INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 9, 2026 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:
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Plan of Correction
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in two of five applicable client records reviewed.
Client #2 was admitted on March 19, 2026 and was still active at the time of the inspection. A treatment plan update was completed on May 29, 2026 and the next update was due no later than July 29, 2026; however, the update was completed on September 4, 2026.
Client #3 was admitted on April 13, 2026 and was still active at the time of the inspection. A treatment plan update was completed on June 21, 2026 and the next update was due no later than August 21, 2026; however, the update was completed on September 4, 2026.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
On 9/16/26, Project/Facility Director, met with AOD treatment counselors to provide re-training on timelines and expectations for treatment plan updates. Project/Facility Director reviewed need to complete updates every sixty days for clients. Project/Facility director plans to follow up with staff during regularly scheduled supervision to ensure compliance and ongoing maintenance. Project/Facility Director will conduct client file reviews as well as have treatment counselors self-audit client charts and discuss during weekly/bi-weekly supervision. Will be in compliance with this standard effective immediately (9/21/26). |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in four of seven client records reviewed.
Client #1 was admitted on February 4, 2026 and was still active at the time of the inspection. The individual treatment plan, completed on February 18, 2026, indicated the client was to receive one individual counseling session per week. There was no documentation in the record showing the client received any individual counseling sessions during the weeks of May 3, 2026, June 14, 2026, July 5, 2026, August 2, 2026, August 9, 2026, and August 30, 2026.
Client #2 was admitted on March 19, 2026 and was still active at the time of the inspection. The individual treatment plan, completed on April 2, 2026, indicated the client was to receive one individual counseling session per week. There was no documentation in the record showing the client received any individual counseling sessions during the weeks of April 12, 2026, May 10, 2026, and May 17, 2026.
Client #3 was admitted on April 13, 2026 and was still active at the time of the inspection. The individual treatment plan, completed on April 27, 2026, indicated the client was to receive one individual counseling session per week. There was no documentation in the record showing the client received an individual counseling session during the week of May 17, 2026.
Client #7 was admitted on November 20, 2025 and was discharged on May 27, 2026. The individual treatment plan, completed on December 4, 2025, indicated the client was to receive one individual counseling session per week. There was no documentation in the record showing the client received any individual counseling sessions during the weeks of December 7, 2025, December 21, 2025, December 28, 2025, February 8, 2026, March 15, 2026, and May 17, 2026.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
During a treatment team meeting on 9/16/26, Project/Facility Director provided training on the need to provide services according to the individual treatment plan. Guidance was provided to staff on ways to reflect in the client file or progress note if there was a planned reason as to why the client would not be receiving services according to the treatment plan (ex. client or staff on vacation therefore no planned session).
Project/Facility Director will follow up during regularly scheduled supervisions and conduct monthly file checks to ensure compliance with this regulation. Facility will be in compliance with this regulation effective immediately, 9/21/26. |
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 and the facility's policy and procedure manual, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in two of four applicable client records reviewed.
The facility's policy and procedure manual stated that follow-ups will occur 30 days after the client ' s discharge.
Client #5 was admitted on March 3, 2026 and was discharged on May 29, 2026. There was no follow-up information documented in the record at the time of the inspection.
Client #7 was admitted on November 20, 2025 and was discharged on May 27, 2026. There was no follow-up information documented in the record at the time of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
During a treatment team meeting on 9/16/26, Project/Facility Director, provided an overview and re-training on the agency's policy and procedure regarding client follow up. Reviewed documentation guidelines for follow up activity including documenting 30 Day Follow Up form and/or outreach attempts for follow up in client file. Project/Facility director will follow up with implementation of 30 Day Follow up during regularly scheduled supervisions and monthly file checks. The facility will be in compliance with this regulation effective immediately, 9/21/26. |