risk/Quality Committee in the month following completion of the scheduled audit. The Director of HR is responsible for implementation of these corrective actions. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling rooms in all areas of the facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization has disabled the cameras located in community areas utilized for group counseling sessions. The organization will submit an exception request to the Department allowing for the use of the cameras as a security measure. This exception request will be submitted by 6/30/2026. The CEO and Director of Facilities Mgmt are responsible for the implementation of this corrective action. |
705.9 (4) (ii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(ii) Assignments of staff during emergencies.
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Observations
Based on a review of employee records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in three out of twenty-one applicable records reviewed.
Employee #3 was hired on September 20, 2025 as a clinical supervisor and was still in the position as of the date of the inspection. Employee #3 was to be trained to perform assigned tasks during emergencies prior to working a shift. Documentation in the records shows the training occurred; however, there is no date as to when the employee received the training.
Employee #5 was hired on October 6, 2025 as a counselor and was still in the position as of the date of the inspection. Employee #5 was to be trained to perform assigned tasks during emergencies prior to working a shift. Documentation in the records shows the training occurred; however, there is no date as to when the employee received the training.
Employee #9 was hired on January 26, 2026 as a counselor and was still in the position as of the date of the inspection. Employee #9 was to be trained to perform assigned tasks during emergencies prior to working a shift. Documentation in the records shows the training did not occur until February 12, 2026.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The identified staff will re-take the Organization's Fire Safety Training by 7/15/26 to create fully documented training completion. The Organization will ensure all training documentation is completed accurately and thoroughly. The Organization has implemented a compliance monitoring schedule which includes quarterly quality assurance audits of HR files for all new hires and ongoing training audits for existing employees. Audit findings will be submitted to the Risk/Quality Committee in the month following completion of the scheduled audit. The Director of HR is responsible for implementation of these corrective actions. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspected on May 21, 2026, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag.
A fire extinguisher located in the detoxification unit by the back door and a fire extinguisher located in the building identified as the mansion in the men ' s hallway did not have inspection tags to verify when the fire extinguisher was last inspected.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Facilities contacted the fire equipment vendor and had all tags on all extinguishers replaced with new tags. This was completed by 6/12/26. The organization will inspect fire extinguisher tags once per month at a minimum and report findings to the Risk and Quality Mgmt. Committee. The Director of Facilities is responsible for the implementation of this corrective action. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to instruct all staff in the use of fire extinguishers upon staff employment in three out of twenty-one applicable records reviewed.
Employee #3 was hired on September 20, 2025 as a clinical supervisor and was still in the position as of the date of the inspection. Employee #3 was to be instructed in the use of a fire extinguisher upon employment. Documentation in the records shows the training occurred; however, there is no date as to when the employee received the training.
Employee #5 was hired on October 6, 2025 as a counselor and was still in the position as of the date of the inspection. Employee #5 was to be instructed in the use of a fire extinguisher upon employment. Documentation in the records shows the training occurred; however, there is no date as to when the employee received the training.
Employee #9 was hired on January 26, 2026 as a counselor and was still in the position as of the date of the inspection. Employee #9 was to be instructed in the use of a fire extinguisher upon employment; however, the training did not occur until February 12, 2026.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The identified staff will re-take the Organization's Fire Safety Training, including the P.A.S.S. principles by 7/15/26 to create fully documented training completion. The Organization will ensure all training documentation is completed accurately and thoroughly. The Organization has implemented a compliance monitoring schedule which includes quarterly quality assurance audits of HR files for all new hires and ongoing training audits for existing employees. Audit findings will be submitted to the Risk/Quality Committee in the month following completion of the scheduled audit. The Director of HR is responsible for implementation of this corrective action. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs during the inspection, dated June 2025 through April 2026, the facility failed to document the number of persons in the facility at the time of the drill.
The fire drill log dated April 25, 2026 did not document the number of people in the facility at the time of the drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization will ensure that fire drill reports for 6/25 and 4/26 are amended to document the number of people in the facility at the time of the drill. This information will be retrieved from census and employee time sheet records. The Organization will ensure that 100% of fire drill reports contain all required information. Fire drill records will be audited each month for compliance. Audit findings will be reported to the Risk/ Quality Committee each month. The Director of Facility Operations and the Risk Manager are responsible for the implementation of this corrective action. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility ' s written plan for the coordination of client treatment and rehabilitation services which includes but is not limited to the written procedures for the management of treatment/rehabilitation services for clients, the facility failed to include procedures with time frames for the completion of a case consultation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In Compliance with 709.53 the Organization has adopted and implemented a Case Consultation & Transition Plan policy and documentation format. Staff were trained and began using this format on 6/19/26. The Organization has incorporated monitoring of the appropriate use of Case Consultation notes into the Annual Compliance Monitoring Schedule. Audit findings will be submitted to the Risk/Quality Committee in the month following completion of the scheduled audit. The Director of Clinical Services is responsible for implementation of this corrective action. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review, the facility failed to present a completed plan documenting the qualifications and training of staff to the Department licensing representatives at the time of the project's site visit. As of the date of the inspection, the facility was unable to produce a fully complete and accurate Staffing Requirements Facility Summary Report, which documents staff qualifications and training. At the time of the licensing inspection, he Department licensing representative continued to work with the facility to provide the correct information; however the plan was not completed until after the licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of HR has been trained in appropriate and accurate completion of the Staffing Requirements Facility Summary Report. The Organization has incorporated ongoing quarterly quality assurance auditing of the Staffing Requirements Facility Summary Report into the Annual Compliance Monitoring Schedule. Audit findings will be submitted for review to the Risk/Quality Committee in the month following completion of the scheduled audit. The Director of HR is responsible for implementation of these corrective actions. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a follow-up, within seven days, per the facility ' s policy in four out of four applicable records reviewed.
Client #1 was admitted to the detoxification level of care on April 27, 2026, and discharged on May 2, 2026. A follow up was due no later than May 9, 2026; however, there was no documentation that one was completed.
Client #2 was admitted to the detoxification level of care on May 3, 2026, and discharged on May 7, 2026. A follow up was due no later than May 14, 2026; however, there was no documentation that one was completed.
Client #3 was admitted to the detoxification level of care on August 8, 2025, and discharged on August 12, 2025. A follow up was due no later than August 19, 2025; however, there was no documentation that one was completed.
Client #4 was admitted to the detoxification level of care on August 17, 2025, and discharged on August 22, 2025. A follow up was due no later than August 29, 2025; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization has provided appropriate training for accurate completion of Patient Follow Up. The Organization has incorporated monthly auditing of indicated patient records into the Annual Compliance Monitoring Schedule. Audit findings will be submitted to the Risk/Quality Committee in the month following completion of the scheduled audit. The Risk Manager is responsible for implementation of these corrective actions. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on a review of patient records, the program failed to obtain patient consent to contact the previous narcotic treatment program to obtain the patient ' s treatment history in one out of two applicable records reviewed.
Patient #5 was admitted to the detoxification level of care on May 15, 2026, and was still active at the time of the inspection. There was no documentation in the record that the facility obtained an informed and voluntary release of information and made contact with the previous narcotic treatment facility.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Organization will provide refresher training to intake and nursing staff regarding appropriate completion of indicated release of information forms for the previous narcotic treatment facility, and mandatory documentation of contact with that provider as part of the standard patient intake process. Documentation of this training will be maintained in the employees' HR files. Monitoring of appropriate completion of previous narcotic treatment provider release of information and contact documentation has been incorporated into the Annual Compliance Monitoring Schedule with findings reported monthly to Risk/Quality Management Committee in the month following the completion of the scheduled audit. The Director of Nursing, Director of HR and Risk Manager are responsible for implementation of these corrective actions. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in two out of two applicable records reviewed.
Patient #5 was admitted to the detoxification level of care on May 15, 2026, and was still active at the time of the inspection. There was no documentation that the facility notified the transferring facility of the admission and the initial dose given.
Patient #17 was admitted to the inpatient non-hospital residential level of care on April 17, 2026, and discharged on May 14, 2026. There was no documentation that the facility notified the transferring facility of the admission and the initial dose given.
This is a repeat citation from the April 29- May 1, 2025, licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization will provide refresher training to nursing staff regarding appropriate completion of documentation of notice of initial dosing to the previous narcotic treatment provider. Documentation of this training will be maintained in the employees' HR files. Monthly monitoring of appropriate documentation of initial dosing notification to the previous narcotic treatment provider has been incorporated into the Annual Compliance Monitoring Schedule with findings reported monthly to Risk/Quality Management Committee in the month following the completion of the scheduled audit. The Director of Nursing, Director of HR and Risk Manager are responsible for implementation of these corrective actions. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to follow their written plan for intake and admission to complete a personal history within seventy-two hours of admission, per facility policy, in three out of seven records reviewed.
Client #15 was admitted on May 1, 2026, and still was active at the time of the inspection. The record did not contain documentation that the personal history had been completed at the time of the inspection.
Client #17 was admitted on April 17, 2026, and discharged on May 14, 2026. A personal history was due no later than April 20, 2026; however, it was not completed until April 24, 2026.
Client #18 was admitted to the detoxification level of care on February 16, 2026, and stepped down to the inpatient non-hospital residential level of care on February 17, 2026. The record did not contain documentation that the personal history had been completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization will provide refresher training to all clinical staff regarding timely completion of the Comprehensive Biopsychosocial Assessment tool, including full personal history, within 72 hours of admission. Documentation of this training will be maintained in the employees' HR files. The Organization has incorporated monthly auditing of timely completion of required 72-hour assessments into the Annual Compliance Monitoring Schedule. Audit findings will be submitted for review to the Risk/Quality Management Committee in the month following the scheduled audit. The Director of Clinical Services, Director of HR and the Risk Manager are responsible for implementation of these corrective actions. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of client records, the facility failed to document a physical examination by the physician within twenty-four hours, per facility policy in one out of two applicable records reviewed.
Client #15 was admitted on May 1, 2026, and was still active at the time of the inspection. An physical was due no later than May 2, 2026; however, there was no documentation that one was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization will provide refresher training to all medical staff regarding timely completion of the history and physical examination, within 24 hours of admission. Documentation of this training will be maintained in the employees' HR files. The Organization has incorporated monthly auditing of timely completion of required history and physical examinations into the Annual Compliance Monitoring Schedule. Audit findings will be submitted for review to the Risk/Quality Management Committee in the month following the scheduled audit. The Medical Director, Director of HR and the Risk Manager are responsible for implementation of these corrective actions. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within five days of admission, per facility policy, in three out of seven records reviewed.
Client #15 was admitted on May 1, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than May 6, 2026; however, there was no documentation that one was completed.
Client #16 was admitted to the detoxication level of care on May 5, 2026, and stepped down to the inpatient non- hospital residential level of care on May 10, 2026. A comprehensive treatment plan was due no later than May 15, 2026; however, there was no documentation that one was completed.
Client #19 was admitted to the detoxification level of care on January 6, 2026, and stepped down to the inpatient non-hospital residential level of care on January 11, 2026, and discharged on February 10, 2026. A comprehensive treatment plan was due no later than January 16, 2026; however, it was not completed until January 24, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization will provide refresher training to all clinical staff regarding timely completion and timely ongoing reviews of the Master Treatment Plan, as dictated per the Organization's policy. Documentation of this training will be maintained in the employees' HR files. The Organization has incorporated monthly auditing of timely completion and ongoing reviews of the Master Treatment Plan into the Annual Compliance Monitoring Schedule. Audit findings will be submitted for review to the Risk/Quality Management Committee in the month following the scheduled audit. The Director of Clinical Services, Director of HR and the Risk Manager are responsible for implementation of these corrective actions. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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 the client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client and included written documentation of the type and frequency of treatment and rehabilitation services in two out of five applicable client records reviewed.
Client #14 was admitted to the detoxification level of care on April 25, 2026, and stepped down to the inpatient non-hospital residential level of care on April 30, 2026, and is still active at the time of the inspection. A comprehensive treatment plan dated May 15, 2026, did not include the type and frequency of treatment and rehabilitation services.
Client #17 was admitted to the inpatient non-hospital residential level of care on April 17, 2026, and discharged on May 14, 2026. A comprehensive treatment plan dated April 24, 2026, did not include the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization will provide refresher training to all clinical staff regarding accurate completion of the Master Treatment Plan, including identified type and frequency of treatment and rehabilitation services to be provided. Documentation of this training will be maintained in the employees' HR files. The Organization has incorporated monthly auditing of identified type and frequency of treatment/rehabilitation services included in the MTP, into the Annual Compliance Monitoring Schedule. Audit findings will be submitted for review to the Risk/Quality Management Committee in the month following the scheduled audit. The Director of Clinical Services, Director of HR and the Risk Manager are responsible for implementation of these corrective actions. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every fifteen days, per facility policy, in one out of three applicable records reviewed.
Client #18 was admitted to the detoxification level of care on February 16, 2026, and stepped down to the inpatient non-hospital residential level of care on February 17, 2026, and discharged on March 19, 2026. A treatment plan was completed on February 17, 2026, and the next update was due no later than March 3, 2026; however, it was not completed until March 10, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization will provide refresher training to all clinical staff regarding timely ongoing reviews/updates of the Master Treatment Plan, as dictated per the Organization's policy. Documentation of this training will be maintained in the employees' HR files. The Organization has incorporated monthly auditing of timely reviews/updates of the Master Treatment Plan the into the Annual Compliance Monitoring Schedule. Audit findings will be submitted for review to the Risk/Quality Management Committee in the month following the scheduled audit. The Director of Clinical Services, Director of HR and the Risk Manager are responsible for implementation of these corrective actions. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual which included information relative to the client ' s involvement with the project to include case consultations in four out of four applicable client records.
Client #13 was admitted to the detoxification level of care on April 22, 2026, and stepped down to the inpatient non-hospital residential level of care on April 27, 2026, and discharged on May 19, 2026. There was no case consultation documented in the client record.
Client #17 was admitted to the inpatient non-hospital residential level of care on April 17, 2026, and discharged on May 14, 2026. There was no case consultation documented in the client record.
Client #18 was admitted to the detoxification level of care on February 16, 2026, and stepped down to the inpatient non-hospital residential level of care on February 17, 2026, and discharged on March 19, 2026. There was no case consultation documented in the client record.
Client #19 was admitted to the detoxification level of care on January 6, 2026, and stepped down to the inpatient non-hospital residential level of care on January 11, 2026, and discharged on February 10, 2026. There was no case consultation documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization has adopted and implemented a Case Consultation & Transition Plan policy and documentation format. Staff were trained and began using this format on 6/19/26. The Organization has incorporated monitoring of the appropriate documentation of Case Consultation into the Annual Compliance Monitoring Schedule. Audit findings will be submitted to the Risk/Quality Committee in the month following completion of the scheduled audit. The Director of Clinical Services is responsible for implementation of this corrective action. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 provide a complete client record, that included a follow-up, within seven days, per facility policy in two out of four applicable records reviewed.
Client #17 was admitted to the detoxification level of care on April 17, 2026, and discharged on May 14, 2026. A follow up was due no later than May 20, 2026; however, there was no documentation that one was completed.
Client #19 was admitted to the detoxification level of care on January 6, 2026, and stepped down to the inpatient non-hospital residential level of care on January 11, 2026, and discharged on February 10, 2026. A follow up was due no later than February 17, 2026; however, there was no documentation that one was completed.
This is a repeat citation from the May 22, 2024, and April 29-May 1, 2025, licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization has provided appropriate training for accurate completion of Patient Follow Up. The Organization has incorporated monthly auditing of timely completion of patient follow-up into the Annual Compliance Monitoring Schedule. Audit findings will be submitted to the Risk/Quality Committee in the month following completion of the scheduled audit. The Director of Clinical Services and Risk Manager is responsible for implementation of these corrective actions |
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.
A plan of correction for completing and documenting individual training plans was submitted and approved by the Department for the May 22, 2024, and the April 29-May 1, 2025, licensing inspections. Completing and documenting individual training plans was again found to be a deficiency in the May 20-21, 2026, licensing inspection.
A plan of correction for completing and documenting counselor training hours was submitted and approved by the Department for the May 22, 2024, and April 29-May 1, 2025, annual licensing inspections. Completing and documenting counselor training hours was again found to be a deficiency in the May 20-21, 2026, licensing inspection.
A plan of correction for completing and documenting follow up contacts in the inpatient non-hospital residential level of care was submitted and approved by the Department for the May 22, 2024, and April 29-May 1, 2025, annual licensing inspections. Completing and documenting follow up contacts was again found to be a deficiency in the May 20-21, 2026, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization has incorporated regular monthly review of existing plans of correction, including timely completion of stated activities and ongoing progress of all submitted plans of correction into the monthly Risk and Quality Management Committee as a standing agenda item. This will ensure ongoing consistent leadership review of all plans of correction activities. The CEO, Medical Director, Director of Nursing, Director of Clinical Services, Director of HR and the Risk Manager are responsible for the full implementation of this plan of correction. POC monitoring will continue monthly at a minimum until all identified deficiencies have been corrected and compliance is met and maintained for a period of 3 consecutive months. Auditing frequency may then be adjusted to a frequency determined by the committee for monitoring of sustained compliance. |