INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on August 18-20, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clear Choices, LLC, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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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 administrative information, the facility failed to document an assessment of staff training needs for the training year January 1, 2026, through December 31, 2026.
The facility policy and procedures state that an assessment of staff training needs is completed annually by clinical supervisor or facility director. To complete their narrative report, the responsible party will provide each employee with a Staff Training Needs Assessment form one month prior to report being due and are required to submit within two weeks of receipt. The clinical supervisor or director will take the information each staff provided and formulate a narrative report of the overall staff training needs.
There was no report of staff training need for the January 1, 2026-December 31, 2026 training year.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 5-7, 2025 licensing inspection.
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Plan of Correction
0055 ? 704.11(a)(1) LICENSURE
Training Needs Assessments
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that a documented assessment of staff training needs was not completed for the January 1, 2026, through December 31, 2026, training year. The facility also acknowledges that this is a repeat citation.
2. The Clinical Supervisor/Facility Director will complete and maintain a comprehensive staff training needs assessment for all applicable employees.
3. Each employee will be provided with a Staff Training Needs Assessment form and required to identify individual training needs. The Clinical Supervisor or Facility Director will compile the information into an overall assessment of staff training needs.
4. The facility's staff development policy and procedure will be reviewed with applicable administrative and clinical staff to ensure the required assessment is completed within the established timeframe.
5. A tracking mechanism will be implemented to ensure the annual training needs assessment is completed, reviewed, and maintained in the facility's administrative records.
6. The Facility Director will review the training needs assessment annually and verify completion prior to development of the annual training plan.
Monitoring:
The Facility Director or designee will conduct an annual review of the staff development records to verify that the staff training needs assessment has been completed and incorporated into the annual training plan. Any identified deficiencies will be corrected immediately.
Responsible Person: Clinical Supervisor/Facility Director
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704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of administrative information, the facility failed to document an overall plan for addressing staff training needs, for the training year January 1, 2026- December 31, 2026.
The facility policy and procedures state that an overall training plan is completed annually by the clinical supervisor or facility director and will highlight the main points provided by the staff of their needs and the outline of meeting those needs for the staff.
There was no overall training plan for the January 1, 2026-December 31, 2026 training year.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 5-7, 2025 licensing inspection.
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Plan of Correction
0057 ? 704.11(a)(2) LICENSURE
Overall Training Plan
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that an overall plan for addressing staff training needs was not documented for the January 1, 2026, through December 31, 2026, training year. This is a repeat citation.
2. The Clinical Supervisor/Facility Director will develop and maintain an annual overall training plan based upon the identified training needs of facility personnel.
3. The training plan will identify required training topics, applicable staff, anticipated completion timeframes, and the method by which identified training needs will be addressed.
4. The completed training needs assessment will be reviewed prior to development of the annual training plan to ensure the plan directly addresses identified staff needs.
5. The annual training plan will be maintained in the facility's administrative records and made available for review during licensing inspections.
6. A calendar reminder and administrative tracking process will be implemented to ensure the annual training plan is completed in a timely manner.
Monitoring:
The Facility Director will review the training plan quarterly to verify that scheduled training is being completed and that identified staff training needs are being addressed. Any missed or incomplete training will be rescheduled and documented.
Responsible Person: Clinical Supervisor/Facility Director
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative information, the facility failed to document an evaluation of the overall training plan for the training year January 1, 2025, through December 31, 2025.
The facility policy and procedures state that an evaluation of the overall training plan for the previous training year is completed annually by either the clinical supervisor or the facility director and should explain how Clear Choices, LLC either did or did not meet their training goals from the previous year.
There was no annual evaluation of the January 1, 2025-Decmber 31, 2025 overall training plan.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 5-7, 2025 licensing inspection.
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Plan of Correction
0061 ? 704.11(a)(4) LICENSURE
Evaluation of Overall Training Plan
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that an annual evaluation of the overall training plan for January 1, 2025, through December 31, 2025, was not documented. This is a repeat citation.
2. The Clinical Supervisor/Facility Director will complete an annual evaluation of the previous year's overall training plan.
3. The evaluation will identify the training goals established for the previous year, determine whether the goals were met, and document areas requiring improvement.
4. Results of the annual evaluation will be used when completing the subsequent year's staff training needs assessment and overall training plan.
5. The facility will establish an annual administrative deadline and calendar reminder to ensure the evaluation is completed and maintained.
6. Executive Leadership will review the completed evaluation to verify that the required component of the staff development program has been completed.
Monitoring:
The Facility Director will review staff development documentation annually to verify that the prior year's training plan has been evaluated and that the results are incorporated into the following year's training process.
Responsible Person: Clinical Supervisor/Facility Director
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the personnel training records, the facility failed to have each counselor complete at least 25 clock hours of annual training in one of one applicable record.
Staff #3 was hired as counselor on October 31, 2020, and was still in the position at the time of inspection. Staff #3 documented nine hours of training for the January 1, 2025-December 31, 2025, training year.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 5-7, 2025 licensing inspection.
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Plan of Correction
0083 ? 704.11(f)(2) LICENSURE
Training Hours Required ? Counselors
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that one applicable counselor did not complete the required 25 clock hours of annual training during the January 1, 2025, through December 31, 2025, training year. The identified counselor had nine documented training hours.
2. The Clinical Supervisor/Facility Director will review the training record of the identified counselor, and all currently employed counselors to verify compliance with annual training requirements.
3. Counselors will receive an annual training hours requirement tracker identifying required training hours and the deadline for completion.
4. The Facility Director/Clinical Supervisor will review counselor training hours throughout the year rather than waiting until the end of the training year.
5. Counselors who are not progressing toward completion of the required 25 hours will receive written notification and a corrective training schedule.
6. The facility will ensure required counselor training includes applicable areas identified in 704.11(f)(2), including client recordkeeping, confidentiality, treatment planning, counseling techniques, substance use assessment, aftercare planning, ethics, relapse prevention, and other applicable areas.
Monitoring:
Training records will be reviewed quarterly by the Clinical Supervisor/Facility Director. Any counselor identified as being below the required training-hour threshold will be placed on an individualized training completion schedule and monitored until compliance is achieved.
Responsible Person: Clinical Supervisor/Facility Director
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one of seven records.
Client #3 was admitted on April 23, 2026, and was still active at the time of inspection. Fax were sent to a transportation agency on June 1, 2026, July 1, 2026, and August 3, 2026, and there was no consent to release information form in the record.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 5-7, 2025 licensing inspection.
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Plan of Correction
0276 ? 709.28(c) LICENSURE
Confidentiality ? Consent to Release Information
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that information was released without a documented informed and voluntary consent to release information in one applicable client record.
2. The identified client record was reviewed by the Clinical Supervisor/Facility Director, and staff were counseled regarding the requirement to obtain appropriate written authorization before releasing information contained in a client record.
3. All active client records will be reviewed by two staff to verify that a valid consent to release information is present before information is disclosed to outside agencies.
4. The release-of-information process will be reviewed with all clinical, medical, and administrative staff responsible for communicating client information outside the facility.
5. Staff will be instructed that no information may be released to an outside entity unless an appropriate written authorization is present and applicable to the requested disclosure.
Monitoring:
The Clinical Supervisor will conduct monthly audits of client records involving releases of information to verify that required consents are present before disclosures occur. Any deficiency will result in immediate corrective action and staff retraining as appropriate.
Responsible Person: Clinical Supervisor/Facility Director
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on the release of information form in two of seven records.
Client #2 was admitted on September 25, 2025, and was still active at the time of inspection. A release of information form to the funder was signed and dated by the client on September 25, 2025, and did not document the specific information that was to be disclosed.
Client #4 was admitted on November 6, 2025, and discharged February 17, 2026. A release of information form to the funder was signed and dated by the client on November 7, 2025, and did not document the specific information that was to be disclosed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
0279 ? 709.28(c)(2) LICENSURE
Confidentiality ? Specific Information Disclosed
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that two of seven applicable records did not identify the specific information authorized for disclosure on the release of information form.
2. The identified records were reviewed with the Clinical Supervisor and assigned staff.
3. The facility's release-of-information form and procedure will be reviewed by no less than two staff to ensure the specific information to be disclosed is clearly identified before the authorization is signed.
4. All staff responsible for obtaining releases of information will receive retraining regarding completion of each required component of the authorization.
5. Staff will be instructed that general or nonspecific descriptions of information are not sufficient when completing a release of information.
6. The Clinical Supervisor will verify the completeness of release forms before information is released whenever practicable.
Monitoring:
Monthly record audits will include review of release-of-information forms for required elements, including documentation of the specific information authorized for disclosure.
Responsible Person: Clinical Supervisor
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent will expire in one of seven records.
Client #1 was admitted on March 9, 2026, and was still active at the time inspection. A release of information form to a government agency was signed and dated by the client on March 9, 2026, and did not document when the consent will expire.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
0287 ? 709.28(c)(6) LICENSURE
Confidentiality ? Expiration of Consent
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that one of seven applicable records did not document the date, event, or condition upon which the consent to release information would expire.
2. The identified client record was reviewed, and the finding was addressed through supervisory review with the responsible staff member.
3. All release-of-information forms currently in use will be reviewed to ensure an expiration date, event, or condition is documented.
4. Staff responsible for obtaining releases will receive retraining regarding the required components of a valid written consent.
5. The release-of-information form will be reviewed by a minimum of two staff as part of the admission and ongoing record review process before information is disclosed.
Monitoring:
The Clinical Supervisor will conduct monthly audits of release-of-information documentation to verify that expiration information is properly documented. Deficiencies will be corrected immediately, and staff will receive additional training when necessary.
Responsible Person: Clinical Supervisor
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of medical staff coverage, the facility failed to provide narcotic treatment physician services for at least 1 hour per week onsite for every ten patients for nine of eighteen weeks.
Physician service hours were reviewed from April 5, 2026, through July 8, 2026.
For the week of April 19, 2026, through April 25, 2026, the facility's census was 132 patients. The facility was required to provide 13.2 hours of onsite physician services; however, the physician hours totaled 12.25 hours.
For the week of May 3, 2026, through May 9, 2026, the facility's census was 132 patients. The facility was required to provide 13.2 hours of onsite physician services; however, the physician hours totaled 11.75 hours.
For the week of May 10, 2026, through May 16, 2026, the facility's census was 132 patients. The facility was required to provide 13.2 hours of onsite physician services; however, the physician hours totaled 13 hours.
For the week of May 24, 2026, through May 30, 2026, the facility's census was 128 patients. The facility was required to provide 12.8 hours of onsite physician services; however, the physician hours totaled 4 hours.
For the week of May 31, 2026, through June 6, 2026, the facility's census was 126 patients. The facility was required to provide 12.6 hours of onsite physician services; however, the physician hours totaled 5.25 hours.
For the week of June 7, 2026, through June 13, 2026, the facility's census was 125 patients. The facility was required to provide 12.5 hours of onsite physician services; however, the physician hours totaled 5.75 hours.
For the week of June 14, 2026, through June 20, 2026, the facility's census was 121 patients. The facility was required to provide 12.1 hours of onsite physician services; however, the physician hours totaled 10.25 hours.
For the week of June 28, 2026, through July 4, 2026, the facility's census was 123 patients. The facility was required to provide 12.3 hours of onsite physician services; however, the physician hours totaled 10.75 hours.
For the week of July 5, 2026, through July 11, 2026, the facility's census was 123 patients. The facility was required to provide 12.3 hours of onsite physician services; however, the physician hours totaled 11.75 hours.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 5-7, 2025 licensing inspection.
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Plan of Correction
M025 ? 715.6(d) LICENSURE
Physician Staffing
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that the facility did not provide the required minimum of one hour per week of narcotic treatment physician services onsite for every ten patients during nine of the eighteen weeks reviewed.
2. The Medical Director and Facility Director will review weekly patient census and physician coverage requirements to determine the minimum number of onsite narcotic treatment physician hours required each week.
3. Physician schedules will be developed based upon the facility's current census and anticipated census to ensure sufficient onsite physician coverage.
4. The facility will maintain a physician coverage schedule that identifies required hours and actual hours provided.
5. When a scheduled narcotic treatment physician is unavailable, the Medical Director/Facility Director will arrange qualified physician coverage to prevent a reduction in required onsite physician hours.
6. Weekly census and physician-hour calculations will be reviewed by facility leadership before the end of each service week.
Monitoring:
The Facility Director will conduct a weekly review of census and onsite physician hours. Monthly reports will be reviewed by the Medical Director to verify continued compliance with 715.6(d).
Responsible Person: Medical Director/Facility Director
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715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of medical staff coverage, the facility failed to ensure that one-third of all required narcotic treatment physician time was provided by a narcotic treatment physician in five of eighteen weeks.
Physician service hours were reviewed from April 5, 2026, through July 8, 2026.
For the week of April 19, 2026, through April 25, 2026, the required physician time was 13.2 hours, and 4.4 of those hours were to be provided by a narcotic treatment physician; however, the physician documented 3.25 hours.
For the week of May 3, 2026, through May 9, 2026, the required physician time was 13.2 hours, and 4.4 of those hours were to be provided by a narcotic treatment physician; however, the physician documented 3.75 hours.
For the week of May 24, 2026, through May 30, 2026, the required physician time was 12.8 hours, and 4.2 of those hours were to be provided by a narcotic treatment physician; however, the physician documented 0 hours.
For the week of June 14, 2026, through June 20, 2026, the required physician time was 12.1 hours, and 4.03 of those hours were to be provided by a narcotic treatment physician; however, the physician documented 2 hours.
For the week of July 5, 2026, through July 11, 2026, the required physician time was 12.3 hours, and 4.1 of those hours were to be provided by a narcotic treatment physician; however, the physician documented 3.75 hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
M027 ? 715.6(e) LICENSURE
Physician Staffing ? One-Third Physician Requirement
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that the facility failed to ensure that at least one-third of required narcotic treatment physician time was provided by a narcotic treatment physician during five of the eighteen weeks reviewed.
2. The Medical Director and Facility Director will review weekly required physician hours and calculate the minimum portion that must be provided by a narcotic treatment physician.
3. Physician assistant and certified registered nurse practitioner schedules will be coordinated with narcotic treatment physician schedules to ensure that no more than two-thirds of required physician time is provided by a PA or CRNP.
4. A physician coverage tracking log will document required physician hours, hours provided by narcotic treatment physicians, and hours provided by PA/CRNP staff.
5. The Medical Director will review the schedule before each service week to verify that one-third physician requirement is satisfied.
6. Any anticipated staffing shortage will be addressed in advance through schedule modification or additional qualified physician coverage.
Monitoring:
The Facility Director will complete a weekly staffing compliance review, with monthly review by the Medical Director. Any variance will be addressed immediately and documented.
Responsible Person: Medical Director/Facility Director
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to have a narcotic treatment physician determine the patient 's initial dose and schedule in three of four applicable records.
Patient #1 was admitted on March 9, 2026, and was still active at the time inspection. An initial dose order was documented by the CRNP on March 9, 2026.
Patient #3 was admitted on April 23, 2026, and was still active at the time of inspection. An initial dose order was documented by the CRNP on April 23, 2026.
Patient #4 was admitted on November 6, 2025, and discharged on February 17, 2026. An initial dose order was documented by the CRNP on November 6, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
M159 ? 715.17(c)(1)(i-vi) LICENSURE
Medication Control ? Initial Dose and Schedule
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that the narcotic treatment physician did not determine the patient's initial dose and schedule in three of four applicable records.
2. The identified patient records were reviewed by the Medical Director.
3. The admission and medication-ordering process will be revised to require review and determination of the initial dose and schedule by the narcotic treatment physician before the initial medication is administered.
4. Medical providers will receive education regarding the regulatory requirement governing determination of the initial dose and schedule.
5. Nursing and medical staff will be instructed to verify that the required narcotic treatment physician determination is documented in the patient record before proceeding with the initial medication order.
6. The electronic medical record workflow will be reviewed to identify opportunities to require physician review and documentation before completion of the admission medication process.
Monitoring:
The Medical Director or designee will conduct monthly audits of newly admitted patient records to verify that the initial dose and schedule were determined and documented by the narcotic treatment physician.
Responsible Person: Medical Director
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715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient in two of two applicable records.
Patient #4 was admitted on November 6, 2025, and discharged on February 17, 2026. There was no documentation of any transfer paperwork being sent in the record.
Patient #5 was admitted on April 26, 2010, and discharged on May 11, 2026. A fax was sent to the receiving facility and did not include medical and psychosocial summaries.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
M193 ? 715.20(1) LICENSURE
Patient Transfers
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that patient transfer records did not consistently contain the required transfer documentation in two of two applicable records.
2. The identified transfer records were reviewed by the Clinical Supervisor/Medical Director, and staff involved in the transfers were educated regarding required transfer documentation.
3. The transfer checklist will be revised to identify all required components, including admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, current patient status, and written patient consent.
4. Staff responsible for patient transfers will be retrained on the facility's transfer policy and the documentation required to accompany a transferred patient.
5. A transfer packet checklist will be completed before records are transmitted to the receiving narcotic treatment program.
6. The Clinical Supervisor/Facility Director will verify that required transfer documentation is complete before the transfer is considered closed.
Monitoring:
The Clinical Supervisor will audit all patient transfers monthly for completeness. Any missing documentation will be addressed immediately, and corrective education will be provided to responsible staff.
Responsible Person: Clinical Supervisor/Medical Director
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to include the results of an annual physical examination by the narcotic treatment physician in one of four applicable records.
Patient #7 was admitted on July 7, 2021, and discharged on July 11, 2026. The last annual physical was completed July 17, 2025. There was no annual physical documented for 2026 in the record.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 5-7, 2025 licensing inspection.
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Plan of Correction
M225 ? 715.23(b)(5) LICENSURE
Patient Records ? Annual Physical Examination
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that an annual physical examination and annual reevaluation by the narcotic treatment physician was not documented in one applicable patient record. This is a repeat citation.
2. The identified record was reviewed by the Medical Director, and the findings were discussed with appropriate medical and clinical staff.
3. All active patient records will be reviewed to identify patients whose annual physical examination is due or overdue.
4. An annual physical examination tracking system will be maintained to identify each patient's admission/annual due date and completion status.
5. Patients approaching their annual physical due date will be scheduled in advance to ensure timely completion.
6. The Medical Director or Designee will review outstanding annual physical examinations monthly and address any overdue examinations.
Monitoring:
The Medical Director will conduct monthly audits of annual physical examination records. Results will be reviewed with leadership, and any missed examination will be addressed immediately.
Responsible Person: Medical Director
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to include the results of an annual clinical evaluation in one of two applicable records.
The facility policy and procedures state the primary counselor is responsible for an annual evaluation of the patient ' s progress.
Patient #5 was admitted on April 26, 2010, and discharged on May 11, 2026. The last annual clinical evaluation was completed April 29, 2025. There was no annual clinical evaluation documented for 2026 in the record.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 5-7, 2025 licensing inspection.
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Plan of Correction
M267 ? 715.23(c)(1-7) LICENSURE
Patient Records ? Annual Clinical Evaluation
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that an annual clinical evaluation was not documented in one of two applicable patient records. This is a repeat citation.
2. The identified patient record was reviewed by the Clinical Supervisor and assigned counselor.
3. All active patient records will be audited to identify patients whose annual clinical evaluation is due or overdue.
4. The primary counselor will be responsible for completing the annual clinical evaluation within the required timeframe.
5. The evaluation will address the required areas, including employment/education/training, legal standing, substance abuse, financial management abilities, physical and emotional health, fulfillment of treatment objectives, and family/community support.
6. The completed annual evaluation will be submitted for review, date, and signature by the Medical Director.
7. An annual evaluation tracking log will be maintained to monitor due dates and completion.
Monitoring:
The Clinical Supervisor will conduct weekly meetings which will review annual clinical evaluations and annual case consultations. Any missed evaluation will be addressed immediately.
Responsible Person: Clinical Supervisor/Medical Director
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in three of four applicable records.
The facility ' s policy and procedures state that the psychosocial evaluation must be completed within 30 days.
Client #1 was admitted on March 9, 2026, and was still active at the time inspection. There was no psychosocial evaluation in the record.
Client #2 was admitted on September 25, 2025, and was still active at the time of inspection. There was no psychosocial evaluation in the record.
Client #4 was admitted on November 6, 2025, and discharged on February 17, 2026. There was no psychosocial evaluation in the record.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 5-7, 2025 licensing inspection.
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Plan of Correction
1871 ? 709.91(b)(6) LICENSURE
Intake and Admission ? Psychosocial Evaluation
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that psychosocial evaluations were not documented in three of four applicable client records. This is a repeat citation.
2. The identified active client records will be reviewed, and outstanding psychosocial evaluations will be completed as clinically appropriate.
3. The facility will reinforce its policy requiring completion of the psychosocial evaluation within the established timeframe.
4. Intake and clinical staff will receive retraining regarding the requirement to complete and document a psychosocial evaluation for each client.
5. A tracking mechanism will be implemented to identify the psychosocial evaluation due date for each newly admitted client.
6. The Clinical Supervisor will review admission records to verify completion of the psychosocial evaluation.
Monitoring:
The Clinical Supervisor will conduct monthly audits of newly admitted client records to verify that psychosocial evaluations are completed and documented within the required timeframe.
Responsible Person: Clinical Supervisor
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan in three of four applicable records.
The facility ' s policy and procedures state that the preliminary treatment plan will be completed at intake.
Client #1 was admitted on March 9, 2026, and was still active at the time inspection. There was no preliminary treatment plan in the record.
Client #2 was admitted on September 25, 2025, and was still active at the time of inspection. There was no preliminary treatment plan in the record.
Client #4 was admitted on November 6, 2025, and discharged on February 17, 2026. There was no preliminary treatment plan in the record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1873 ? 709.91(b)(7) LICENSURE
Intake and Admission ? Preliminary Treatment and Rehabilitation Plan
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that preliminary treatment and rehabilitation plans were not documented in three of four applicable client records.
2. The identified active records will be reviewed, and missing preliminary treatment plans will be addressed as clinically appropriate.
3. Intake staff and clinical staff will be retrained regarding the requirement that a preliminary treatment and rehabilitation plan be completed at intake.
4. The admission workflow will be reviewed to ensure the preliminary treatment plan is included as a required component of the intake process.
5. A checklist will be utilized to verify completion of required intake documentation before the admission process is considered complete.
6. The Clinical Supervisor will review newly admitted client records to verify the presence of a preliminary treatment and rehabilitation plan.
Monitoring:
Monthly admission record audits will be completed by the Clinical Supervisor. Any missing preliminary treatment plan will be immediately brought to the attention of the assigned clinician for corrective action.
Responsible Person: Clinical Supervisor
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709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to develop a treatment plan with the client in three of four applicable records.
The facility's policy and procedures state that a treatment plan is to be developed within 30 days.
Client #2 was admitted on September 25, 2025, and was still active at the time of inspection. The treatment plan was due no later than October 25, 2025; however, it was documented on November 3, 2025, and did not indicate it was developed with the client.
Client #3 was admitted on April 23, 2026, and was still active at the time of inspection. The treatment plan was due no later than May 23, 2026; however, it was documented on June 22, 2026, and did not indicate it was developed with the client.
Client #4 was admitted on November 6, 2025, and discharged on February 17, 2026. The treatment plan was documented on November 14, 2025, and did not indicate it was developed with the client.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 5-7, 2025 licensing inspection.
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Plan of Correction
1875 ? 709.92(a) LICENSURE
Treatment and Rehabilitation Services ? Individual Treatment Plan
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that treatment plans were not developed with the client in three of four applicable records. This is a repeat citation.
2. The identified active client records will be reviewed to ensure treatment plans are completed within the facility's established 30-day timeframe.
3. Clinical staff will receive retraining regarding the requirement that the individual treatment and rehabilitation plan be developed with the client.
4. The treatment plan documentation process will be revised to require clear documentation that the client participated in development of the plan.
5. The Clinical Supervisor will review treatment plans for timeliness, completeness, and evidence of client participation before the record is considered compliant.
6. An electronic tracking mechanism will be utilized to identify upcoming treatment plan due dates and prevent overdue plans.
Monitoring:
The Clinical Supervisor will conduct monthly audits of treatment plans to verify timely completion and documentation of client participation. Findings will be reviewed with clinical staff during supervision.
Responsible Person: Clinical Supervisor
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three of four applicable records.
The facility's policy and procedures state follow-up contact is to be completed for all discharges within 30 days.
There was no follow-up information documented in client records #4, 5 and 7.
Client #4 was admitted on November 6, 2025, and discharged on February 17, 2026.
Client #5 was admitted on April 26, 2010, and discharged on May 11, 2026.
Client #7 was admitted on July 7, 2021, and discharged on July 11, 2026.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 5-7, 2025 licensing inspection.
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Plan of Correction
1911 ? 709.93(a)(11) LICENSURE
Client Records ? Follow-up Information
Plan of Correction:
1. Clear Choices, LLC acknowledges the finding that follow-up information was not documented in three of four applicable client records. This is a repeat citation.
2. The records identified during the inspection were reviewed by the Clinical Supervisor.
3. All recently discharged client records will be audited to identify missing follow-up documentation.
4. The facility's policy requires follow-up contact for all discharges within 30 days. This requirement will be reinforced with all clinical staff.
5. A discharge follow-up tracking log will be implemented to identify the discharge date, follow-up due date, responsible staff member, date of contact, and outcome of the follow-up.
6. Counselors will be responsible for completing and documenting follow-up contact within the required timeframe.
7. The Clinical Supervisor will review the tracking log and outstanding follow-ups to ensure timely completion.
Monitoring:
The Clinical Supervisor will review the discharge follow-up log monthly and conduct quarterly chart audits to verify that required follow-up information is documented in the client record. Any missed follow-up will be addressed immediately with the responsible staff member.
Responsible Person: Clinical Supervisor
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