INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 8, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ADAPPT Outpatient Treatment Services 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, conducted on January 8, 2026, the facility failed to designate counseling space that ensured privacy so that counseling sessions cannot be seen or heard outside of the counseling room and that the room walls extended from the floor to the ceiling.
One counseling space was not enclosed and did not have walls that extended from the floor to ceiling. This counseling space is exposed to the office hallway and is also the entryway into another counseling office; therefore, privacy cannot be ensured.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director shall ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room by moving counseling activities to space that extends from the floor to the ceiling, including repurposing appropriate space. This shall be completed by 2/27/26. It shall be reviewed by Project Director again by 2/27/26. Regulations will be reviewed with all staff by the Project Director by 2/27/26. |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven client records reviewed.
Client # 1 was admitted on August 19, 2025 and discharged on October 17, 2025. The facility failed to document a release of information for the funding source, and it was verified that billing had occurred.
Client # 6 was admitted on July 16, 2025 and was active at the time of the inspection. The facility failed to document a release of information for the funding source, and it was verified that billing had occurred.
Client # 7 was admitted on August 19, 2025 and was active at the time of the inspection. The facility failed to document a release of information for the funding source, and it was verified that billing had occurred.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Project Director shall retrain staff on the need to obtain an informed and voluntary consent from their client for the disclosure of information contained in the client record, specifically release of information for the funding source by 2/27/26. The Project Director shall review compliance prior to 3/27/26 through file review. Client 6 and 7 have been discharged from the facility due to closure. |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in one of seven client records reviewed.
Client # 6 was admitted on July 16, 2025 and was active at the time of the inspection. A release of information form for a probation officer and a government agency signed by the client on July 11, 2025, did not specify the specific information to be disclosed.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Project Director shall retrain staff on the need to obtain an informed and voluntary consent from their client for the disclosure of information contained in the client record, specifically to specify the information being disclosed by 2/27/26. The Project Director shall review compliance prior to 3/27/26 through file review. Client #6 was discharged from facility due to closure. |
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 a review of client records and the facility's policy and procedure manual, the facility failed to ensure that the intake procedures included documentation of a completed psychosocial evaluation, within 14 days of admission, per facility policy, in seven of seven client records reviewed.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Project Director will review the policy, however, due to our intent of closure and relinquishing the license, we will not be completing new admissions. Retraining of the policy will be completed by 2/27/26.
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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 project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in four of seven records reviewed.
Client # 2 was admitted on March 26, 2025 and discharged on September 18, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on April 17, 2025, indicated that the client was to receive one individual counseling session and two group counseling sessions per week; however, there was no individual counseling session documented for the week of May 11, 2025 through May 17, 2025 and only one group counseling session for the weeks of June 1, 2025 through June 7, 2025 and June 15, 2025 through June 21, 2025.
Client # 3 was admitted on February 25, 2025 and discharged on August 19, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on March 11, 2025, indicated that the client was to receive one individual counseling session and two group counseling sessions per week; however, there were no individual counseling sessions documented for the weeks of May 18, 2025 through May 24, 2025, June 15, 2025 through June 21, 2025, and August 3, 2025 through August 9, 2025 and only one group counseling session for the weeks of March 30, 2025 through April 5, 2025, June 15, 2025 through June 21, 2025, July 6, 2025 through July 12, 2025 and July 13, 2025 through July 19, 2025.
Client # 6 was admitted on July 16, 2025 and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on August 1, 2025, indicated that the client was to receive one individual counseling session and one group counseling sessions per week; however, there were no individual counseling sessions documented for the weeks of November 23 2025 through November 29, 2025 and December 21, 2025 through December 27, 2025 and no group counseling sessions for the weeks of November 23, 2025 through November 29, 2025, November 30, 2025 through December 6, 2025 and December 7, 2025 through December 13, 2025.
Client # 7 was admitted on August 19, 2025 and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on September 4, 2025, indicated that the client was to receive one individual counseling session and one group counseling sessions per week; however, there were no individual counseling sessions documented for the week of November 23 2025 through November 29, 2025 and no group counseling sessions for the weeks of November 23, 2025 through November 29, 2025, November 30, 2025 through December 6, 2025 and December 7, 2025 through December 13, 2025.
This is a repeat citation from the December 19, 2024 annual renewal licensing inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Project Director shall retrain staff to ensure that counseling services are provided according to the individual treatment and rehabilitation plan by 2/27/26. The Project Director shall complete a file reviews by 3/14/26 to ensure compliance. |