D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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CORA SERVICES, INC.
8540 VERREE ROAD
PHILADELPHIA, PA 19111

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Survey conducted on 10/01/2025

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on October 01, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cora Services, Inc was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:	Plan of Correction
705.10 (d) (1) LICENSURE Fire safety. 705.10. Fire safety. (d) Fire drills. The residential facility shall: (1) Conduct unannounced fire drills at least once a month.
Observations Based on a review of fire drill logs from October 2024 - September 2025, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the months of October 2024, November 2024 or January 2025 through July 2025.These findings were reviewed with facility staff during the licensing process.	Plan of Correction CORA will conduct and document unannounced fire drills at least once monthly. VP of operations is responsible for oversight of fire drills including planning and will meet with maintenance manager monthly to review implementation and documentation of completed fire drills. CORA will be in compliance with this regulation immediately (10/9/25). Facility Director will check the agency fire drill log monthly to monitor compliance.
709.93(a)(5) LICENSURE Client records 709.93. Client records. (a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following: (5) Progress notes.
Observations Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed within 48 hours after therapy sessions, per facility policy, in four of seven records reviewed. Client # 1 was admitted on November 11, 2024 and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on November 25, 2024, December 04, 2024, December 09, 2024, December 16, 2024, January 02, 2025, January 15, 2025, February 07, 2025, February 18, 2025, March 04, 2025, March 11, 2025, March 21, 2025, April 10, 2025, May 29, 2025, June 16, 2025, July 08, 2025, July 16, 2025, July 29, 2025, August 05, 2025, August 12, 2025, September 04, 2025, and September 11, 2025, that were not completed until December 04, 2024, December, 16, 2024, December 16, 2024, January 06, 2025, January 10, 2025, January 20, 2025, February 24, 2025, February 24, 2025, March 20, 2025, March 20, 2025, April 02, 2025, April 27, 2025, June 02, 2025, June 28, 2025, August 01, 2025, August 05, 2025, August 05, 2025, August 18, 2025, August 18, 2025, September 22, 2025, and September 22, 2025, respectively. Client # 2 was admitted on December 16, 2024 and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on January 15, 2025, February 05, 2025, March 05, 2025, April 09, 2025, April 16, 2025, April 23, 2025, May 07, 2025, June 04, 2025, June 11, 2025, June 18, 2025, July 23, 2025, July 30, 2025, that were not completed until January 29, 2025, February 11, 2025, March 28, 2025, April 27, 2025, April 27, 2025, April 27, 2025. May 15, 2025, June 25, 2025, June 25, 2025, June 25, 2025, August 06, 2025, and August 06, 2025, respectively. Client #5 was admitted on October 21, 2024 and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on December 16, 2024, December 23, 2024, January 13, 2025, March 17, 2025, and May 19, 2025, that were not completed until December 19, 2024, December 31, 2024, January 16, 2025, March 20, 2025, and May 23, 2025, respectively. Client #6 was admitted on November 12, 2024 and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on January 16, 2025, January 23, 2025, January 30, 2025, March 19, 2025, April 09, 2025, May 07, 2025, May 21, 2025, May 28, 2025, June 04, 2025, June 18, 2025, June 18, 2025, July 02, 2025, August 27, 2025, September 03, 2025, September 24, 2025, that were not completed until January 21, 2025, January 27, 2025, February 03, 2025, March 25, 2025, April 14, 2025, May 12, 2025, May 28, 2025, June 02, 2025, June 09, 2025, June 23, 2025, June 23, 2025, July 09, 2025, September 02, 2025, September 09, 2025, and September 30, 2025, respectively. These findings were reviewed with facility staff during the licensing process.	Plan of Correction Project and Facility Director updated policy related to completion of progress notes. Policy was updated to reflect that progress notes should be completed within 5 business days of service. Project and Facility Director discussed the policy change with counselors during supervisions facilitated week of 10/6/25. Project and Facility Director will conduct an in-service training to review updated policy on 10/15/25. CORA will be in compliance with updated policy as of 10/15/25. Project and Facility Director is responsible for ensuring implementation of and compliance with updated policy. Project and Facility Director will monitor compliance during supervisions with counselors (bi-weekly) as well as during monthly team meetings. Project and Facility Director will also use ongoing monthly file checks to ensure compliance with updated policy.