INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 23, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, STR Addiction Counseling, 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of six personnel records, the facility failed to ensure that one counselor assistant was given a written semiannual performance evaluation based upon measurable performance standards.
Employee #6 was hired on July 22, 2024 as a counselor assistant. Employee #6 did not receive a semiannual performance evaluation in the last year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will complete and review a performance evaluation with the Counselor Assistant on 10/8/25.
Moving forward, the HR Manager will ensure that all semi-annual and annual performance evaluations are completed on time and appropriately. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of six personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #6 was hired on July 22, 2024 as a counselor assistant and was current in that position. Employee #6 has a high school diploma and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Employee #6 ' s personnel records did not have documentation of direct observation occurring from July 22, 2024 through October 22, 2024. There was also no documentation of direct observation the weeks of November 12, 19, 26, and December 3, 10 and 17, 2024.
Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week. "
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services will directly observe the Counselor Assistant from the weeks of 9/29/25 to 12/22/25. The Director of Clinical Services will then observe the Counselor Assistant for one hour a week from 12/29/25 to 2/2/26.
The HR Manager has updated the supervision forms to ensure that direct observation is documented on the form.
Moving forward, the HR Manager will be responsible for the auditing and ensuring proper documentation of supervisions and direct observation. |
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 provide a complete client record, which is to include follow up information within 30 days of discharge, per the facility ' s policy and procedures manual, in two out of three applicable discharged records reviewed.
Client #6 was admitted on March 3, 2025 and discharged on March 26, 2025. A follow up contact was due no later than April 26, 2025; however, there was no documentation that one was completed.
Client #7 was admitted on December 18, 2024 and discharged on January 31, 2025. A follow up contact was due no later than March 2, 2025; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow up calls will be made to client #6 and client #7 no later then 10/10/25.
Staff was retrained on completing follow up calls and timeframe for compeltion on 10/6/25.
Moving forward, the Director of Quality Assurance will work with the Executive Director to audit follow up calls on a monthly basis. |
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 ensure that the clients received counseling services according to their individual treatment plan in three out of seven records reviewed.
Client #8 was admitted on August 12, 2025 and was still active at the time of the inspection. The treatment plan dated September 4, 2025, indicated one individual counseling session and three hours a day of group counseling, six times a week. There was no documentation that the client received one individual counseling session the week of September 8, 2025.
Client #9 was admitted on July 14, 2025 and was still active at the time of the inspection. The treatment plan dated August 5, 2025, indicated one individual counseling session and three hours a day of group counseling, six times a week. There was no documentation that the client received an individual session the week of September 15, 2025.
Client #10 was admitted on August 12, 2025 and was still active at the time of the inspection. The treatment plans dated August 19 and September 15, 2025, indicated one individual counseling session a week and three hours a day of group counseling, six times a week. There was no documentation that the client received three of six days of group counseling the week of September 15, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director retrained staff documentation and timeframes for completion for treatment plans, individual notes, missed session notes and group notes on 9/29/25.
Client #8 is no longer in services.
Client #9 is no longer in services.
Client #10 is no longer in services.
Moving forward, the Executive Director and Office Manager will audit documentation on a weekly basis to ensure compliance. |
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 provide a complete client record, which is to include follow up information within 30 days of discharge, per the facility ' s policy and procedures manual, in three out of three applicable discharged records reviewed.
Client #11 was admitted on January 9, 2025 and discharged on January 16, 2025. A follow up contact was due no later than February 16, 2025; however, there is no documentation that one was completed.
Client #12 was admitted on June 9, 2025 and discharged on August 5, 2025. A follow up contact was due no later than September 5, 2025; however, there is no documentation that one was completed.
Client #14 was admitted on June 16, 2025 and discharged on August 14, 2025. A follow up contact was due no later than September 14, 2025; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow up calls will be made to client #11, client #12, and client #14 no later then 10/10/25.
Staff was retrained on completing follow up calls and timeframe for compeltion on 10/6/25.
Moving forward, the Director of Quality Assurance will work with the Executive Director to audit follow up calls on a monthly basis. |