INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 3, 2025 through September 4, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Silver Linings USA Limited Liability Company 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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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure counselor assistants documented to the facility director, upon the completion of each calendar year, that they are working towards counselor status in one of one applicable personnel record reviewed. Employee #5 was hired as a counselor assistant on December 21, 2021. There was no documentation, in the record, to the facility director indicating how the employee was working towards counselor status for the end of the 2024 calendar year.This is a repeat citation from the July 26, 2024 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has created a template for current and any potential counselor assistants that will state the status of each employee working toward getting counselor status that will be given to the Lead Therapist and or Clinical Director. This form is being implemented effective 9/8/25 and will be put in current counselor charts for any employees that did not have it in their chart from previous years to get their HR chart in compliance. For new employees that are counselor assistants this form will be due at the end of the calendar year. This will be monitored by the Executive Assistant and Lead Counselor by doing HR chart audits on a monthly basis. At this time if the counselor assistants do not have this form completed, they will be notified or given the date when it will be due (end of the calendar year). |
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 personnel records, the facility failed to document an individual training plan for each employee, with the plan being developed annually with input from both the employee and their supervisor and appropriate to that employee's skill level in four of five applicable personnel records reviewed.Employee # 1 was hired as the project director and facility director on September 5, 2022. There was no current individual training plan developed with input from the employee and supervisor documented in the personnel record at the time of the inspection.Employee # 3 was hired as a counselor on July 31, 2023. There was no current individual training plan developed with input from the employee and supervisor documented in the personnel record at the time of the inspection.Employee # 4 was hired as a counselor on June 2, 2025. There was no current individual training plan developed with input from the employee and supervisor documented in the personnel record at the time of the inspection.Employee # 5 was hired as a counselor assistant on December 12, 2021. There was no current individual training plan developed with input from the employee and supervisor documented in the personnel record at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The individual training plan was being completed annually for all staff but was not being put in the HR chart to show that it was being completed. Employee #1, #3, #4, and #5's HR charts were updated 9/5/25 to include their individual training plan in their HR file.
This task has now been given to the Lead Counselor to take over to make sure that each employee is given a training plan that is appropriate to that employee's skill level as well as being put in the HR chart. This will be reviewed by the supervisor for each employee on an annual basis as well. |
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 personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training, during the facility's January 1, 2024 through December 31, 2024 training year, in two of two applicable personnel records reviewed.Employee # 2 was hired as a lead counselor on April 24, 2023. The personnel record documented 6 hours of training received during the training year reviewed. Employee # 3 was hired as a counselor on July 31, 2023. The personnel record documented 21.25 hours of training received during the training year reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has a new system in place that includes a tracking system of all the CEUS that each employee is required and when they are each due. Lead Counselor has been put in chart of this and will them make sure to notify the staff member of when they will need to get their hours completed by. If the employees do not get their trainings completed by the time frame needed staff may be held to disciplinary measures. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor assistant, after one year in the position, completed 30 clock hours of annual training in one of one applicable personnel record reviewed. Employee #5 was hired as a counselor assistant on December 21, 2021. At the time of the inspection, there were 16.5 clock hours of training documented, in the personnel record, during the December 21, 2023 through December 21, 2024 year.This is a repeat citation from the July 26, 2024 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has a new system in place that includes a tracking system of all the CEUS that each employee is required and when they are each due. Lead Counselor has been put in chart of this and will them make sure to notify the staff member of when they will need to get their hours completed by. If the employees do not get their trainings completed by the time frame needed they may be help to disciplinary measures. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon staff employment in one of one applicable personnel record reviewed.Employee # 4 was hired as a counselor on June 2, 2025. At the time of the inspection, there was no training in the use of fire extinguishers documented in the personnel record. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon hire all staff are instructed on the use of the fire extinguisher. This is documented in their HR chart. Due to a change in staff employee #4 did not get that documentation that was necessary to show that they completed the fire extinguisher training. Moving forward the executive assistant will make sure that this is completed and inputted in the employee's HR chart. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on an administrative review of the August 2024 through August 2025 fire drill logs, the facility failed to conduct fire drills during normal staffing conditions.The fire drill logs for the months of October 2024, June 2025, and July 2025 indicated the fire drills were conducted on a Sunday, which is outside of the facility's posted operating hours of Monday through Friday from 8:00am to 9:00pm and Saturday from 8:30am to 2:00pm.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility staff were instructed not to schedule fire drills on days that were designated for client make up days/times that are outside of typical business hours.
All facility fire drills will be conducted during posted operating hours of Monday through Thursday from 8:30am to 8:30pm, Friday from 8:00am to 4:00pm and Saturday from 9:00am to 12:00pm.
Operations Manager will approve fire drill dates and times with staff conducting the drills.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies in one of one applicable personnel record reviewed.Employee # 4 was hired as a counselor on June 2, 2025. At the time of the inspection, there was no documentation of staff emergency preparedness training in the personnel record.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon hire all staff are trained on performing assigned tasks during emergencies This is documented in their HR chart. Due to a change in staff employee #4 did not get that documentation that was necessary to show that they completed the training on performing assigned tasks during emergencies. Moving forward the executive assistant will make sure that this is completed and inputted in the employee's HR chart. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 the facility's August 2024 through August 2025 fire drill logs, the facility failed to ensure their written fire drill logs included documentation of problems encountered and whether the fire alarm or smoke detector was operative at the time of the drill.Every monthly fire drill log documented during the reviewed period did not include documentation of any problems encountered and whether the fire alarm or smoke detector was operative during the time of the drill.This is a repeat citation from the July 26, 2024 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has created an updated fire drill log where there is a spot to check off that the fire drill and smoke detectors were operating during drill. There is also a space to document any problems or lack of problems that were encountered during drill.
Operations manager will go through the fire drill logs on a monthly basis to ensure that the logs are being documented corrected. If the drills are missing anything it will be given back to the staff member who completed it and asked to be redone. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the August 2024 through August 2025 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.Every monthly fire drill conducted, during the reviewed period, indicated only the side door was used as the fire drill exit route. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility staff were instructed to use alternate exit routes during the fire drills. Each month the fire drill will show that alternate exit routes were used in case of emergency. Operations Manager will be put in charge of approving all fire drills and ensuring that there was alternate exit routes utilized. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the August 2024 through August 2025 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts. The facility's posted hours of operation are Monday through Friday from 8:00am to 9:00pm and Saturday from 8:30am to 2:00pm.Every fire drill reviewed was completed between 10:30am and 12:00pm. There were no afternoon or evening fire drills conducted during the reviewed period.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility staff were instructed not to schedule fire drills on days that were designated for client make up days/times that are outside of typical business hours.
All facility fire drills will be conducted during posted operating hours of Monday through Thursday from 8:30am to 8:30pm, Friday from 8:00am to 4:00pm and Saturday from 9:00am to 12:00pm.
Operations Manager will approve fire drill dates and times with staff conducting the drills and ensure that they are completing during day group and night group and not at the same time every time there is a drill.
The operations manager will audit the logs monthly to ensure that the drills are being done correctly and in different times of the operating hours.
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the facility failed to document, and make available to the public, an annual report which is to include, but not be limited to, a statement disclosing the names of officers, directors and principal shareholders.This is a repeat citation from the September 15, 2022, October 3, 2023, and July 26, 2024 annual licensing renewal inspections.This finding was discussed with facility staff during the licensing process.
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Plan of Correction
The facility has since put up a form in the client area that shows the names of the officers, directors, and principal shareholders. The facility will also make sure to put this on their website in a place that is visible to anyone who visits the site. This will be updated if needed if anything shall change immediately on both the website and on site.
An annual report that includes the names of the officers, directors and principal shareholders will be created and made available to the public. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to document annual written individual staff performance evaluations and copies of which shall be reviewed and signed by the employee in three of four applicable personnel records reviewed. Employee # 1 was hired as the project director and facility director on September 5, 2022. The most recent annual performance evaluation documented in the personnel record was completed on March 4, 2023. There was no annual performance evaluation documented for the 2024 calendar year.Employee # 3 was hired as a counselor on July 31, 2023. The annual performance evaluation was completed by the supervisor on July 30, 2025; however, the evaluation was not reviewed and signed by the employee at the time of the inspection. Employee # 5 was hired as a counselor assistant on December 21, 2021. The annual performance evaluation was completed by the supervisor on May 15, 2025; however, the evaluation was not reviewed and signed by the employee at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All employees are given annual reviews which gives staff a performance evaluation and is reviewed and signed by the employee and their supervisor. Due to staff changes staff evaluations were not put in the HR charts. This has now been giving to the Executive assistant to make sure that all staff get their yearly performance evaluations and are inputted in their HR chart.
The executive director will be going through the HR charts every month to ensure that the HR charts are up to date and will notify staff members if there is something that needs to be updated in their HR chart. |
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 complete an informed and voluntary consent to release information form prior to the disclosure of information in two of fourteen client records reviewed.Client # 6 was admitted to the partial hospitalization activity on June 11, 2025 and was discharged on July 3, 2025. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. Client # 10 was admitted to the outpatient activity on January 21, 2025 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All consents to release information will be documented correctly making sure that all information is documented including the name of the person, agency, or organization to whom the disclosure is made to. The counselor or counselor assistant will be in charge of checking those releases of clients on their caseload and will fix it with client if any information is missing. It will also be checked by the director as well.
All charts have been audited by Clinical Director and notified clinical team which consents to release information forms needed to be updated and put any information necessary to make the releases compliant.
Client #6 has been discharged so unable to update the client's ROI.
Client #10 is still active and the ROI was updated on the day of the licensing process after it was reviewed with the staff.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made to on consent to release information forms in five of fourteen client records reviewed. Client # 1 was admitted to the partial hospitalization activity on March 17, 2025 and was discharged on April 10, 2025. The release of information forms to an employer, a funding source, and a pharmacy were signed by the client on March 17, 2025; however, all three release forms did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made. Client # 4 was admitted to the partial hospitalization activity on March 20, 2025 and was discharged on April 10, 2025. The release of information form to a funding source was signed by the client on March 20, 2025; however, the release form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.Client # 5 was admitted to the partial hospitalization activity on December 18, 2024 and was discharged on January 17, 2025. The release of information forms to a referral source, a funding source, a support person, a contact person, and a pharmacy were signed by the client on December 18, 2024; however, all five release forms did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.Client # 6 was admitted to the partial hospitalization activity on June 11, 2025 and was discharged on July 3, 2025. The release of information form to a contact person was signed by the client on June 11, 2025; however, the release form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made. Client # 8 was admitted to the outpatient activity on August 28, 2025 and was still active at the time of the inspection. The release of information forms to a referral source, a funding source, a support person, a pharmacy and a contact person were signed by the client on August 28, 2025; however, all five release forms did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.This was a repeat citation from the July 26, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All consents to release information will be documented correctly making sure that all information is documented including the name of the person, agency, or organization to whom the disclosure is made to. The counselor or counselor assistant will be in charge of checking those releases of clients on their caseload and will fix it with client if any information is missing. It will also be checked by the director as well.
All charts have been audited by Clinical Director and notified clinical team which consents to release information forms needed to be updated and put any information necessary to make the releases compliant.
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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 consent to release information forms in four of fourteen client records reviewed. Client # 4 was admitted to the partial hospitalization activity on March 20, 2025 and was discharged on April 10, 2025. The release of information forms to a funding source, another treatment provider, and a pharmacy were signed by the client on March 20, 2025; however, all the release forms did not include the specific information to be disclosed. Client # 5 was admitted to the partial hospitalization activity on December 18, 2024 and was discharged on January 7, 2025. The release of information forms to a referral source, a funding source, a support person, a contact person, and a pharmacy were signed by the client on December 18, 2024; however, all the release forms did not include the specific information to be disclosed.Client # 6 was admitted to the partial hospitalization activity on June 11, 2025 and was discharged on July 3, 2025. The release of information form to another treatment provider was signed by the client on June 11, 2025; however, the release form did not include the specific information to be disclosed. Client # 8 was admitted to the outpatient activity on August 28, 2025 and was still active at the time of the inspection. The release of information form to a pharmacy was signed by the client on August 28, 2025; however, the release form did not include the specific information to be disclosed.This was a repeat citation from the July 26, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All consents to release information will document the specific information to be disclosed on consent and release information forms.
The counselor or counselor assistant will hold the responsibility to check said releases of clients on their caseload and will fix it with client if any information is missing. It will also be checked by the director for review.
All charts have been audited by Clinical Director who has notified clinical team which consents to release information forms required update in order to make the releases compliant. This will be a part of the clinical audit that goes out to clinical team once a week on Mondays.
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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 document the purpose of the disclosure on release of information forms in five of fourteen client records reviewed.Client # 1 was admitted to the partial hospitalization activity on March 17, 2025 and was discharged on April 10, 2025. The release of information form to a pharmacy was signed and dated by the client on March 17, 2025; however, the release form did not include the purpose of the disclosure. Client # 4 was admitted to the partial hospitalization activity on March 20, 2025 and was discharged on April 10, 2025. The release of information forms to a funding source, another treatment provider, and a pharmacy were signed by the client on March 20, 2025; however, the release forms did not include the purpose of the disclosure.Client # 5 was admitted to the partial hospitalization activity on December 18, 2024 and was discharged on January 7, 2025. The release of information forms to a referral source, a funding source, a support person, a contact person, and a pharmacy were signed by the client on December 18, 2024; however, the release forms did not include the purpose of the disclosure. Client # 6 was admitted to the partial hospitalization activity on June 11, 2025 and was discharged on July 3, 2025. The release of information form to another treatment provider was signed by the client on June 11, 2025; however, the release form did not include the purpose of the disclosure.Client # 8 was admitted to the outpatient activity on August 28, 2025 and was still active at the time of the inspection. The release of information forms to a referral source, a funding source, a support person, a pharmacy and a contact person were signed by the client on August 28, 2025; however, the release forms did not include the purpose of the disclosure.This was a repeat citation from the July 26, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All consents to release information will be documented correctly making sure that all information is documented including the name of the person, agency, or organization to whom the disclosure is made to. It will also make sure the purpose of disclosure is documented. The counselor or counselor assistant will be in charge of checking those releases of clients on their caseload and will fix it with client if any information is missing. It will also be checked by the director as well.
All charts have been audited by Clinical Director and notified clinical team which consents to release information forms needed to be updated and put any information necessary to make the releases compliant.
This will now be a part of the clinical audit that goes out to clinical team once a week on Mondays.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on a release of information form in one of fourteen client records reviewed. Client # 12 was admitted to the outpatient activity on October 25, 2025 and was discharged on May 16, 2025. The release of information form to a probation officer was signed by the witness on April 1, 2025; however, the release form did not include a dated signature of the client. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All consents to release information will be documented correctly making sure that all information is documented including name of the person, agency, or organization to whom the disclosure is made to, dated signature of client or guardian, as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients.) It will also make sure the purpose of disclosure is documented. The release will also have a spot to show a date, event, or condition upon which the consent would expire. The counselor or counselor assistant will be in charge of checking those releases of clients on their caseload and will fix it with client if any information is missing. It will also be checked by the director as well. This was reviewed in staff meeting 9/15/25.
All charts have been audited by Clinical Director and notified clinical team which consents to release information forms needed to be updated and put any information necessary to make the releases compliant. This was completed 9/15/25.
This will now be a part of the clinical audit that goes out to clinical team once a week on Mondays.
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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 on consent to release information forms in two of fourteen client records reviewed. Client # 4 was admitted to the partial hospitalization activity on March 20, 2025 and was discharged on April 10, 2025. The release of information forms to a pharmacy and another treatment provider were signed by the client on March 20, 2025; however, the release forms did not include a date, event, or condition upon which the consent would expire.Client # 5 was admitted to the partial hospitalization activity on December 18, 2024 and was discharged on January 7, 2025. The release of information forms to a referral source, a contact person, a funding source, a support person, and a pharmacy were signed by the client on December 18, 2024; however, the release forms did not include a date, event, or condition upon which the consent would expire.This is a repeat citation from the July 26, 2024 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All consents to release information will be documented correctly making sure that all information is documented including the name of the person, agency, or organization to whom the disclosure is made to. It will also make sure the purpose of disclosure is documented. The release will also have a spot to show a date, event, or condition upon which the consent would expire. The counselor or counselor assistant will be in charge of checking those releases of clients on their caseload and will fix it with client if any information is missing. It will also be checked by the director as well. This was reviewed in staff meeting 9/15/25.
All charts have been audited by Clinical Director and notified clinical team which consents to release information forms needed to be updated and put any information necessary to make the releases compliant. This was completed 9/15/25
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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 document that a copy of a client consent was offered to the client in two of fourteen client records reviewed. Client # 4 was admitted to the partial hospitalization activity on March 20, 2025 and was discharged on April 10, 2025. The release of information forms to a funding source and a referral source were signed by the client on March 20, 2025; however, there was no documentation in the record indicating a copy of each client consent was offered to the client.Client # 5 was admitted to the partial hospitalization activity on December 18, 2024 and was discharged on January 7, 2025. The release of information forms to a funding source, a support person, and a pharmacy were signed by the client on December 18, 2024; however, there was no documentation in the record indicating a copy of each client consent was offered to the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A copy of client consent shall be offered to the client, and a copy is maintained in the client record. Due to client #4 and client #5 being discharged already the chart was unable to be updated. The counselor or counselor assistant will be in charge of making sure that it is documented in the client's chart and will fix it with client if any information is missing. It will also be checked by the director as well. This was reviewed in staff meeting 9/15/25. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, which is to include the reason for termination, in one of one applicable client record reviewed.Client # 11 was admitted to the outpatient activity on February 25, 2025 and was administratively discharged on February 26, 2025. There was no documentation in the record indicating the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project. This is a repeat citation from the October 3, 2023 and July 26, 2024 annual licensing renewal inspections. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Due to client #11 being discharged in February 2025 unfortunately this client was not provided the correct services and was not given a proper notification of their discharge. All clinical staff has been given a training by the Clinical Director at their clinical meeting on 9/15/25. Moving forward any client that is to be involuntarily terminated will be given notice in writing of the decision why they are discharging client and will be uploaded into the client's EMR chart as well.
Clinical Director provided a training on 9/15/25 during staff meeting to the clinical team. The clinical director will make sure that this is being done by chart audits that go out every week on Monday which includes discharge clients. Clinical staff will be notified if chart is out of compliance.
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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 the facility's August 2024 through August 2025 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility.There were reportable events where police and/or ambulance personnel were present at the facility on October 18, 2024, January 28, 2025 and February 26, 2025; however, all three events were not reported to the Department at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to staff changes, there was miscommunication of who was to be sending the reports to DDAP. This has now been rectified and will be the Operations Manager responsibility. The staff was given a training at their staff meeting on 9/15/25 and given an update on the internal incident reporting forms. The forms now have added lines to check off that include the reportable incident type if they are applicable to the incident.
These include:
1. Physical or sexual assault by staff or a client.
2. Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
3. A significant disruption of services due to a disaster or another occurrence that results in the closure of a facility for more than 1 day.
4. Event at the facility requiring the presence of police, fire or ambulance
personnel.
5. Outbreak of a contagious disease.
The Operations Manager will review and sign off on any newly completed internal incident reporting forms and determine if an unusual incident requires that the incident be reported to DDAP within 3 business days.
The incidents from October 2024, January 2025 and February 2025 have been reported to DDAP 9/24/25 by the Operations manger.
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709.82(a) 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:
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Observations
Based on a review of client records, the facility failed to document and develop an individual treatment and rehabilitation plan in two of five applicable client records reviewed. The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within 10 days of admission. Client # 4 was admitted to the partial hospitalization activity on March 20, 2025 and was discharged on April 10, 2025. The individual treatment and rehabilitation plan was completed on March 23, 2025; however, there was no documentation indicating the treatment plan was developed with the client. Client # 5 was admitted to the partial hospitalization activity on December 18, 2024 and was discharged on January 7, 2025. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection. This is a repeat citation from the July 26, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #4 and #5 are discharged and unable to update their chart to include their individual treatment plan.
Moving forward during the weekly audit report that the Clinical Director sends out it will let the clinicians know if their treatment plans have been or not been done in the timely manner within 7 days of being admitted. If the treatment plan is not done in a timely manner staff will have disciplinary action.
All clinical staff has been given a training by the Clinical Director at their clinical meeting on 9/15/25 on treatment planning and how this is an essential part of the client's treatment that needs to be created with the client and counselor/counselor assistant. The treatment plan needs to be developed within 7 days of intake. The initial treatment plan shall be completed day of intake. |
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 client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of four applicable client records reviewed.Client # 1 was admitted to the partial hospitalization activity on March 17, 2025 and was discharged on April 10, 2025. The individual treatment and rehabilitation plan was completed on March 19, 2025, but the type and frequency of treatment and rehabilitation services was not included on the treatment plan.Client # 3 was admitted to the partial hospitalization activity on June 9, 2-25 and was discharged on June 26, 2025. The individual treatment and rehabilitation plan was completed on June 13, 2025, but the type and frequency of treatment and rehabilitation services was not included on the treatment plan.Client # 4 was admitted to the partial hospitalization activity on March 20, 2025 and was discharged on April 10, 2025. The individual treatment and rehabilitation plan was completed on March 23, 2025, but the type and frequency of treatment and rehabilitation services was not included on the treatment plan.Client # 6 was admitted to the partial hospitalization activity on June 11, 2025 and was discharged on July 3, 2025. The individual treatment and rehabilitation plan was completed on June 13, 2025, but the type and frequency of treatment and rehabilitation services was not included on the treatment plan.This is a repeat citation from the July 26, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1, #3, #4, and #6 treatment plans have all been updated to include the type and frequency of treatment and rehabilitation services. All clinical staff has been given a training by the Clinical Director at their clinical meeting on 9/15/25 on how to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan. The Clinical Director will audit charts and send out a report and let clinical staff know if treatment plans need to be corrected. |
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 client records, the facility failed to document the proposed type of support service on the individual treatment and rehabilitation plan in two of four client records reviewed.Client # 3 was admitted to the partial hospitalization activity on June 9, 2025 and was discharged on June 26, 2025. The individual treatment and rehabilitation plan was completed on June 13, 2025, but the type and frequency of treatment and rehabilitation services was not included on the treatment plan.Client # 4 was admitted to the partial hospitalization activity on March 20, 2025 and was discharged on April 10, 2025. The individual treatment and rehabilitation plan was completed on March 23, 2025, but the type and frequency of treatment and rehabilitation services was not included on the treatment plan.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client ##3 and #4 treatment plans have all been updated to include the type and frequency of treatment and rehabilitation services. All clinical staff has been given a training by the Clinical Director at their clinical meeting on 9/15/25 on how to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan. The Clinical Director will audit charts and send out a report and let clinical staff know if treatment plans need to be corrected. |
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 client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in six of seven applicable client records reviewed.Client # 1 was admitted to the partial hospitalization activity on March 17, 2025 and was discharged on April 10, 2025. There was no documentation of follow-up information in the record at the time of the inspection.Client # 2 was admitted to the partial hospitalization activity on January 21, 2025 and was discharged on February 7, 2025. There was no documentation of follow-up information in the record at the time of the inspection.Client # 4 was admitted to the partial hospitalization activity on March 20, 2025 and was discharged on April 10, 2025. There was no documentation of follow-up information in the record at the time of the inspection.Client # 5 was admitted to the partial hospitalization activity on December 18, 2024 and was discharged on January 7, 2025. There was no documentation of follow-up information in the record at the time of the inspection.Client # 6 was admitted to the partial hospitalization activity on June 11, 2025 and was discharged on July 3, 2025. There was no documentation of follow-up information in the record at the time of the inspection.Client # 7 was admitted to the partial hospitalization activity on February 12, 2025 and was discharged on February 25, 2025. There was no documentation of follow-up information in the record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow up is being conducted and is in the client's charts currently. During the audit the Clinical Director was unable to access where the follow up calls are being conducted due to access restriction in our EMR system. The follow up is conducted by admissions/marketing staff and they have different access in the EMR system. Moving forward during the state audits it will be visible to show where the follow up calls are being documented. |
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 document and develop, with the client, an individual treatment and rehabilitation plan in three of five applicable client records reviewed. The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within 10 days of admission. Client # 9 was admitted to the outpatient activity on June 26, 2025 and was still active at the time of the inspection. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection. Client # 12 was admitted to the outpatient activity on October 25, 2024 and was discharged on May 16, 2025. The individual treatment and rehabilitation plan was completed on November 8, 2024; however, there was no documentation indicating the treatment plan was developed with the client.Client # 13 was admitted to the outpatient activity on March 24, 2025 and was discharged on June 16, 2025. The individual treatment and rehabilitation plan was due to be completed by April 3, 2025; however, the plan was not completed until April 14, 2025.This is a repeat citation from the July 26, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #9, #12, and #13 have individual treatment plans completed in their chart. All clinical staff has been given a training by the Clinical Director at their clinical meeting on 9/15/25 on treatment planning and how this is an essential part of the client's treatment that needs to be created with the client and counselor/counselor assistant. The treatment plan needs to be developed within 7 days of intake. The initial treatment plan shall be completed day of intake. The Clinical Director will audit charts and send out a report and let clinical staff know if treatment plans need to be completed. |
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 client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of four applicable client records reviewed.Client # 10 was admitted to the outpatient activity on January 21, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 28, 2025, but the type and frequency of treatment and rehabilitation services was not included on the treatment plan.Client # 12 was admitted to the outpatient activity on October 25, 2025 and was discharged on May 16, 2025. The individual treatment and rehabilitation plan was completed on November 8, 2024, but the type and frequency of treatment and rehabilitation services was not included on the treatment plan.Client # 13 was admitted to the outpatient activity on March 24, 2025 and was discharged on June 16, 2025. The individual treatment and rehabilitation plan was completed on April 14, 2025, but the type and frequency of treatment and rehabilitation services was not included on the treatment plan.Client # 14 was admitted to the outpatient activity on March , 2025 and was discharged on June 17, 2025. The individual treatment and rehabilitation plan was completed on November 8, 2024, but the type and frequency of treatment and rehabilitation services was not included on the treatment plan.This is a repeat citation from the July 26, 2024 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #10, #12, #13, and #14 treatment plans have all been updated to include the type and frequency of treatment and rehabilitation services. All clinical staff has been given a training by the Clinical Director at their clinical meeting on 9/15/25 on how to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan. The Clinical Director will audit charts and send out a report and let clinical staff know if treatment plans need to be corrected. |
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 maintain a complete client record, which is to include the documentation of follow-up information, in four of four applicable client records reviewed.Client # 11 was admitted to the outpatient activity on February 25, 2025 and was discharged on February 26, 2025. There was no documentation of follow-up information in the record at the time of the inspection.Client # 12 was admitted to the outpatient activity on October 25, 2025 and was discharged on May 16, 2025. There was no documentation of follow-up information in the record at the time of the inspection.Client # 13 was admitted to the outpatient activity on March 24, 2025 and was discharged on June 16, 2025. There was no documentation of follow-up information in the record at the time of the inspection.Client # 14 was admitted to the outpatient activity on March , 2025 and was discharged on June 17, 2025. There was no documentation of follow-up information in the record at the time of the inspection.This is a repeat citation from the July 26, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow up is being conducted and is in the client's charts currently. During the audit the Clinical Director was unable to access where the follow up calls are being conducted due to access restriction in our EMR system. The follow up is conducted by admissions/marketing staff and they have different access in the EMR system. Moving forward during the state audits it will be visible to show where the follow up calls are being documented. |
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 an administrative review, the facility failed to comply with plans of correction that were previously approved by the Department. Plans of correction for failing to document and make available to the public an annual report, including a statement disclosing the names of officers, directors and principal shareholders were submitted and approved by the Department for the September 15, 2022, October 3, 2023, and July 26, 2024 annual licensing inspections. Failing to document and make available to the public an annual report, including a statement disclosing the names of officers, directors and principal shareholders was again found to be a deficiency during the September 3, 2025 through September 4, 2025 annual licensing inspection.Plans of correction for failing to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination were submitted and approved by the Department for the September 15, 2022, October 3, 2023, and July 26, 2024 annual licensing inspections. Failing to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination was again found to be a deficiency during the September 3, 2025 through September 4, 2025 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The plan of corrections was not followed up on from previous audits. This has been addressed with the CEO, Clinical Director, lead Counselor and Operations manager. This was also addressed in clinical meeting on 9/15/25. There will be consequences moving forward if clinical staff is not able to comply with having their charts stay in compliance.
Clinical Director will be going over trainings during staff meetings once a month on issues that occurred during this and previous corrective action plans to ensure this does not reoccur. Clinical
Director will also be auditing charts on a weekly basis and clinical staff will be getting that once a week on Mondays.
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