INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11-12, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lone Star Behavioral Health LLC dba Keystone Retreat Behavioral Health 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of personnel records, the facility failed to ensure that the clinical supervisors participated in documented monthly meetings with their supervisor to discuss duties and performance for the first 6 months of employment in that position.
Employee #2 was promoted to a clinical supervisor position on March 16, 2026 and was still in that position at the time of the inspection. No monthly supervision was documented.
Employee #3 was hired as a clinical supervisor on March 2, 2026 and was still in that position at the time of the inspection. No monthly supervision was documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will ensure that all clinical supervisors participate in documented monthly supervision meetings with their direct supervisor for the first six months of employment or promotion into the clinical supervisor position, in accordance with 704.6(e). The meetings will include discussion of the clinical supervisor's duties, performance, supervision responsibilities, documentation expectations, and any identified training or performance needs. Meeting documentation will include the date of the meeting, participants, topics discussed, follow-up items, and signatures of the clinical supervisor and supervising staff member.
The Facility Director is responsible for implementing this corrective action and maintaining compliance. The Clinical Director, is responsible for conducting and documenting the monthly supervision meetings with each clinical supervisor during the required six-month period. The Quality Assurance Manager will conduct monthly audits of supervision documentation to verify that required meetings are occurring and that records are complete.
All applicable supervisory staff will be retrained on the requirements of 704.6(e), including the requirement for documented monthly supervisory meetings during the first six months after hire or promotion into the clinical supervisor role. Training will include review of the supervision documentation form, required meeting content, timelines for completion, and the process for submitting completed documentation for review. The Facility Director will review the employment and promotion dates of all current clinical supervisors to ensure that required monthly supervision is scheduled and documented timely.
The facility will be in full compliance with this standard by September 15, 2026. Ongoing compliance will be maintained through monthly Quality Assurance audits of supervision documentation and follow-up by the Facility Director when any missing or incomplete documentation is identified.
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the facility's staff development program, the facility failed to complete an assessment of staff training needs for training year January 1, 2026 - December 31, 2026.
This finding was reviewed with the facility staff during the inspection process.
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Plan of Correction
The Project Director will ensure that an annual assessment of staff training needs is completed for all agency personnel for each training year. The assessment will identify required trainings, staff-specific training needs identified through individual training plans, regulatory training requirements, and programmatic areas requiring additional staff development. The completed assessment will be used to guide the agency's annual staff development program and training schedule for the training year.
The Project Director is responsible for achieving and maintaining compliance with this standard. The Facility Director will coordinate completion of the training needs assessment with department supervisors and will ensure that all staff positions are included in the review. Department supervisors are responsible for identifying training needs for staff under their supervision and submitting the information to the Facility Director by the established deadline. The Human Resource Manager will conduct an annual review of the staff development file to verify that the training needs assessment has been completed and retained.
To maintain compliance, the Facility Director will add the annual training needs assessment to the staff development calendar and will track completion prior to the start of each training year. Supervisory staff will be reminded annually of their responsibility to evaluate staff training needs and provide input for the assessment. Any missing or incomplete information will be addressed through supervisory follow-up by the Facility Director until the assessment is complete.
The facility will be in full compliance with this standard by September 15, 2026. Ongoing compliance will be maintained through annual completion of the training needs assessment and Quality Assurance review of the staff development program documentation.
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the facility's staff development program, the facility failed to develop a mechanism to collect feedback on completed trainings.
This finding was reviewed with the facility staff during the inspection process.
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Plan of Correction
The Project Director will ensure that the staff development program includes a formal mechanism to collect feedback on all completed trainings. The facility will implement a standardized training feedback form to be completed by staff after each training. The feedback form will include, at minimum, staff evaluation of the training content, trainer effectiveness, relevance to job duties, and any additional training needs identified by the staff member.
The Project Director is responsible for achieving and maintaining compliance with this standard. The Human Resource Manager will coordinate implementation of the feedback process and ensure that training feedback forms are available and completed following each training. Department supervisors are responsible for ensuring that staff under their supervision complete the feedback form after assigned trainings. The Quality Assurance Manager will review staff development records quarterly to verify that completed training feedback forms are maintained with training documentation.
To maintain compliance, the Facility Director will update the staff development policies and procedures to include the training feedback process, time frames for completion, and staff responsible for collection and review. Supervisory staff will be informed of the requirement to obtain feedback following completed trainings. Any missing feedback forms identified during Quality Assurance review will be addressed through supervisory follow-up by the Facility Director.
The facility will be in full compliance with this standard by September 15, 2026. Ongoing compliance will be maintained through use of the standardized training feedback form and quarterly Quality Assurance review of staff development documentation.
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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 Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee in the required time frame, appropriate to that employee's skill level in 15 out of 15 employee records reviewed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that a written individual training plan is developed annually for each employee and that each plan is appropriate to the employee's skill level, job duties, experience, and identified training needs. The individual training plan will be completed with input from both the employee and the employee's supervisor and will identify required trainings, position-specific training needs, professional development goals, and projected time frames for completion.
The Project Director is responsible for achieving and maintaining compliance with this standard. The Facility Director and Human Resource Manager will coordinate the annual completion of individual training plans and ensure that all employees have a current plan on file. Department supervisors are responsible for meeting with each employee under their supervision to obtain employee input, assess skill level and training needs, develop the individual training plan, and submit the completed plan to the Facility Director by the established deadline. The Quality Assurance Manager will review personnel and staff development records quarterly to verify that current individual training plans are completed and maintained for all employees.
To maintain compliance, the Facility Director will add annual individual training plan completion to the staff development calendar and will track completion for all employees. Supervisors will receive instruction on the requirement to complete training plans annually with employee input and to ensure that each plan reflects the employee's current skill level and job responsibilities. Any missing, incomplete, or outdated individual training plans identified during review will be corrected through supervisory follow-up by the Facility Director.
The facility will be in full compliance with this standard by September 15, 2026. Ongoing compliance will be maintained through annual completion of individual training plans, tracking by the Facility Director and Human Resource Manager, and quarterly Quality Assurance review of personnel and staff development documentation.
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to provide either individual paper towels or a mechanical dryer in each patient's bathroom. Room #220 did not have any paper towels.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director will ensure that each patient bathroom is equipped with either individual paper towels or a mechanical hand dryer as required by the standard. Paper towels were placed in Room #220 immediately upon identification of the concern, and all patient bathrooms will be reviewed to ensure that required hand-drying supplies are available and accessible.
The Facility Director is responsible for achieving and maintaining compliance with this standard. The Maintenance Supervisor is responsible for ensuring that paper towel dispenser are present and operable in each patient bathroom. Housekeeping staff are responsible for checking bathrooms daily and restocking paper towels as needed. The Quality Assurance Manager will review physical plant inspection logs monthly to verify that bathroom supply checks are completed and any deficiencies are corrected timely.
To maintain compliance, the Facility Director will add bathroom hand-drying supplies to the facility's daily environmental rounds checklist. The Maintenance Supervisor will conduct weekly inspections of all patient bathrooms to confirm that each bathroom contains an operable soap dispenser and individual paper towels. Any missing supplies or non-operable equipment will be corrected immediately and documented on the inspection log.
The facility will be in full compliance with this standard by September 15, 2026. Ongoing compliance will be maintained through daily environmental rounds, weekly Maintenance Supervisor inspections, and monthly Quality Assurance review of physical plant inspection documentation.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ventilate toilet and wash rooms by exhaust fan or window. The ventilation fan in the bathroom in room #217 was inoperable.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will ensure that the bathroom in Room #217 is ventilated by an operable exhaust fan or window as required by the standard. The inoperable exhaust fan in Room #217 will be repaired or replaced by the Maintenance Supervisor, and all patient bathrooms will be inspected to confirm that ventilation systems are present and functioning properly.
The Facility Director is responsible for achieving and maintaining compliance with this standard. The Maintenance Supervisor is responsible for completing the repair or replacement of the ventilation fan in Room #217 and documenting completion of the work. Housekeeping and maintenance staff are responsible for reporting any nonfunctioning exhaust fans, windows, or other ventilation concerns identified during routine room checks. The Quality Assurance Manager will review physical plant inspection documentation monthly to verify that bathroom ventilation checks are completed and deficiencies are corrected timely.
To maintain compliance, the Facility Director will add bathroom ventilation to the facility's physical plant inspection checklist. The Maintenance Supervisor will conduct weekly inspections of toilet and wash rooms to confirm that exhaust fans are operable or windows are functional and available for ventilation. Any nonfunctioning ventilation equipment identified during inspections will be repaired as soon as possible and documented on the maintenance log.
The facility will be in full compliance with this standard by September 15, 2026. Ongoing compliance will be maintained through weekly Maintenance Supervisor inspections, routine staff reporting of ventilation concerns, timely maintenance follow-up, and monthly Quality Assurance review of physical plant documentation.
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705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, the facility failed to store all food items off the floor. There was a container of pickles on the floor in the refrigerator.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
The container of pickles identified on the floor in the refrigerator was immediately removed from the floor and placed on appropriate shelving so that all food items are stored off the floor. The Facility Director and Food Service/Kitchen staff will ensure that all food items are stored on shelving, racks, or other approved storage surfaces and are not placed directly on the floor at any time.
The Facility Director is responsible for overall oversight and ensuring corrective action is implemented and maintained. Food Service/Kitchen staff are responsible for daily compliance by verifying that all food is stored off the floor during food handling, storage, and cleaning activities. The House Manager or designee will conduct routine checks of refrigerators, freezers, dry storage areas, and other food storage locations to verify ongoing compliance.
Staff responsible for food storage will be re-educated on the requirement that all food items must be stored off the floor. Supervisory follow-up will include documented weekly inspections of food storage areas for four weeks and monthly inspections thereafter. Any identified noncompliance will be corrected immediately, and the Facility Director will review inspection results to ensure the corrective action remains effective.
The facility will be in full compliance with this standard by August 19, 2026.
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms in the residential facility are unobstructed. The emergency exit door in the gym did not open.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
The facility immediately repaired the emergency exit door in the gym and ensured the exit door was functional and able to open as required. The Maintenance Supervisor is responsible for inspecting the gym emergency exit door and all other designated emergency exits to ensure they are unobstructed, operational, and accessible at all times.
Facility staff will be re-educated by the Facility Director, regarding fire safety requirements, including the requirement that all stairways, hallways, room exits, and building exits remain unobstructed and fully operational. Staff will be instructed to immediately report any blocked, damaged, or non-operational exit to the Maintenance Supervisor and Facility Director.
To maintain ongoing compliance, the Maintenance Supervisor, will complete routine inspections of emergency exits, including the gym emergency exit door, to verify that each exit is unobstructed and opens properly. Any identified concern will be corrected immediately and documented. The Facility Director will provide supervisory follow up by reviewing inspection documentation and confirming completion of any corrective maintenance.
The facility will be in full compliance with this standard by September 15, 2026.
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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 personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure three employees received the required training in the use of the fire extinguishers upon employment.
Employee #3 was hired on March 2, 2026 for the position of clinical supervisor and was still employed at the time of the inspection. She did not have the training as of the time of the inspection.
Employee #9 was hired on March 2, 2026 for the position of counselor and was still employed at the time of the inspection. She did not have the training until March 17, 2026.
Employee #14 was hired on April 3, 2026 for the position of counselor and was still employed at the time of the inspection. He did not have the training as of the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resource Manager will ensure that all current staff who have not received fire extinguisher training complete the required instruction and that documentation of completion is placed in each employee's personnel record. The Human Resource Manager, will coordinate fire extinguisher instruction for all new hires upon employment and prior to the employee working independently. The Human Resources Manager will maintain a new-hire training checklist and will verify that fire extinguisher training is completed and documented at the time of hire.
The Clinical Supervisor will immediately review personnel files for all active clinical and non-clinical staff to confirm that required fire extinguisher training documentation is present. Any missing documentation will be reported to the Facility Director and Human Resources for correction. Although this standard is related to personnel training rather than clinical chart documentation, the facility will use the same compliance methodology applied to documentation standards: staff training, supervisor verification, and ongoing oversight by the assigned responsible staff person.
To maintain compliance, the Facility Director will conduct monthly audits of new-hire personnel files for three months and quarterly audits thereafter to verify that fire extinguisher training has been completed upon employment and properly documented. Audit findings will be reviewed with the Human Resources and Clinical Supervisor, and any identified deficiencies will be corrected immediately through staff follow-up and supervisory review. Facility will be in full compliance by September 15, 2026.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure four employees received the required training to perform assigned tasks during emergencies.
Employee #3 was hired on March 2, 2026 for the position of clinical supervisor and was still employed at the time of the inspection. She did not have the training as of the time of the inspection.
Employee #9 was hired on March 2, 2026 for the position of counselor and was still employed at the time of the inspection. She did not have the training as of the time of the inspection.
Employee #13 was hired on April 29, 2026 for the position of counselor and was still employed at the time of the inspection. She did not have the training as of the time of the inspection.
Employee #14 was hired on April 3, 2026 for the position of counselor and was still employed at the time of the inspection. He did not have the training as of the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director shall ensure that all personnel on all shifts are trained to perform assigned emergency tasks during fire drills and actual emergencies. The Director of Operations and Operations Supervisor shall review the facility's fire safety procedures, emergency task assignments, evacuation routes, and staff responsibilities with all current staff members. All newly hired staff shall receive this training during orientation prior to working independently. Training shall include a review of assigned duties by job title, the location and use of fire safety equipment, evacuation procedures, accountability procedures, and documentation requirements following each drill.
The Operations Supervisor shall conduct supervisory follow-up after each fire drill to confirm that staff performed assigned duties correctly and shall provide immediate re-education to any staff member who does not complete assigned responsibilities as required. The Director of Operations shall monitor fire drill documentation monthly to verify that drills are completed on all shifts and that staff participation, assigned tasks, and any corrective follow-up are documented.
The Facility Director shall be responsible for overall oversight and maintaining compliance with this standard. Director of Operations shall report the results of monthly monitoring to the Facility Director for review. Any identified deficiencies shall be corrected through staff retraining, documented supervisory follow-up, and continued monitoring until sustained compliance is demonstrated. The facility will be in full compliance with this standard by September 20, 2026.
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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 from December, 2025 through July, 2026, the facility failed to maintain a written fire drill record including exit route used, problems encountered and whether the fire alarm or smoke detector was operative.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will ensure that the facility's fire drill record is revised to include all required documentation elements, including the date, time, amount of time required for evacuation, exit route used, number of persons in the facility at the time of the drill, problems encountered, and whether the fire alarm or smoke detector was operative. The revised fire drill log will be implemented immediately and used for all fire drills going forward.
The Operations Director and Operations Supervisors will train all staff responsible for conducting or documenting fire drills on the required elements of the fire drill record and the correct completion of the revised log. Training will include review of the regulatory requirement, completion expectations, and the process for submitting completed logs for supervisory review.
The on shift Operations Supervisor will review each completed fire drill log after every drill to verify that all required information is present and complete. Any incomplete documentation will be returned to the staff member responsible for completion and corrected immediately. The Facility Director will conduct a monthly review of fire drill records to ensure continued compliance.
The facility will be in full compliance with this standard by August 30, 2026.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from December, 2025 through July, 2026 the facility failed to conduct a fire drill during sleeping hours at least every 6 months. No sleep drills were conducted.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Operations Director is responsible for achieving and maintaining compliance with this standard. The Operations Director will ensure that sleeping-hour fire drills are scheduled and conducted at least once every six months, as required. The fire drill schedule will be reviewed and updated to include both sleeping-hour and non-sleeping-hour drills. Facility staff will be trained on the fire drill requirements, including the requirement that at least one drill be conducted during sleeping hours every six months, proper documentation of each drill, and the procedure for promptly reporting completion of the drill to supervisory staff. Supervisory follow-up will include monthly review of the fire drill log by the Operations Director to verify that required drills are completed within the required timeframe and that documentation is accurate and complete. Any missed, incomplete, or improperly documented drill will be addressed immediately through staff retraining and corrective supervisory action. The Operations Director will maintain oversight of the fire drill schedule and documentation on an ongoing basis to ensure continued compliance.
The facility will be in full compliance with this standard by September 31, 2026.
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705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs from December, 2025 through July, 2026 the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will revise the fire drill documentation process to ensure each fire drill log clearly indicates whether a fire alarm or smoke detector was set off during the drill. The Operations Director will update the fire drill log form to include a required field documenting that the alarm or smoke detector was activated, the date and time of the drill, staff present, evacuation time, and any corrective action needed.
The Operations Director will train all staff responsible for conducting or documenting fire drills on the revised procedure and the requirement to set off a fire alarm or smoke detector during each fire drill. Training will include review of the updated fire drill log, expectations for complete documentation, and the process for reporting any deficiencies identified during a drill.
The Operations Director will conduct supervisory follow up by reviewing each completed fire drill log immediately after the drill to verify that alarm or smoke detector activation was documented. The Facility Director will provide ongoing oversight by reviewing fire drill logs monthly to ensure continued compliance. Any missing or incomplete documentation will be addressed with the responsible staff member through immediate corrective counseling and retraining as needed.
Facility Director, Operations Director, and Operations Supervisors are responsible for conducting and documenting fire drills.
The facility will be in full compliance with this standard immediately upon implementation of the revised fire drill log and staff training, no later than August 31, 2026.
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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 detox and inpatient client records, the facility failed to notify the emergency contact of the client leaving the facility against medical advice within 12 hours in four out of four applicable records reviewed.
Client #5 was admitted on June 11, 2026 and discharged on June 14, 2026.
Client #6 was admitted on July 8, 2026 and discharged on July 14, 2026.
Client #7 was admitted on May 10, 2026 and discharged on May 16, 2026.
Client #13 was admitted on July 17, 2026 and discharged on July 25, 2026.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective immediately, the facility will ensure that the emergency contact for any client who leaves the facility against medical advice is notified within 12 hours, unless the client has revoked consent or otherwise restricted disclosure in accordance with applicable confidentiality requirements. The Operation Director or Operations Supervisor onsite will be the designated staff member notifying the client's EC. The Clinical Director will conduct weekly audits of all AMA discharges for 90 days to verify that emergency contact notification was completed within 12 hours when permitted and that documentation is complete. Audit findings will be reported to the Executive Director and reviewed during the Quality Assurance and Performance Improvement meeting. All applicable staff will receive in-service training on the revised AMA discharge procedure, emergency contact notification requirements, documentation standards, confidentiality and consent considerations, and supervisor escalation requirements. Training will be provided by the Director of Clinical and will be completed within 7 business days. New hires will receive this training during orientation, and refresher training will be provided quarterly at staff meetings for at least 6 months, then annually thereafter or sooner if audit findings indicate a need for additional education. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the purpose of the disclosure in 13 out of 28 records reviewed.
Client #1 was admitted on August 7, 2026 and was still active at the time of the inspection. A release of information dated August 7, 2026 is to a family member.
Client #2 was admitted on August 5, 2026 and was still active at the time of the inspection. A release of information dated August 5, 2026 is to a family member.
Client #3 was admitted on August 5, 2026 and was still active at the time of the inspection. A release of information dated August 5, 2026 is to a family member.
Client #8 was admitted on July 7, 2026 and was still active at the time of the inspection. A release of information dated July 7, 2026 is to a family member.
Client #11 was admitted on July 25, 2026 and was still active at the time of the inspection. A release of information dated July 25, 2026 is to a family member.
Client #14 was admitted on May 2, 2026 and was discharged on June 1, 2026. A release of information dated May 2, 2026 is to a family member.
Client #15 was admitted on June 30, 2026 and was still active at the time of the inspection. A release of information dated June 30, 2026 is to a family member.
Client #20 was admitted on June 9, 2026 and was discharged on July 10, 2026. A release of information dated June 9, 2026 is to a family member.
Client #23 was admitted on August 2, 2026 and was still active at the time of the inspection. A release of information dated August 2, 2026 is to a family member.
Client #24 was admitted on June 24, 2026 and was discharged on July 23, 2026. A release of information dated June 24, 2026 is to a family member.
Client #25 was admitted on June 12, 2026 and was discharged on July 10, 2026. A release of information dated June 12, 2026 is to a family member.
Client #26 was admitted on July 8, 2026 and was discharged on July 19, 2026. A release of information dated July 8, 2026 is to a family member.
Client #27 was admitted on June 18, 2026 and was discharged on July 17, 2026. A release of information dated June 18, 2026 is to a family member.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility will ensure that every informed and voluntary consent for disclosure of client record information includes a clearly documented purpose of disclosure prior to any information being released. The Clinical Director will revise and review the release of information process with all clinical and intake staff to confirm that the purpose of disclosure field is completed, specific to the disclosure being made, and reviewed with the client before the client signs the consent. Any incomplete consent form will be corrected before use and before disclosure occurs.
All clinical staff, intake staff, and any staff responsible for obtaining client consents will receive refresher training on confidentiality requirements, completion of informed and voluntary consents, and the requirement to document the purpose of disclosure. Training will be provided by the Clinical Director and will include review of the applicable regulation, review of the facility release of information form, examples of acceptable purpose-of-disclosure entries, and instruction that releases may not be used if the purpose is blank, vague, or incomplete.
Supervisory follow up will be completed by the Clinical Supervisor through weekly chart audits for 60 days. Audits will include review of all newly completed releases of information to verify that the purpose of disclosure is present and appropriate. Audit findings will be documented and reviewed with staff during supervision. If an incomplete or deficient consent is identified, the staff member responsible for obtaining the consent will receive immediate corrective coaching, and the consent will be corrected before any disclosure is made when clinically and legally appropriate.
The Clinical Director is responsible for overall oversight of this corrective action and for ensuring ongoing compliance with § 709.28(c)(3). Following the initial 60-day weekly audit period, the Clinical Supervisor will conduct monthly random chart audits for three months and report results to the Clinical Director. Continued noncompliance will result in additional staff training and increased supervisory review until sustained compliance is demonstrated.
The facility will be in full compliance with this standard by September 1, 2026.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client and facility records, the facility failed to inform the Department of an unusual incident within the required three days. It was discovered that the facility had an unusual incident occur on March 14, 2026, June 22, 2026 and July 30, 2026 all which involved presence of an ambulance. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will achieve and maintain compliance with 709.34(c)(4) by ensuring that all unusual incidents requiring police, fire, or ambulance personnel are reported to the Department within three business days, to the extent permitted by State and Federal confidentiality laws. The Unusual Incident Portal was set up in DDAP on July 31, 2026, and will be used as the designated reporting mechanism for all applicable incidents moving forward.
The Facility Director will be responsible for overall implementation and ongoing compliance with this standard. The Director of Nursing will be responsible for ensuring that clinical staff are trained on identifying reportable unusual incidents, documenting incidents in the clinical chart, notifying supervisory personnel immediately, and submitting or assisting with the submission of required information through the DDAP Unusual Incident Portal. The Assistant Director of Nursing will provide supervisory follow up after any incident involving emergency personnel to confirm that the incident was reviewed, documented in the client record as applicable, and reported within the required timeframe.
All applicable staff will receive training on the unusual incident reporting requirements, including the three-business-day reporting timeframe, the types of incidents that must be reported, and the use of the DDAP Unusual Incident Portal. Supervisory follow up will occur through review of incident documentation and clinical chart entries following any event requiring emergency personnel. The Facility Director will conduct periodic monitoring of incident records to verify that reportable incidents are submitted timely and that documentation is complete.
The facility will be in full compliance with this standard by September 1st, 2026.
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709.81(b)(1) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of partial hospitalization client records, the facility failed to disclose to the client of criteria for admission, treatment, completion, and discharge in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the criteria for admission, treatment, completion, and discharge in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight.
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709.81(b)(2)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(i) Project policies.
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Observations
Based on a review of partial hospitalization client records, the facility failed to disclose to the client of project policies in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the Project Policies in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight.
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709.81(b)(2)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of partial hospitalization client records, the facility failed to disclose to the client of hours of operation in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the hours of operations in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight.
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709.81(b)(2)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of partial hospitalization client records, the facility failed to disclose to the client of the fee schedule in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the Fee Schedule in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight.
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709.81(b)(2)(iv) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(iv) Services provided.
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Observations
Based on a review of partial hospitalization client records, the facility failed to disclose to the client of services provided in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the Services Provided in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight.
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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 the partial hospitalization client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in six out of six applicable client records reviewed.
Client #15 was admitted on June 30, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 3, 2026 with no type or frequency identified.
Client #17 was admitted on July 22, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 25, 2026 with no type or frequency identified.
Client #18 was admitted on July 17, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 21, 2026 with no type or frequency identified.
Client #19 was admitted on May 1, 2026 and was discharged on June 1, 2026. A comprehensive treatment plan was developed on May 4, 2026 with no type or frequency identified.
Client #20 was admitted on June 9, 2026 and was discharged on July 10, 2026. A comprehensive treatment plan was developed on June 12, 2026 with no type or frequency identified.
Client #21 was admitted on May 12, 2026 and was discharged on June 10, 2026. A comprehensive treatment plan was developed on May 15, 2026 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will revise its clinical chart documentation process to ensure that each individual treatment and rehabilitation plan includes the required type and frequency of treatment and rehabilitation services. The Clinical Director will update the treatment plan documentation expectations and review the standard with all clinical staff. Therapists will be responsible for documenting the type and frequency of services on each client's comprehensive treatment plan at the time the plan is developed and whenever the plan is updated.
Training will be provided to clinical staff by the Clinical Director regarding the requirements of 709.82(a)(2), including how to clearly identify the type of treatment and rehabilitation service and the expected frequency of each service in the treatment plan. Training will include review of the revised documentation procedure, examples of compliant treatment plan language, and instruction on correcting incomplete documentation prior to supervisory approval.
Supervisory follow-up will be completed by the Clinical Supervisor through review of new and updated treatment plans during routine chart supervision. Any treatment plan missing the required type or frequency of services will be returned to the assigned Therapist for immediate correction. The Clinical Supervisor will document follow-up with staff when corrections are required and will monitor for repeated documentation issues.
The Quality Assurance Director will be responsible for ongoing oversight of compliance with this standard. The Quality Assurance Director will conduct monthly chart audits for three months to verify that treatment plans include the type and frequency of treatment and rehabilitation services. Audit results will be reviewed with the Clinical Director and Clinical Supervisor, and any identified trends will be addressed through additional staff training or corrective action as needed.
The facility will be in full compliance with the standard by September 30, 2026.
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709.82(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document proposed type of support service on individual treatment plans in six out of six applicable records reviewed.
Client #15 was admitted on June 30, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 3, 2026 with no support services identified.
Client #17 was admitted on July 22, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 25, 2026 with no support services identified.
Client #18 was admitted on July 17, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 21, 2026 with no support services identified.
Client #19 was admitted on May 1, 2026 and was discharged on June 1, 2026. A comprehensive treatment plan was developed on May 4, 2026 with no support services identified.
Client #20 was admitted on June 9, 2026 and was discharged on July 10, 2026. A comprehensive treatment plan was developed on June 12, 2026 with no support services identified.
Client #21 was admitted on May 12, 2026 and was discharged on June 10, 2026. A comprehensive treatment plan was developed on May 15, 2026 with no support services identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will ensure that all individual treatment and rehabilitation plans include the proposed type of support service, as required by 709.82(a)(3). The Clinical Director, in collaboration with the Clinical Supervisors, will review the treatment planning process and update staff expectations to require that support services are clearly identified and documented on every comprehensive treatment plan, including services such as case management, family support, peer support, recovery support, medical coordination, psychiatric services, community referrals, or other clinically indicated supports.
All clinical staff responsible for developing treatment plans will receive training from the Clinical Director on the documentation requirements for individual treatment and rehabilitation plans, with specific emphasis on identifying and documenting proposed support services based on each client's assessed needs. Training will include review of the regulation, examples of compliant documentation, and instruction on where support services must be documented in the clinical chart.
The Clinical Director will conduct supervisory follow-up through chart reviews and individual supervision to verify that support services are documented on treatment plans prior to approval. Any deficiencies identified during supervisory review will be returned to the assigned counselor for correction prior to finalization whenever possible.
Ongoing compliance will be monitored by the Director of Compliance and Regulatory Affairs through monthly clinical chart audits for a minimum of three months. Audit results will be reported to the Clinical Director and Clinical Supervisors. If continued noncompliance is identified, additional staff training and corrective supervision will be implemented. The Clinical Director will be responsible for overall oversight of implementation and continued compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026.
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709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
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Observations
Based on a review of partial hospitalization client records, the facility failed to provide a complete client record, which is to include a follow-up in the required timeframe of 30 days, per the facility's policy and procedure manual, in three out of three applicable records reviewed.
Client #19 was admitted on May 1, 2026 and was discharged on June 1, 2026. No follow-up was documented.
Client #20 was admitted on June 9, 2026 and was discharged on July 10, 2026. No follow-up was documented.
Client #21 was admitted on May 12, 2026 and was discharged on June 10, 2026. No follow-up was documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will achieve and maintain compliance with 709.83(a)(11) by implementing a standardized follow-up documentation process to ensure that follow-up information is completed and entered into each applicable client record within 30 days of discharge, in accordance with the facility's policy and procedure manual.
The Clinical Director will be responsible for overall oversight of compliance with this standard. The Program Supervisor will review discharge records weekly to verify that follow-up contacts are assigned, completed, and documented within the required timeframe. The Office Manager will be responsible for completing follow-up contacts and documenting the follow-up information in the client record.
All clinical staff and office manager will receive training on the follow-up documentation requirement, including the 30-day timeframe, required documentation elements, and the location and method for entering follow-up information in the client record. Training will be completed by the Clinical Director and documented on staff training records.
Supervisory follow-up will include weekly chart audits for discharged clients for a minimum of three months. Audit results will be reviewed by the Clinical Director and Clinical Supervisors, and any missing or late follow-up documentation will be addressed immediately with the responsible staff member through corrective coaching and additional training as needed. After three months of sustained compliance, audits will continue monthly as part of the facility's ongoing quality assurance process.
The facility will be in full compliance with this standard by September 15, 2026.
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709.62(c)(1) LICENSURE Disclosure documentation
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of detox client records, the facility failed to disclose to the client of criteria for admission, treatment, completion, and discharge in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the criteria for admission, treatment, completion, and discharge in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight. |
709.62(c)(2)(i) LICENSURE Orientation Proj policies
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(i) Project policies, which include the following:
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Observations
Based on a review of detox client records, the facility failed to disclose to the client of project policies in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the Project Policies in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight. |
709.62(c)(2)(ii) LICENSURE Orientation - Op hours
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of detox client records, the facility failed to disclose to the client of hours of operation in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the hours of operations in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight |
709.62(c)(2)(iii) LICENSURE Orientation - Fee Schedule
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of detox client records, the facility failed to disclose to the client of the fee schedule in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the Fee Schedule in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight. |
709.62(c)(2)(iv) LICENSURE Orientation - Services Provided
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(iv) Services provided.
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Observations
Based on a review of detox client records, the facility failed to disclose to the client of services provided in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the Services Provided in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight. |
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 detox client records, the facility failed to provide a complete client record, which is to include a follow-up in the required timeframe of 30 days, per the facility's policy and procedure manual, in two out of two applicable records reviewed.
Client #5 was admitted on June 11, 2026 and was discharged on June 14, 2026. No follow up was documented.
Client #7 was admitted on May 10, 2026 and was discharged on May 16, 2026. No follow up was documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will achieve and maintain compliance with 709.63 by implementing a standardized follow-up documentation process to ensure that follow-up information is completed and entered into each applicable client record within 30 days of discharge, in accordance with the facility's policy and procedure manual.
The Clinical Director will be responsible for overall oversight of compliance with this standard. The Program Supervisor will review discharge records weekly to verify that follow-up contacts are assigned, completed, and documented within the required timeframe. The Office Manager will be responsible for completing follow-up contacts and documenting the follow-up information in the client record.
All clinical staff and office manager will receive training on the follow-up documentation requirement, including the 30-day timeframe, required documentation elements, and the location and method for entering follow-up information in the client record. Training will be completed by the Clinical Director and documented on staff training records.
Supervisory follow-up will include weekly chart audits for discharged clients for a minimum of three months. Audit results will be reviewed by the Clinical Director and Clinical Supervisors, and any missing or late follow-up documentation will be addressed immediately with the responsible staff member through corrective coaching and additional training as needed. After three months of sustained compliance, audits will continue monthly as part of the facility's ongoing quality assurance process.
The facility will be in full compliance with this standard by September 15, 2026.
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709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of inpatient client records, the facility failed to disclose to the client of criteria for admission, treatment, completion, and discharge in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the criteria for admission, treatment, completion, and discharge in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on a review of inpatient client records, the facility failed to disclose to the client of project policies in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the Project Policies in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight. |
709.51(b)(2)(ii) LICENSURE Hours of Operation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of inpatient client records, the facility failed to disclose to the client of hours of operation in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the hours of operations in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight |
709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of inpatient client records, the facility failed to disclose to the client of the fee schedule in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the Fee Schedule in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight. |
709.51(b)(2)(iv) LICENSURE Services Provided
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iv) Services provided.
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Observations
Based on a review of inpatient client records, the facility failed to disclose to the client of services provided in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the Services Provided in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight. |
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 inpatient client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in seven out of seven client records reviewed.
Client #8 was admitted on July 7, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 8, 2026 with no type or frequency identified.
Client #9 was admitted on July 15, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 16, 2026 with no type or frequency identified.
Client #10 was admitted on July 15, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 18, 2026 with no type or frequency identified.
Client #11 was admitted on July 25, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 30, 2026 with no type or frequency identified.
Client #12 was admitted on May 6, 2026 and was discharged on June 3, 2026. A comprehensive treatment plan was developed on May 8, 2026 with no type or frequency identified.
Client #13 was admitted on July 17, 2026 and was discharged on July 25, 2026. A comprehensive treatment plan was developed on July 18, 2026 with no type or frequency identified.
Client #14 was admitted on May 2, 2026 and was discharged on June 1, 2026. A comprehensive treatment plan was developed on May 6, 2026 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will revise its clinical chart documentation process to ensure that each individual treatment and rehabilitation plan includes the required type and frequency of treatment and rehabilitation services. The Clinical Director will update the treatment plan documentation expectations and review the standard with all clinical staff. Therapists will be responsible for documenting the type and frequency of services on each client's comprehensive treatment plan at the time the plan is developed and whenever the plan is updated.
Training will be provided to clinical staff by the Clinical Director regarding the requirements of 709.52(a)(2), including how to clearly identify the type of treatment and rehabilitation service and the expected frequency of each service in the treatment plan. Training will include review of the revised documentation procedure, examples of compliant treatment plan language, and instruction on correcting incomplete documentation prior to supervisory approval.
Supervisory follow-up will be completed by the Clinical Supervisor through review of new and updated treatment plans during routine chart supervision. Any treatment plan missing the required type or frequency of services will be returned to the assigned Therapist for immediate correction. The Clinical Supervisor will document follow-up with staff when corrections are required and will monitor for repeated documentation issues.
The Quality Assurance Director will be responsible for ongoing oversight of compliance with this standard. The Quality Assurance Director will conduct monthly chart audits for three months to verify that treatment plans include the type and frequency of treatment and rehabilitation services. Audit results will be reviewed with the Clinical Director and Clinical Supervisor, and any identified trends will be addressed through additional staff training or corrective action as needed.
The facility will be in full compliance with the standard by September 30, 2026.
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709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of inpatient client records, the facility failed to document proposed type of support service on individual treatment plans in three out of seven records reviewed.
Client #10 was admitted on July 15, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 18, 2026 with no support services identified.
Client #11 was admitted on July 25, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 30, 2026 with no support services identified.
Client #13 was admitted on July 17, 2026 and was discharged on July 25, 2026. A comprehensive treatment plan was developed on July 18, 2026 with no support services identified.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director will ensure that all individual treatment and rehabilitation plans include the proposed type of support service, as required by 709.52 The Clinical Director, in collaboration with the Clinical Supervisors, will review the treatment planning process and update staff expectations to require that support services are clearly identified and documented on every comprehensive treatment plan, including services such as case management, family support, peer support, recovery support, medical coordination, psychiatric services, community referrals, or other clinically indicated supports.
All clinical staff responsible for developing treatment plans will receive training from the Clinical Director on the documentation requirements for individual treatment and rehabilitation plans, with specific emphasis on identifying and documenting proposed support services based on each client's assessed needs. Training will include review of the regulation, examples of compliant documentation, and instruction on where support services must be documented in the clinical chart.
The Clinical Director will conduct supervisory follow-up through chart reviews and individual supervision to verify that support services are documented on treatment plans prior to approval. Any deficiencies identified during supervisory review will be returned to the assigned counselor for correction prior to finalization whenever possible.
Ongoing compliance will be monitored by the Director of Compliance and Regulatory Affairs through monthly clinical chart audits for a minimum of three months. Audit results will be reported to the Clinical Director and Clinical Supervisors. If continued noncompliance is identified, additional staff training and corrective supervision will be implemented. The Clinical Director will be responsible for overall oversight of implementation and continued compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026.
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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 inpatient client records, the facility failed to provide a complete client record, which is to include a follow-up in the required timeframe of 30 days, per the facility's policy and procedure manual, in three out of three applicable records reviewed.
Client #12 was admitted on May 6, 2026 and was discharged on June 3, 2026. No follow up was documented.
Client #13 was admitted on July 17, 2026 and was discharged on July 25, 2026. No follow up was documented.
Client #14 was admitted on May 2, 2026 and was discharged on June 1, 2026. No follow up was documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will achieve and maintain compliance with 709.53 by implementing a standardized follow-up documentation process to ensure that follow-up information is completed and entered into each applicable client record within 30 days of discharge, in accordance with the facility's policy and procedure manual.
The Clinical Director will be responsible for overall oversight of compliance with this standard. The Program Supervisor will review discharge records weekly to verify that follow-up contacts are assigned, completed, and documented within the required timeframe. The Office Manager will be responsible for completing follow-up contacts and documenting the follow-up information in the client record.
All clinical staff and office manager will receive training on the follow-up documentation requirement, including the 30-day timeframe, required documentation elements, and the location and method for entering follow-up information in the client record. Training will be completed by the Clinical Director and documented on staff training records.
Supervisory follow-up will include weekly chart audits for discharged clients for a minimum of three months. Audit results will be reviewed by the Clinical Director and Clinical Supervisors, and any missing or late follow-up documentation will be addressed immediately with the responsible staff member through corrective coaching and additional training as needed. After three months of sustained compliance, audits will continue monthly as part of the facility's ongoing quality assurance process.
The facility will be in full compliance with this standard by September 15, 2026
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709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of outpatient client records, the facility failed to disclose to the client of criteria for admission, treatment, completion, and discharge in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the criteria for admission, treatment, completion, and discharge in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of outpatient client records, the facility failed to disclose to the client of project policies in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the Project Policies in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of outpatient client records, the facility failed to disclose to the client of hours of operation in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the hours of operations in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of outpatient client records, the facility failed to disclose to the client of the fee schedule in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the Fee Schedule in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of outpatient client records, the facility failed to disclose to the client of services provided in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected this deficiency by placing the Services Provided in the client handbook and orientation packet. These materials are provided to each client during the intake and orientation process to ensure the required information is disclosed and available for review.
The Office Manager and Operations Supervisors are responsible for ensuring that each client receives the handbook and orientation packet at admission. Clinical staff will be trained on the revised intake and orientation documentation requirements, including where the disclosure is located in the client materials and how to document that the information was reviewed with the client in the chart.
The Clinical Director will provide supervisory follow-up through routine chart reviews to verify that the required disclosure is documented consistently in each applicable record. Any missing or incomplete documentation will be addressed with the assigned staff member through immediate corrective feedback and follow-up review. The Facility Director is responsible for overall oversight of implementation and ongoing compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026, and will maintain compliance through continued staff training, supervisory chart review, and administrative oversight. |
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 the outpatient client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in five out of five applicable client records reviewed.
Client #23 was admitted on August 2, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on August 6, 2026 with no type or frequency identified.
Client #24 was admitted on June 24, 2026 and was discharged on July 23, 2026. A comprehensive treatment plan was developed on June 26, 2026 with no type or frequency identified.
Client #25 was admitted on June 12, 2026 and was discharged on July 10, 2026. A comprehensive treatment plan was developed on June 17, 2026 with no type or frequency identified.
Client #26 was admitted on July 8, 2026 and was discharged on July 19, 2026. A comprehensive treatment plan was developed on July 8, 2026 with no type or frequency identified.
Client #27 was admitted on June 18, 2026 and was discharged on July 17, 2026. A comprehensive treatment plan was developed on June 22, 2026 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will revise its clinical chart documentation process to ensure that each individual treatment and rehabilitation plan includes the required type and frequency of treatment and rehabilitation services. The Clinical Director will update the treatment plan documentation expectations and review the standard with all clinical staff. Therapists will be responsible for documenting the type and frequency of services on each client's comprehensive treatment plan at the time the plan is developed and whenever the plan is updated.
Training will be provided to clinical staff by the Clinical Director regarding the requirements of 709.92, including how to clearly identify the type of treatment and rehabilitation service and the expected frequency of each service in the treatment plan. Training will include review of the revised documentation procedure, examples of compliant treatment plan language, and instruction on correcting incomplete documentation prior to supervisory approval.
Supervisory follow-up will be completed by the Clinical Supervisor through review of new and updated treatment plans during routine chart supervision. Any treatment plan missing the required type or frequency of services will be returned to the assigned Therapist for immediate correction. The Clinical Supervisor will document follow-up with staff when corrections are required and will monitor for repeated documentation issues.
The Quality Assurance Director will be responsible for ongoing oversight of compliance with this standard. The Quality Assurance Director will conduct monthly chart audits for three months to verify that treatment plans include the type and frequency of treatment and rehabilitation services. Audit results will be reviewed with the Clinical Director and Clinical Supervisor, and any identified trends will be addressed through additional staff training or corrective action as needed.
The facility will be in full compliance with the standard by September 30, 2026.
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of outpatient client records, the facility failed to document proposed type of support service on individual treatment plans in five out of five applicable records reviewed.
Client #23 was admitted on August 2, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was developed on August 6, 2026 with no support services identified.
Client #24 was admitted on June 24, 2026 and was discharged on July 23, 2026. A comprehensive treatment plan was developed on June 26, 2026 with no support services identified.
Client #25 was admitted on June 12, 2026 and was discharged on July 10, 2026. A comprehensive treatment plan was developed on June 17, 2026 with no support services identified.
Client #26 was admitted on July 8, 2026 and was discharged on July 19, 2026. A comprehensive treatment plan was developed on July 8, 2026 with no support services identified.
Client #27 was admitted on June 18, 2026 and was discharged on July 17, 2026. A comprehensive treatment plan was developed on June 22, 2026 with no support services identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will ensure that all individual treatment and rehabilitation plans include the proposed type of support service, as required by 709.92 The Clinical Director, in collaboration with the Clinical Supervisors, will review the treatment planning process and update staff expectations to require that support services are clearly identified and documented on every comprehensive treatment plan, including services such as case management, family support, peer support, recovery support, medical coordination, psychiatric services, community referrals, or other clinically indicated supports.
All clinical staff responsible for developing treatment plans will receive training from the Clinical Director on the documentation requirements for individual treatment and rehabilitation plans, with specific emphasis on identifying and documenting proposed support services based on each client's assessed needs. Training will include review of the regulation, examples of compliant documentation, and instruction on where support services must be documented in the clinical chart.
The Clinical Director will conduct supervisory follow-up through chart reviews and individual supervision to verify that support services are documented on treatment plans prior to approval. Any deficiencies identified during supervisory review will be returned to the assigned counselor for correction prior to finalization whenever possible.
Ongoing compliance will be monitored by the Director of Compliance and Regulatory Affairs through monthly clinical chart audits for a minimum of three months. Audit results will be reported to the Clinical Director and Clinical Supervisors. If continued noncompliance is identified, additional staff training and corrective supervision will be implemented. The Clinical Director will be responsible for overall oversight of implementation and continued compliance with this standard.
The facility will be in full compliance with this standard by September 30, 2026.
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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 outpatient client records, the facility failed to provide a complete client record, which is to include a follow-up in the required timeframe of 30 days, per the facility's policy and procedure manual, in two out of two applicable records reviewed.
Client #25 was admitted on June 12, 2026 and was discharged on July 10, 2026. No follow-up was documented.
Client #28 was admitted on June 30, 2026 and was discharged on July 6, 2026. No follow-up was documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will achieve and maintain compliance with 709.93 by implementing a standardized follow-up documentation process to ensure that follow-up information is completed and entered into each applicable client record within 30 days of discharge, in accordance with the facility's policy and procedure manual.
The Clinical Director will be responsible for overall oversight of compliance with this standard. The Program Supervisor will review discharge records weekly to verify that follow-up contacts are assigned, completed, and documented within the required timeframe. The Office Manager will be responsible for completing follow-up contacts and documenting the follow-up information in the client record.
All clinical staff and office manager will receive training on the follow-up documentation requirement, including the 30-day timeframe, required documentation elements, and the location and method for entering follow-up information in the client record. Training will be completed by the Clinical Director and documented on staff training records.
Supervisory follow-up will include weekly chart audits for discharged clients for a minimum of three months. Audit results will be reviewed by the Clinical Director and Clinical Supervisors, and any missing or late follow-up documentation will be addressed immediately with the responsible staff member through corrective coaching and additional training as needed. After three months of sustained compliance, audits will continue monthly as part of the facility's ongoing quality assurance process.
The facility will be in full compliance with this standard by September 15, 2026.
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