INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 24, 2026 through September 25, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Western Pennsylvania Counseling Services LLC dba Forge Health 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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704.11(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 counselors completed at least 25 clock hours of annual training, during the facility's March 1, 2025 through February 28, 2026 training year, in two of two applicable personnel records reviewed. Employee #3 was hired as a counselor on June 24, 2024. There was only 1 hour of annual training documented in the record during the training year reviewed. Employee #4 was hired as a counselor on September 11, 2023. There were only 8.75 hours of annual training documented in the record during the training year reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will review the personnel and training records for Employees #3 and #4 to identify completed training eligible for credit toward the applicable training year. Internal trainings will be reviewed and adjusted as needed to meet the 25-hour requirement. Any outstanding training needs will be identified, and individualized plans will be developed to ensure completion of required training, as applicable. |
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 October 2025 through August 2026 fire drill logs, the facility failed to maintain written fire drill logs, which are to include documentation of the exit route used at the time of the drill. At the time of the inspection, the fire drill logs for the drills conducted during the months of January 2026, February 2026, March 2026, and April 2026 were missing which exit route was used during each drill. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the facility will ensure that all fire drill logs include documentation of the exit route utilized during each drill. The fire drill documentation form will be reviewed and updated, as needed, to include a designated section for "Exit Route Used."
Clinic Director, will ensure that the Peer Support & Front Desk Coordinator completes the fire drill logs for each drill in full to support ongoing monitoring and compliance. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's October 2025 through August 2026 fire drill logs and a discussion with facility staff, the facility failed to ensure a fire alarm or smoke detector was set off during each fire drill. At the time of the inspection, the fire drill logs indicated that due to being located in a multiple occupant building, the fire alarm or smoke detector was not set off during each fire drill conducted during the reviewed period. Facility staff confirmed not setting off the alarm or smoke detector and the facility does not have a current exception for this regulation. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility is located within a multi-suite office building that is occupied by other businesses. Because the facility does not operate independently from the building's common fire alarm system, activating the building-wide fire alarm for routine facility fire drills is not operationally feasible and may unnecessarily disrupt other tenants and building operations.
The facilities VP of Finance submitted an exception on 9/25 to permit the use of an alternative method for conducting fire drills within the facility. Clinic Director will utilize a handheld fire alarm/sounding device to provide an audible drill signal to staff and individuals present within the facility. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities for the project's 2024 fiscal year. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will maintain documentation of its annual revenue review and the determination of whether an independent financial audit is required. If the $500,000 threshold is met in a future fiscal year, the facility will obtain the services of an independent Certified Public Accountant (CPA) to complete the required audit in accordance with applicable requirements.
An exception was submitted by the facilities VP of Finance on September 25, 2026, as the facility did not meet the requirements for a full financial audit by an independent CPA. The Clinic Director will periodically review the facility's financial audit status and determine whether a full audit is necessary in preparation for the following years DDAP inspection. Any changes in the facility's financial status or audit requirements will be assessed to ensure continued compliance with applicable DDAP regulations.
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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 seven of seven client records reviewed. Client #1 was admitted on December 12, 2025 and was 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 disclosures. Client #2 was admitted on March 25, 2026 and was 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 disclosures.Client #3 was admitted on May 14, 2026 and was 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 disclosures.Client #4 was admitted on March 2, 2026 and was discharged on June 15, 2026. 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 disclosures.Client #5 was admitted on March 9, 2026 and was discharged on May 5, 2026. 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 disclosures.Client #6 was admitted on April 2, 2026 and was discharged on May 13, 2026. 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 disclosures.Client #7 was admitted on April 27, 2026 and was discharged on July 9, 2026. 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 disclosures.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the Clinic Director will review the records of all seven clients identified in the finding (Clients #1?#7) to ensure all required consent to release information forms are complete, signed, current, and maintained in the client record.
Any missing or incomplete documentation will be corrected. The facility will also review all active client records to identify and address any additional deficiencies. A separate release of information will be implemented for all clients receiving substance use disorder (SUD) services, with appropriate releases maintained for individuals, providers, funding sources, or other entities to whom information may be disclosed.
Individual supervision and clinical rounds will be used as a forum to train clinicians and review each of the clinically related deficiencies. Clinic Director will collaborate with the executive director and Senior Director of training and development to assist with this process. |
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 a disclosure was to be made to on release of information forms in one of seven client records reviewed.Client #5 was admitted on March 9, 2026 and was discharged on May 5, 2026. There was an informed and voluntary consent to release information form signed by the client; however, the release form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For Client #5, the client's record will be reviewed and the release of information documentation will be corrected to clearly indicate the name of the person, agency, or organization to whom the disclosure is authorized.
Effective immediately, all release of information forms will be reviewed by the Clinic Director, prior to use to ensure that the recipient's name is specifically identified and that all required elements of the release are complete.
Individual supervision and clinical rounds will be used as a forum to train clinicians and review each of the clinically related deficiencies. The Clinic Director will collaborate with the executive director and Senior Director of Training and Development to assist with this process. |
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 and the facility policy and procedure manual, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client, per facility policy, in five of seven client records reviewed. The facility's policy and procedure manual stated the individual treatment and rehabilitation plan will be completed within the first three sessions. Client #1 was admitted on December 12, 2025 and was active at the time of the inspection. The individual treatment plan was completed on September 22, 2026, which is considered late as there were more than three sessions conducted from the date of admission through the date of the treatment plan. Client #2 was admitted on March 25, 2026 and was active at the time of the inspection. The individual treatment plan was completed on September 18, 2026, which is considered late as there were more than three sessions conducted from the date of admission through the date of the treatment plan. Client #5 was admitted on March 9, 2026 and was discharged on May 5, 2026. There were more than three sessions conducted during the treatment episode; however, the individual treatment plan was not completed prior to discharge. Client #6 was admitted on April 2, 2026 and was discharged on May 13, 2026. There were more than three sessions conducted during the treatment episode; however, the individual treatment plan was not completed prior to discharge. Client #7 was admitted on April 27, 2026 and was discharged on July 9, 2026. There were more than three sessions conducted during the treatment episode; however, the individual treatment plan was not completed prior to discharge. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For the active clients (1 & 2), the treatment plans will be reviewed and updated as appropriate to ensure they accurately reflect the client's current treatment needs, goals, objectives, and interventions. The records of the discharged clients (5, 6 & 7) will be reviewed by the Clinical Director to ensure the treatment episode documentation is complete and that any appropriate corrective documentation is addressed in accordance with applicable requirements.
Effective immediately, the Clinical Director will implement a treatment plan tracking system to monitor completion of individual treatment and plans for all clients. The tracking system will identify the client's admission date and/or date of first session and the deadline for completion of the treatment plan within the first three sessions. The Clinical Director will monitor the tracker regularly to identify upcoming and overdue treatment plans.
Individual supervision and clinical rounds will be used as a forum to train clinicians and review each of the clinically related deficiencies. The Clinic Director will collaborate with the Executive Director and Senior Director of Training and Development to assist with this process. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure individual treatment and rehabilitation plans were reviewed and updated at least every sixty days in two of two applicable client records reviewed.Client #3 was admitted on May 14, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 25, 2026, and the first update was due to be completed no later than July 24, 2026; however, there was no treatment plan update completed prior to discharge.Client #4 was admitted on March 2, 2026 and discharged on June 15, 2026. The individual treatment and rehabilitation plan was completed on March 4, 2026, and the first update was due to be completed no later than May 1, 2026; however, there was no treatment plan update completed prior to discharge. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the Clinical Director will implement a treatment plan tracking system to monitor the due dates for all treatment plan reviews and updates. The tracking system will include the date the initial treatment plan was completed and the date the next 60-day update is due.
The Clinical Director will monitor the tracking system on an ongoing basis to ensure updates are completed within the required 60-day window. Clinical staff will be responsible for completing treatment plan reviews and updates within the required timeframe.
The Clinical Director will provide reminders to clinicians regarding upcoming due dates and will follow up on any treatment plan approaching or exceeding its 60-day deadline.
Individual supervision and clinical rounds will be used as a forum to train clinicians and review each of the clinically related deficiencies. The Clinic Director will collaborate with the Executive Director and Senior Director of Training and Development to assist with this process. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to maintain a complete client record, which is to include documentation of case consultation notes, in seven of seven client records reviewed.The facility's policy and procedures stated that case consultations will be completed within seven business days of admission and then every ninety days for the first year of treatment. Client #1 was admitted on December 12, 2025 and was active at the time of the inspection. The first case consultation was due to be completed no later than December 19, 2025; however, the case consultation was documented on September 8, 2026. Client #2 was admitted on March 25, 2026 and was active at the time of the inspection. The first case consultation was due to be completed no later than Wednesday April 1, 2026; however, the case consultation was documented on August 3rd, 2026. Client #3 was admitted on May 14, 2026 and was active at the time of the inspection. The first case consultation was due to be completed no later than May 21, 2026; however, the case consultation was documented on September 22, 2026. Client #4 was admitted on March 2, 2026 and discharged on June 15, 2026. The first case consultation was due to be completed no later than March 9, 2026; however, there were no case consultations documented prior to discharge. Client #5 was admitted on March 9, 2026 and was discharged on May 5, 2026. The first case consultation was due to be completed no later than March 16, 2026; however, there were no case consultations documented prior to discharge. Client #6 was admitted on April 2, 2026 and was discharged on May 13, 2026. The first case consultation was due to be completed no later than April 9, 2026; however, there were no case consultations documented prior to discharge. Client #7 was admitted on April 27, 2026 and was discharged on July 9, 2026. The first case consultation was due to be completed no later than May 4, 2026; however, there were no case consultations documented prior to discharge. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will review and take corrective action on case consultation documentation for each identified client.
As of 9/30/2026 a case consultation tracking system has been implemented for all clinical staff and identifies admission dates, the initial consultation due within seven business days of admission, and subsequent 90-day consultation due dates. Clinical staff are responsible for completing and documenting consultations within the required timeframe.
The Clinical Director will monitor the tracking system and follow up on upcoming or overdue consultations.
Clients #1?#3: Records will be reviewed, and ongoing 90-day consultations will be tracked.
Clients #4?#7: Clients were discharged prior to completion of the required consultations. Records will be reviewed and corrective action taken.
Individual supervision and clinical rounds will be used as a forum to train clinicians and review each of the clinically related deficiencies. The Clinic Director will collaborate with the Executive Director and Senior Director of Training and Development to assist with this process. |
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 documentation of follow-up information, in three of three applicable client records reviewed.Client #4 was admitted on March 2, 2026 and discharged on June 15, 2026. There was no follow-up information documented in the record at the time of the inspection. Client #5 was admitted on March 9, 2026 and discharged on May 5, 2026. There was no follow-up information documented in the record at the time of the inspection. Client #6 was admitted on April 2, 2026 and discharged May 13, 2026. There was no follow-up information documented 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
The Clinical Director will review the records for Clients #4, #5, and #6, discharged on June 15, May 5, and May 13, 2026, and address any missing follow-up documentation as appropriate.
Effective immediately, follow-up requirements will be manually verified at discharge and tracked through completion, independent of electronic system alerts.
The Clinical Director will explore other alternatives to the discharge and follow-up tracking process to ensure alerts and tasks are functioning appropriately following the previous system migration.
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