INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 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, Cleanslate Medical Group of Pennsylvania LLC, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to ensure the hot water temperature did not exceed 120F.
The sink in bathroom in the waiting room was 125.2F and the client ' s bathroom in the back counseling area was 124.3F when tested during the licensing inspection.
These findings were reviewed with facility staff during licensing process.
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Plan of Correction
CleanSlate submitted a maintenance request on 6/15/2026 to have the hot water temperature lowered in both identified bathrooms and have it properly tested for water temperature less then 120 F. On 6/18/2026 water temperatures were corrected and tested at 112 degrees F and 114 degrees F
As of 7/1/2026 the Center Manager at the facility will be responsible for completing a facility inspection checklist on a monthly basis. This checklist will include all DDAP required items and specifically checking the bathroom hot water temperature to ensure it stays under 120 degrees F. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to offer a copy of an informed and voluntary consent to release information form to the client in two of three records reviewed.
Client #1 was admitted to the outpatient program on February 23, 2026, and was active at the time of the licensing inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a commonwealth agency, signed by the client on June 2, 2026, was offered to the client.
Client #2 was admitted to the outpatient program on March 13, 2026, and was active at the time of inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source, signed by the client on April 8, 2026, was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSLate's Release of Information (ROI) form has been updated to include a section allowing patients to indicate whether they accept or decline a copy of the completed ROI. All Pennsylvania location staff will be trained on the revised ROI form on June 17, 2026, and implementation will begin on June 18, 2026, for all new admissions.
During the admission process, Medical Receptionist staff will review ROI forms for completeness and provide a copy to the patient if requested. ROI forms will be reviewed monthly by Medical Receptionist staff to ensure they remain valid and have not expired. In addition, the Center Manager will conduct monthly chart audits to verify ROI completion and compliance.
All currently enrolled patients will be given the opportunity to review their existing ROI forms and complete a new ROI that includes the option to accept or decline a copy. The review and update of all active patient ROI forms will be completed by September 1, 2026. |
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 review of client records, the facility failed to include documentation of a preliminary treatment and rehabilitation plan within thirty days of admission, per facility policy, in two out of three records reviewed.
Client #1 was admitted to the outpatient level of care on February 23, 2026, and was active at the time of the licensing inspection. The preliminary treatment plan was due March 23, 2026; however, it was not documented until March 31, 2026
Client #3 was admitted to the outpatient level of care on February 4, 2026, and was active at the time of the licensing inspection. The preliminary treatment plan was due March 4, 2026; however, it was not documented until May 13, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate's Behavioral Health Director will provide training to all current and newly hired counseling staff on the requirement to complete an initial treatment plan within 30 days of the biopsychosocial assessment. To support compliance with this requirement, patients will be scheduled more frequently during the early phases of treatment to ensure sufficient opportunities for treatment plan development and completion.
The Center Manager will monitor patient scheduling on a weekly basis using the Patient Compliance Report to identify and address any potential barriers to timely treatment plan completion. In addition, the Senior Director of Behavioral Health will conduct bi-weekly group supervision sessions during which up to 35% of each counselor's caseload will be reviewed to verify compliance with initial treatment plan requirements.
The Compliance Department will perform monthly audits of at least 10% of each counselor's caseload to monitor adherence to treatment plan timelines. Any deficiencies identified through the audit process will be communicated to the counselor, Vice President of Operations, and Senior Director of Behavioral Health. Corrective actions, including target completion dates, will be established and monitored to ensure timely resolution and ongoing compliance with regulatory requirements. |
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 document treatment plan updates within 60 days in two out of three records reviewed.
Client #1 was admitted to the outpatient level of care on February 23, 2026, and was active at the time of the inspection. A comprehensive treatment plan was completed on March 31, 2026, and an update was due no later than May 20, 2026; however, there were no treatment plan updates documented.
Client #2 was admitted to the outpatient level of care on March 13, 2026, and was active at the time of the inspection. A comprehensive treatment plan was completed on March 30, 2026, and an update was due no later than May 29, 2026; however, there were no treatment plan updates documented.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 13, 2025, and May 23, 2024 licensing inspections.
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Plan of Correction
CleanSlate's Behavioral Health Director will provide training to all current and newly hired counseling staff on the requirement to complete treatment plan updates every 60 days. Patient scheduling will be maintained in accordance with each patient's level of care to ensure sufficient clinical contact and timely completion of treatment plan updates as required by regulation.
All current active patients will have an updated treatment plan documented in their chart by 7/28/2026 by the facility director assigned at the location. Senior Director of Behavioral Health will ensure facility director prioritizes scheduling and completing active patient treatment plans reviews by the required deadline. Senior Director of Behavioral Health will review with the facility director weekly to ensure completion.
Going forward, the Center Manager will monitor patient scheduling on a weekly basis using the Patient Compliance Report to identify and address any potential barriers to compliance. Additionally, the Senior Director of Behavioral Health will conduct bi-weekly group supervision sessions during which up to 60% of each counselor's caseload will be reviewed to verify timely completion of treatment plan updates. Review will include a caseload tracker kept by the counselor.
The Compliance Department will perform monthly audits of at least 10% of each counselor's caseload to monitor adherence to treatment plan update requirements. Any deficiencies identified through the audit process will be communicated to the counselor, Vice President of Operations, and Senior Director of Behavioral Health. Corrective action plans, including expected completion dates, will be developed and monitored to ensure timely resolution and ongoing compliance with regulatory standards. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing follow ups was submitted and approved by the Department for the May 13, 2025, and May 23, 2024, annual licensing inspections. Completing and documenting treatment plan updates was again found to be a deficiency in the June 9, 2026, licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Historically, compliance with Corrective Action Plan (CAP) requirements has been impacted by scheduling challenges, turnover within the Senior Director of Behavioral Health position, and inconsistencies in caseload management and oversight. These factors contributed to delays in treatment plan reviews, documentation completion, and follow-through on previously established corrective actions.
To address these concerns and ensure sustained compliance, CleanSlate will implement enhanced oversight and accountability measures.
Patient scheduling will be monitored weekly by each Center Manager using the Patient Compliance Report to ensure counseling services are provided at the appropriate frequency and that patients remain actively engaged in treatment. Patients who are not scheduled in accordance with program requirements will be contacted to arrange their next appointment. Patients will be scheduled for counseling appointments at least one week prior to their treatment plan review due date to allow sufficient time for completion and review of all required documentation. If the patient cannot be present for the treatment plan review, a review will be completed and reviewed with the patient for signature at their next attended appointment.
Bi-Weekly group supervision will be conducted by the Sr. Director of Behavioral Health with each counselor in which 50% of caseloads will be reviewed for the documentation completion specifically the treatment plan reviews.
Monthly supervision meetings will be conducted with the Counselor, Behavioral Health Supervisor, and Center Manager to review caseload management, including treatment plan review due dates, documentation completion, and compliance requirements. During these meetings, up to 35% of each counselor's caseload will be reviewed for scheduling and documentation completion. Documentation of these meetings will be submitted to the Vice President of Operations to ensure accountability and timely follow-up on any identified concerns.
The Compliance Department will conduct monthly audits of at least 10% of each counselor's caseload to monitor adherence to treatment plan review and documentation requirements.
Any deficiencies identified through the Compliance audit process will be communicated to the Counselor, Vice President of Operations, Area Manager and Senior Director of Behavioral Health. Corrective actions and expected completion dates will be established and tracked to ensure timely resolution and sustained compliance.
These corrective measures are designed to strengthen clinical oversight, improve accountability at all levels of the organization, and ensure ongoing compliance with treatment planning and documentation requirements. CleanSlate recognizes that previous corrective action efforts lacked consistent oversight and follow-through and has implemented these enhanced monitoring processes to ensure sustained compliance and prevent future deficiencies.
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