INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Serenity LLC 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to ensure hot water temperature did not exceed 120 sink in the bathroom shared by clients and staff, read at a temperature of 148.6 when tested during licensing inspection.
These findings were reviewed with facility staff during licensing process.
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Plan of Correction
Project Director promptly notified maintenance of the water temperature concern identified during the inspection. Corrective action has been taken, in the form of an installed mixing valve to ensure the water does not exceed 120 degrees.
Following installation, Project Director has verified that the corrective action has been completed and the water temperature is measuring 117 degrees.
The installed mixing valve will maintain this temperature.
Following installation, the Project Director will monitor water temperature to ensure the mixing valve continues to operate correctly. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of client consent was offered to the client and a copy maintained in the client record in three out of ten records reviewed.
Client #1 was admitted to the partial hospitalization level of care on January 05, 2026, and was transferred to the intensive outpatient level of care on February 27, 2026, and was discharged on May 1, 2026. A release of information form for a referral source signed by the client on January 05, 2026, did not have documentation that a copy was offered.
Client #2 was admitted to the partial hospitalization level of care on December 29, 2025, was transferred to the intensive outpatient level of care on March 17, 2026, and discharged April 26, 2026. A release of information form for a referral source signed by the client on December 29, 2025, did not have documentation that a copy was offered.
Client #6 was admitted to the partial hospitalization level of care on April 30, 2026, and was active at the time of the licensing process. A release of information form for a referral source signed by the client on April 30, 2026, did not have documentation that a copy was offered.
These findings were reviewed with facility staff during their licensing process.
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Plan of Correction
Project Director reviewed this citation and confirmed the release form was missing the appropriate area for staff to mark whether a copy was offered to a client.
This form has been modified to include the appropriate area for documenting that a copy was offered.
Project Director has tested this new feature and confirmed that it is working on all information release forms.
On 7/17/2026 Clinical Director held an in-service training covering this matter.
Clinical Director will continue to monitor to ensure clients are offered a copy and that it is noted in the client chart |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project, in one of one applicable record reviewed.
Client #4 was admitted to the partial hospitalization level of care on February 18, 2026, and was involuntarily discharged on March 24, 2026. The record did not contain documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
These findings were reviewed with facility staff during their licensing process.
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Plan of Correction
The Project Director and Clinical Director conducted in-service training on 07/17/2026 with all clinical staff members regarding the requirement to provide written notification to clients when treatment is involuntarily terminated. The training reviewed the applicable notification requirements, documentation expectations, and staff responsibility to ensure that written notice is provided and maintained in the client record for all clients to whom this requirement applies. The Project Director and Clinical Director will monitor applicable involuntary discharges on an ongoing basis to ensure continued compliance.
This deficiency is considered resolved effective immediately
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709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to ensure that individual treatment and rehabilitation plans were developed with the client to include written documentation of the type and frequency of treatment and rehabilitation services in seven out of seven records reviewed.
Client #1 was admitted to the partial hospitalization level of care on January 05, 2026, and was transferred to the intensive outpatient level of care on February 27, 2026. A comprehensive treatment plan was completed on January 20, 2026, and did not include frequency of treatment and rehabilitation services.
Client #2 was admitted to the partial hospitalization level of care on December 29, 2025, and was transferred to the intensive outpatient level of care on March 17, 2026. A comprehensive treatment plan was completed on January 14, 2026, and did not include the frequency of treatment and rehabilitation services.
Client #3 was admitted to the partial hospitalization level of care December 29, 2025, and was discharged on March 29, 2026. A comprehensive treatment plan was completed on February 3, 2026, and did not include the frequency of treatment and rehabilitation services.
Client #4 was admitted to the partial hospitalization level of care on February 18, 2026, and was discharged March 24, 2026. A comprehensive treatment plan was completed on February 24, 2026, and did not include the frequency of treatment and rehabilitation services.
Client #5 was admitted to the partial hospitalization level of care on March 24, 2026, and was active at the time of licensing process. A comprehensive treatment plan was completed on April 7, 2026, and did not include the frequency of treatment and rehabilitation services.
Client #6 was admitted to the partial hospitalization level of care on April 30, 2026, and was active at the time of licensing process. A comprehensive treatment plan was completed on May 13, 2026, and did not include the frequency of treatment and rehabilitation services.
Client #7 was admitted to the partial hospitalization level of care on May 8, 2026, and was active at the time of licensing process. A comprehensive treatment plan was completed on May 21, 2026, and did not include the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during their licensing process.
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Plan of Correction
Project Director has ensured that the templates used for individual treatment and rehabilitation plans include clear documentation fields for the type and frequency of treatment and rehabilitation. On 07/17/2026 The Clinical Director provided in-service training to all applicable clinical staff regarding the requirement that each individual treatment and rehabilitation plan be developed with the client and include documentation of the type and frequency of treatment and rehabilitation services.
Clinical Director will continue to monitor this ensuring the proper documentation is in place during the continuing chart audit process. |
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 the client records, the facility failed to review and update treatment plans at least every 30 days, in four out of seven records reviewed.
Client #1 was admitted to the partial hospitalization level of care on January 05, 2026, and was transferred to the intensive outpatient level of care on February 27, 2026. A treatment plan update was completed on January 20, 2026 and the next update was due February 19, 2026; however, an update was not completed prior to the transfer to a lower level of care.
Client #2 was admitted to the partial hospitalization level of care on December 29, 2025, and was transferred to the intensive outpatient level of care on March 17, 2026. A treatment plan update was due February 14, 2026; however, it was not completed until February 20, 2026.
Client #3 was admitted to the partial hospitalization level of care December 29, 2025, and was discharged on March 29, 2026. A treatment plan update was due March 3, 2026; however, it was not completed until March 16, 2026.
Client #5 was admitted to the partial hospitalization level of care on March 24, 2026, and was active at the time of licensing process. A treatment plan update was due May 7, 2026; however, it was not completed until May 26, 2026.
These findings were reviewed with facility staff during their licensing process.
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Plan of Correction
The Clinical Director completed in-service training with applicable clinical staff on 07/17/2026 regarding the requirement that treatment and rehabilitation plans be reviewed and updated at least every 30 days as well as when transitioning levels of care. The training reinforced staff responsibility for monitoring treatment plan review / due dates, completing reviews and updates within the required timeframe, documenting updates in the client record, and ensuring treatment plans remain current when a client transfers to another level of care or remains active in services. The Clinical Director also reviewed expectations for timely documentation and proper use of the electronic medical record system to track upcoming treatment plan update due dates. The Project Director and Clinical Director will monitor treatment plan completion on an ongoing basis to verify that reviews and updates are completed within the required timeframe and documented consistently in each applicable client record.
This deficiency is considered resolved effective immediately
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of the client records, the facility failed to ensure counseling was provided to clients on a regular and scheduled basis to include individual counseling, at least twice weekly, in four out of seven records reviewed.
Client #1 was admitted to the partial hospitalization level of care on January 05, 2026, and was transferred to the intensive outpatient level of care on February 27, 2026. The client only received one individual session during the week of January 11, 2026.
Client #2 was admitted to the partial hospitalization level of care on December 29, 2025, and was transferred to the intensive outpatient level of care on March 17, 2026. The client only received one individual session during the week of February 22, 2026.
Client #5 was admitted to the partial hospitalization level of care on March 24, 2026, and was active at the time of licensing process. The client only received one individual session during the week of May 26, 2026.
Client #6 was admitted to the partial hospitalization level of care on April 30, 2026, and was active at the time of licensing process. The client only received one individual session during the week of May 17, 2026.
These findings were reviewed with facility staff during their licensing process.
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Plan of Correction
The Clinical Director completed in-service training with applicable clinical staff on 07/17/2026 regarding the requirement that clients receive individual counseling on a regular and scheduled basis at least twice weekly. The training clarified that, for purposes of meeting the twice-weekly counseling requirement, each week is measured from Monday through Sunday, rather than from the client's date of admission. The Clinical Director reviewed that the clinical team had been measuring weeks based on the date of admission due to guidance implemented following a prior citation in June 2025, and clarified the corrected expectation moving forward. Staff were instructed that all applicable clients must be scheduled for and receive at least two individual counseling sessions during each Monday-through-Sunday week, unless clinically appropriate documentation supports an exception. The Clinical Director also reviewed scheduling, documentation, and monitoring procedures to ensure individual sessions are planned and completed within the required weekly timeframe. The Project Director and Clinical Director will monitor clinical schedules and client records on an ongoing basis to verify that clients are receiving the required twice-weekly individual counseling services and that documentation is completed accurately and consistently.
This deficiency is considered resolved effective immediately
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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 client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project that included a case consultation note every thirty days starting at admission, per facility policy, in three out of seven records reviewed.
Client #1 was admitted to the partial hospitalization level of care on January 05, 2026, and was transferred to the intensive outpatient level of care on February 27, 2026. A case consultation note was due on February 4, 2026, and wasn't completed until February 11, 2026.
Client #3 was admitted to the partial hospitalization level of care December 29, 2025, and was discharged on March 29, 2026. A case consultation note was completed on January 5, 2026, and the next was due on February 5, 2026; however, there were no further case consultations documented in client record.
Client #5 was admitted to the partial hospitalization level of care on March 24, 2026, and was active at the time of licensing process. A case consultation note was completed on March 31, 2026 and the next due on April 30, 2026; however, there were no further case consultations documented in client record.
These findings were reviewed with facility staff during their licensing process.
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Plan of Correction
The Clinical Director completed in-service training with applicable clinical staff on 07/17/2026 regarding the facility policy requirement that case consultation notes be completed every 30 days starting from the client's date of admission. The training reviewed staff responsibility for tracking case consultation due dates, completing case consultation documentation within the required timeframe, and ensuring that each client record contains complete information relative to the client's involvement with the project. The Project Director and Clinical Director will monitor client records on an ongoing basis to verify that required case consultation sessions and notes are completed timely, documented accurately, and maintained consistently in each applicable client record.
This deficiency is considered resolved effective immediately
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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 client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project, that included progress notes completed within 24 hours of a session, per facility policy, in four of seven records reviewed.
Client #1 was admitted to the partial hospitalization level of care on January 05, 2026, and was transferred to the intensive outpatient level of care on February 27, 2026. The record contained progress notes for individual sessions occurring on January 12, 2026, and January 27, 2026, that were not completed until January 15, 2026, February 2, 2026. Additionally, the record contained progress notes for group sessions occurring on January 25, 2026, January 26, 2026, January 31, 2026, February 08, 2026, February 12, 2026, February 18, 2026, February 22, 2026, February 23, 2026, and February 24, 2026, that were not documented until May 04, 2026, respectively and group session notes dated February 15, 2026, February 19, 2026, February 21, 2026, and February 26, 2026, that were not documented until May 5, 2026.
Client #2 was admitted to the partial hospitalization level of care on December 29, 2025, and was transferred to intensive outpatient level of care on March 17, 2026. The record contained a progress note for an individual session occurring on January 27, 2026, that was not documented until January 27, 2026. Additionally, the record contained progress notes for group sessions occurring on January 25, 2026, January 26, 2026, January 31, 2026, February 8, 2026, February 15, 2026, February 18, 2026, February 19, 2026, February 21, 2026, February 22, 2026, February 23, 2026, February 24, 2026, February 26, 2026, February 28, 2026, and March 3, that were not documented until May 4, 2026.
Client #3 was admitted to the partial hospitalization level of care December 29, 2025, and was discharged on March 29, 2026. The record contained a progress note for individual sessions occurring on February 9, 2026, February 13, 2026, and March 27, 2026, that were not documented until February 20, 2026, and April 22, 2026.
Client #5 was admitted to the partial hospitalization level of care on March 24, 2026, and was active at the time of licensing process. The record contained a progress note for an individual session occurring on April 24, 2026, that was not documented until May 19, 2026
These findings were reviewed with facility staff during their licensing process.
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Plan of Correction
The Clinical Director completed in-service training with applicable clinical staff on 07/17/2026 regarding the facility policy requirement that progress notes be completed within 24 hours of the service session. The training reviewed staff responsibility for completing individual and group progress notes timely, accurately documenting services provided, and ensuring that each client record contains complete information relative to the client's involvement with the project. The Clinical Director also reinforced documentation expectations within the electronic medical record system and reviewed procedures for monitoring outstanding notes so that late or missing documentation is identified and corrected promptly. The Project Director and Clinical Director will monitor client records on an ongoing basis to verify that progress notes are completed within the required timeframe, documented accurately, and maintained consistently in each applicable client record.
This deficiency is considered resolved effective immediately
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709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection on June 15, 2026, the facility failed to display the hours of project operation conspicuously to the general public.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has ensured that the facility's hours of project operation are now displayed conspicuously to the general public as required. Corrective action was completed immediately upon identification of the deficiency, and this matter is considered resolved. The Project Director will continue to monitor the posting to ensure the hours of operation remain visible, accurate, and accessible to the public on an ongoing basis. |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection on June 15, 2026, the facility failed to display a telephone number conspicuously to the general public for emergency purposes.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has ensured that the applicable emergency telephone number is now displayed conspicuously to the general public as required. Corrective action was completed immediately upon identification of the deficiency, and this matter is considered resolved. The Project Director will continue to monitor the posting to ensure the emergency telephone number remains visible, accurate, and accessible to the public on an ongoing basis. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to ensure that individual treatment and rehabilitation plans were developed with the client to include written documentation of the type and frequency of treatment and rehabilitation services in one out of one applicable record reviewed.
Client #10 was admitted to the outpatient level of care October 3, 2025, and was discharged on October 24, 2025. A comprehensive treatment plan was completed on October 8, 2025, and did not include the frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director completed in-service training with applicable clinical staff on 07/17/2026 regarding the requirement that treatment and rehabilitation plans be reviewed and updated at least every 30 days as well as when transitioning levels of care. The training reinforced staff responsibility for monitoring treatment plan review / due dates, completing reviews and updates within the required timeframe, documenting updates in the client record, and ensuring treatment plans remain current when a client transfers to another level of care or remains active in services. The Clinical Director also reviewed expectations for timely documentation and proper use of the electronic medical record system to track upcoming treatment plan update due dates. The Project Director and Clinical Director will monitor treatment plan completion on an ongoing basis to verify that reviews and updates are completed within the required timeframe and documented consistently in each applicable client record.
This deficiency is considered resolved effective immediately
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to complete treatment plan updates every 30 days, per facility policy, in one out of two applicable records reviewed.
Client #8 was transferred to intensive outpatient level of care on February 27, 2026, and was discharged on May 1, 2026. A treatment plan update was due on February 19, 2026, prior to level of care transfer; however, an update was not documented until April 21, 2026.
These findings were reviewed with facility staff during their licensing process.
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Plan of Correction
The Clinical Director completed in-service training with applicable clinical staff on 07/17/2026 regarding the requirement that treatment and rehabilitation plans be reviewed and updated at least every 30 days as well as when transitioning levels of care. The training reinforced staff responsibility for monitoring treatment plan review / due dates, completing reviews and updates within the required timeframe, documenting updates in the client record, and ensuring treatment plans remain current when a client transfers to another level of care or remains active in services. The Clinical Director also reviewed expectations for timely documentation and proper use of the electronic medical record system to track upcoming treatment plan update due dates. The Project Director and Clinical Director will monitor treatment plan completion on an ongoing basis to verify that reviews and updates are completed within the required timeframe and documented consistently in each applicable client record.
This deficiency is considered resolved effective immediately
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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 have a complete client record on an individual which included information relative to the client's involvement with the project, that included progress notes completed within 24 hours of session, per facility policy, in one of three records reviewed.
Client #8 was admitted to intensive outpatient level of care on February 27, 2026, and was discharged on May 1, 2026. The record contained a progress note for an individual session occurring on March 13, 2026, that was not documented until March16, 2026. Additionally, group sessions were held on March 03, 2026, and March 20, 2026, that were not documented until May 05, 2026, and March 26, 2026.
These findings were reviewed with facility staff during their licensing process.
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Plan of Correction
The Clinical Director completed in-service training with applicable clinical staff on 07/17/2026 regarding the facility policy requirement that progress notes be completed within 24 hours of the service session. The training reviewed staff responsibility for completing individual and group progress notes timely, accurately documenting services provided, and ensuring that each client record contains complete information relative to the client's involvement with the project. The Clinical Director also reinforced documentation expectations within the electronic medical record system and reviewed procedures for monitoring outstanding notes so that late or missing documentation is identified and corrected promptly. The Project Director and Clinical Director will monitor client records on an ongoing basis to verify that progress notes are completed within the required timeframe, documented accurately, and maintained consistently in each applicable client record.
This deficiency is considered resolved effective immediately
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709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project including case consultation notes every thirty days starting at admission, per facility policy, in one of three records reviewed.
Client #9 was transferred to the intensive outpatient level of care on March 17, 2026, and was discharged on April 26, 2026. There was no documentation of case consultations in the client record.
These findings were reviewed with facility staff during their licensing process.
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Plan of Correction
The Clinical Director completed in-service training with applicable clinical staff on 07/17/2026 regarding the facility policy requirement that case consultation notes be completed every 30 days starting from the client's date of admission. The training reviewed staff responsibility for tracking case consultation due dates, completing case consultation documentation within the required timeframe, and ensuring that each client record contains complete information relative to the client's involvement with the project. The Project Director and Clinical Director will monitor client records on an ongoing basis to verify that required case consultation sessions and notes are completed timely, documented accurately, and maintained consistently in each applicable client record.
This deficiency is considered resolved effective immediately.
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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 client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan completed ten days prior to discharge, per facility policy, in two out of three applicable records reviewed.
Client #8 was transferred to the intensive outpatient level of care on February 27, 2026, and was discharged on May 1, 2026. The Aftercare plan documented in the client record wasn't completed until May 1, 2026.
Client #9 was transferred to the intensive outpatient level of care on March 17, 2026, and was discharged on April 26, 2026. There was no aftercare plan documented in client record.
These findings were reviewed with facility staff during their licensing process.
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Plan of Correction
The Project Director and Clinical Director provided in-service training to all applicable clinical staff on 7/31/2026 regarding the facility policy requirement that aftercare plans be completed at least ten days prior to discharge for all clients. The training reviewed staff responsibility for identifying anticipated discharge dates, initiating aftercare planning timely, documenting the completed aftercare plan in the client record, and ensuring that the plan includes appropriate discharge planning information and continuing care recommendations. The Clinical Director reinforced expectations for using the electronic medical record system to track upcoming discharges and aftercare planning due dates so that any missing or late documentation is identified and corrected promptly. The Project Director and Clinical Director will monitor applicable client records on an ongoing basis to verify that aftercare plans are completed within the required timeframe, documented accurately, and maintained consistently in each client record.
This deficiency is considered resolved effective immediately
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which included information relative to the client's involvement with the project, including follow-up information within 30 days, per facility policy, in two of three applicable records reviewed.
Client #9 was transferred to the intensive outpatient level of care on March 17, 2026, and was discharged on April 26, 2026. A follow up was due by May 26, 2026; however, it was not documented until June 2, 2026.
Client #10 was admitted to the outpatient level of care October 3, 2025, and was discharged on October 24, 2025. A follow up was due by November 24, 2025; however, there was not one documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and Clinical Director provided in-service training to all applicable clinical staff on 07/31/2026 regarding the facility policy requirement that client follow-up information be completed and documented within 30 days of discharge for all clients. The training reviewed staff responsibility for identifying discharged clients requiring follow-up, tracking the 30-day follow-up due date, completing follow-up attempts timely, and documenting follow-up information or attempts in the client record. The Clinical Director reinforced expectations for using the electronic medical record system to monitor upcoming follow-up due dates and identify any missing or late documentation so that corrective action can occur promptly. The Project Director and Clinical Director will monitor applicable discharged client records on an ongoing basis to verify that follow-up information is completed within the required timeframe.
This deficiency is considered resolved effective immediately.
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709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection on June 15, 2026, the facility failed to display the hours of project operation conspicuously to the general public.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has ensured that the facility's hours of project operation are now displayed conspicuously to the general public as required. Corrective action was completed immediately upon identification of the deficiency, and this matter is considered resolved. The Project Director will continue to monitor the posting to ensure the hours of operation remain visible, accurate, and accessible to the public on an ongoing basis. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection on June 15, 2026, the facility failed to display a telephone number conspicuously to the general public for emergency purposes.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has ensured that the applicable emergency telephone number is now displayed conspicuously to the general public as required. Corrective action was completed immediately upon identification of the deficiency, and this matter is considered resolved. The Project Director will continue to monitor the posting to ensure the emergency telephone number remains visible, accurate, and accessible to the public on an ongoing basis. |