INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Keystone Drug and Alcohol 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(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 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 #4 was hired as a Counselor Assistant on October 1, 2025 and was active in that position at the time of the licensing process. Employee #4 has a high school diploma equivalent 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 clinical supervisor. Employee #4 ' s personnel record did not have documentation of direct observation occurring from October 1, 2025, through December 31, 2025, or close supervision from January 1, 2026, to the time of the licensing inspection.
Direct Observation is defined by regulation as follows: " In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring, and evaluating their activities."
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
Keystone Drug and Alcohol acknowledges that Employee #4's personnel record did not contain documentation sufficient to demonstrate compliance with the direct-observation and close-supervision requirements of 28 Pa. Code § 704.9(c)(5). The facility determined that the deficiency resulted from an inadequate documentation and monitoring system. Although supervisory staff were present and Employee #4 was not permitted to work independently, Keystone lacked a standardized direct-observation form, required chart cross-references, a supervision-tracking calendar, or a Facility Director audit process to verify that supervision was documented in accordance with regulatory requirements. Effective June 17, 2026, Keystone Drug and Alcohol voluntarily placed Employee #4 under a new 90-calendar-day corrective direct-observation period. This corrective period will remain in effect from June 17, 2026, through September 14, 2026. During this 90-day corrective period, Employee #4 may conduct counseling activities only when a trained counselor or clinical supervisor is physically present in the room and directly observing the activity. This requirement applies to individual, group, and family counseling; assessments; treatment planning; case consultations; and other clinical activities performed by Employee #4. Each direct observation will be documented. The record will include the date, start and end times, duration, type of clinical activity observed, client record or case reference, skills evaluated, feedback provided, corrective instruction when applicable, and the dated signatures of Employee #4 and the observing counselor or clinical supervisor. clinical note will identify the qualified staff member who was present and directly observing the activity. Employee #4 will also participate in a documented supervision meeting each week during the corrective period. The weekly supervision record will include a formal review of assigned cases, review of the direct-observation records completed during that week, identified strengths and training needs, corrective feedback, required follow-up actions, and the signatures and dates of Employee #4 and the supervisor |
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 that the counselor assistant documented to the facility director by the completion of each calendar year that they are working toward counselor status in one out of one applicable record reviewed.
Employee #4 was hired on October 1, 2025, as a counselor assistant and was still current in that position. Documentation of working toward counselor status was not documented by the end of the calendar year.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Keystone Drug and Alcohol acknowledges that Employee #4's personnel record did not contain documentation completed by the end of calendar year 2025 demonstrating that the employee was working toward meeting the qualifications for the position of counselor as required by 28 Pa. Code § 704.10(b).
Employee #4 was hired as a Counselor Assistant on October 1, 2025, and possesses a GED with no college degree. The facility determined that the deficiency resulted from the absence of a standardized process requiring counselor assistants and their supervisors to develop, document, and annually review a written plan for attaining counselor status.
The Counselor Status Professional Development Plan was implemented and signed by Employee #4, the Clinical Supervisor, and the Facility Director on July 23, 2026. The Facility Director and Clinical Supervisor will conduct the first documented progress review on September 22, 2026, and quarterly thereafter. Employee #4's annual written documentation demonstrating progress toward counselor status will be completed and placed in the personnel record no later than December 31 of each calendar year.
The professional development plan identifies the certification requirements, anticipated completion dates, qualifying counseling experience requirements, clinical supervision requirements, education and training requirements, examination requirements, and the responsibilities of Employee #4, the Clinical Supervisor, and the Facility Director.
Keystone will maintain a Counselor Certification Progress File for Employee #4. The file will include verification of the employee's GED, a current signed job description, qualifying work-experience documentation, clinical supervision records, training certificates, training-hour summaries, certification correspondence, application documents, and annual written progress reviews.
The Clinical Supervisor will review Employee #4's progress toward counselor status quarterly. The quarterly review will document qualifying employment hours, clinical-supervision hours, completed education and training hours, outstanding certification requirements, barriers to completion, and the actions required before the next review.
Employee #4 will submit written documentation to the Facility Director by December 31 of each calendar year demonstrating continued progress toward counselor status. This documentation may include the annual professional development review, training records, qualifying experience and supervision-hour summaries, correspondence with the certification board, certification application documents, or other evidence of progress.
The Facility Director implemented a Counselor Assistant Annual Compliance Calendar that identifies the required year-end documentation deadline for every counselor assistant. The Facility Director will audit all counselor-assistant personnel records each December to verify that the required documentation has been completed before the end of the calendar year.
The Facility Director is responsible for monitoring implementation of this Plan of Correction. The Clinical Supervisor is responsible for providing and documenting quarterly professional-development reviews and qualifying clinical supervision. Employee #4 is responsible for participating in identified training, supervision, experience, certification, and annual documentation activities.
Any counselor assistant who does not demonstrate continued progress toward meeting counselor qualifications will receive a revised professional development plan, additional supervision, and administrative corrective action as appropriate.
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of administrative documents, the facility failed to follow the staff development program policy for completion of a mechanism to collect feedback on completed trainings, within 30 minutes of the conclusion of the training in four out of four personnel records reviewed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Based on a review of administrative documents, the facility failed to follow the staff development program policy by not completing a mechanism to collect feedback on completed training within 30 minutes of the conclusion of the training in four out of four personnel records reviewed.
This finding was reviewed with the facility staff during the licensing process.
The facility determined that employees were informally discussing completed trainings; however, Keystone did not have a consistently implemented process to document the feedback, verify that it was completed within the required timeframe, and maintain the feedback with the employee's training records. The facility also determined that the existing 30-minute timeframe was not operationally practical and was not consistently monitored.
The facility determined that employees were informally discussing completed trainings; however, Keystone did not have a consistently implemented process to document the feedback, verify that it was completed within the required timeframe, and maintain the feedback with the employee's training records. The facility also determined that the existing 30-minute timeframe was not operationally practical and was not consistently monitored.
Effective 7/23/2026Keystone Drug and Alcohol revised the Training Feedback section of its Staff Development Program Policy. The revised policy requires documented feedback for every internal or external training used to meet an employee's annual training requirements.
Training feedback shall be completed at the conclusion of the training or no later than the end of the employee's next scheduled workday. Feedback may be collected through Keystone's Training Feedback Questionnaire, an individual evaluation provided by the training organization, an identifiable electronic evaluation, or a documented verbal discussion between the employee and supervisor
When feedback is obtained through a verbal discussion, the supervisor shall document the employee's name, training title, training date, date of the discussion, relevance of the training to the employee's position, knowledge or skills gained, additional training needs, and the names or signatures of the employee and supervisor. An undocumented verbal conversation will not satisfy the facility's training-feedback requirement.
A training will not be considered administratively complete until the facility has received both evidence of training completion and the corresponding feedback documentation.
For training completed through Bayside Learning, employees will complete Keystone's Training Feedback Questionnaire unless Bayside provides identifiable individual feedback for the employee and completed training.
Applicable staff were trained regarding the revised policy and feedback procedure on 7/28/2026. Employees were informed of the required timeframe and their responsibility to submit the training certificate and feedback documentation to the Facility Director or designee.
Applicable staff were trained regarding the revised policy and feedback procedure on [STAFF TRAINING DATE]. Employees were informed of the required timeframe and their responsibility to submit the training certificate and feedback documentation to the Facility Director or designee.
The Facility Director or designee will review 100% of completed staff training records monthly for twelve months. The review will verify that each completed training has corresponding evidence of completion, documented employee feedback, the date feedback was completed, and documentation that the feedback was completed within the timeframe established by facility policy.
Any missing or incomplete feedback documentation will be addressed immediately with the employee and supervisor. The employee will be required to complete the missing documentation using the actual date of completion. Documentation will not be backdated.
The results of the monthly review will be documented on Keystone's Staff Training Compliance Review and reviewed as part of the facility's quality-assurance process. The Facility Director is responsible for implementing and monitoring this Plan of Correction.
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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 the personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level, in one out of four personnel records reviewed.
Employee #1 was hired as the Project Director on September 1, 2024, and was current in that position during the licensing process. The personnel record did not contain a written individual training plan for the current training year.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Keystone Drug and Alcohol acknowledges that Employee #1's personnel record did not contain a written individual training plan for the current training year as required by 28 Pa. Code § 704.11(b)(1).
At the time of the licensing inspection, Employee #1 was identified in the personnel record as the Project Director. Employee #1 no longer serves as the Project Director. The Facility Director currently serves as Keystone Drug and Alcohol's Project Director.
Employee #1 remains the owner and Chief Executive Officer of Keystone Drug and Alcohol. If Employee #1 continues to perform client-facing, clinical, administrative, or other employee duties for the facility, an annual written individual training plan will be completed that is appropriate to her current responsibilities, skill level, education, experience, and identified training needs.
The facility determined that the deficiency resulted from a failure to consistently follow Keystone's existing Staff Development Program Policy. Keystone had an established policy requiring annual individual training plans; however, the facility did not have a centralized tracking and verification process to ensure that a current plan was completed and maintained for every applicable employee.
For newly hired employees, an initial individual training plan will be developed within the timeframe established in Keystone's Staff Development Program Policy. The plan will then be reviewed and updated annually according to Keystone's established training year.
The Facility/Project Director will review the Individual Training Plan Tracking Log monthly until all required plans are completed for the current training year. The Facility/Project Director will then conduct quarterly personnel-file audits for twelve months to verify continued compliance.
The audit will verify that each applicable employee has a current individual training plan, that the employee and supervisor participated in developing the plan, and that the plan is signed, dated, appropriate to the employee's current role and skill level, and maintained in the personnel record.
Any missing or incomplete individual training plan identified during monitoring will be corrected immediately and addressed with the employee responsible or supervisor. Audit findings will be documented and reviewed with the Clinical Supervisor and necessary staff members
The Facility/Project Director is responsible for implementing and monitoring this Plan of Correction.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director in one out of one applicable personnel record reviewed.
Employee #1 was hired as the project director on September 1, 2024, and was current in that position. Employee #1's employee record only documented 6 hours of annual training for the training year December 15, 2024 - December 14, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Keystone Drug and Alcohol acknowledges that Employee #1's personnel record documented only 6 of the 12 annual training hours required for the Project Director position during the December 15, 2024 through December 14, 2025 training year. Employee #1 no longer serves as Project Director. Facility Director and Project Director are now one employee. The facility's organizational chart, staffing report, job descriptions, and personnel records will be updated to reflect the current leadership structure. The Facility/Project Director will review the training tracker quarterly and again no later than 30 days before the end of the training year. The CEO or Clinical Supervisor will verify the Facility/Project Director's completed hours and supporting documentation annually. Any missing training or documentation identified during monitoring will be corrected before the end of the applicable training year. The Facility/Project Director is responsible for implementing this Plan of Correction. |
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 administrative documents, the facility failed to 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 in eleven out of eleven fire drill records reviewed.
The written fire drill logs dated July 2025 through May 2026 did not include documentation of the time each fire drill was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Keystone Drug and Alcohol acknowledges that the fire-drill records reviewed from July 2025 through May 2026 did not document the time of day each fire drill was conducted as required by 28 Pa. Code § 705.28(d)(4).
The facility determined that the deficiency resulted from the fire-drill form not clearly identifying a required field for the time the drill was initiated. The fire drills were conducted; however, the time of day was not documented.
Effective 7/22/2026, Keystone revised its Fire Drill Record to include all required information: date, time the drill began, evacuation time, exit route used, number of people present, problems encountered, and whether the fire alarm or smoke detector was operative.
The staff conducting the drill will complete and sign the Fire Drill Record immediately following each drill. The Facility/Project Director will review the completed record monthly to verify that all required fields are completed.
Any missing information will be addressed immediately with the responsible staff member. Keystone will not alter or backdate the previously completed fire-drill records.
The Facility/Project Director is responsible for implementing and monitoring this Plan of Correction.
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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 obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of seven records reviewed.
Client #5 was admitted on October 6, 2025, and was discharged on February 23, 2026. There was no documentation that the facility obtained an informed and voluntary consent from the client for the funding source. The facility confirmed that billing had occurred.
This is a repeat citation from the August 29, 2024 and June 13, 2025 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Keystone Drug and Alcohol acknowledges that Client #5's funding-source consent was not signed until approximately three months after admission. Although the consent was present in the client record, it was not valid at the time information was initially disclosed to the funding source and billing activity occurred.
The facility determined that the deficiency resulted from failure to verify completion of the funding-source consent before insurance verification, authorization, billing, or other disclosure to the payer. Keystone's prior corrective process relied on staff completion of the consent but did not include a secondary billing verification or administrative monitoring process.
Effective 6/22/2026, a valid funding-source consent must be signed and dated by the client and witness before Keystone verifies benefits, requests authorization, submits a claim, or discloses client information to a funding source.
The intake staff member will verify completion of the funding-source consent and document the verification on the intake checklist. The billing staff member will complete a second verification before creating or submitting the first claim. If the consent is missing, unsigned, incomplete, or expired, the account will be placed on administrative and billing hold until a valid consent is obtained.
The Facility/Project Director reviewed all active client records to verify that a valid funding-source consent was present for each payer receiving client information. Any missing or deficient consent was corrected using the actual date completed. No consent will be backdated.
The Facility/Project Director will audit 100% of newly admitted client records weekly for 90 days. The audit will verify that the funding-source consent was signed before the first eligibility check, authorization request, claim submission, or payer disclosure. Following the initial 90-day monitoring period, the Facility/Project Director will conduct a monthly audit for twelve months.
Any disclosure or billing activity identified without a valid consent will be immediately reviewed, documented, and addressed through corrective action. The Facility/Project Director is responsible for implementing and monitoring this Plan of Correction.
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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 obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency, or organization to whom disclosure was made in one out of seven records reviewed.
Client #5 was admitted on October 6, 2025, and was discharged on February 23, 2026. The record contained an informed and voluntary consent form that was signed by the client on October 6, 2025, for an " emergency contact " , that did not identify the name of the emergency contact.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Keystone Drug and Alcohol acknowledges that Client #5's consent identified the recipient only as "emergency contact" and did not include the specific name of the person to whom disclosure could be made as required by 28 Pa. Code § 709.28(c)(1).
The facility determined that the deficiency occurred because an incomplete consent was accepted during intake and there was no secondary review to verify that the specific person, agency, or organization was identified before the consent was placed into use.
Client #5 has been discharged. Keystone will not alter or backdate the original consent. An administrative review documenting the deficiency and corrective action will be maintained using the actual date of review.
Effective 6/22/2026, all consents must identify the full name of the specific person, agency, or organization authorized to receive information. General terms such as "emergency contact," "insurance," "probation," "court," or "family member" will not be accepted without the specific recipient's name.
The intake staff member will review each consent for completeness before it is signed and placed into use. Incomplete consent will be corrected with the client using the actual date before any information is disclosed.
The Facility/Project Director will complete a one-time review of all active client records to verify that each current consent identifies the specific person, agency, or organization. Any incomplete consent will be replaced before additional information is disclosed.
The Facility/Project Director will review 100% of new admission consent forms weekly for 90 days and monthly thereafter for twelve months. Any incomplete consent will be corrected immediately, and the staff member responsible will receive additional instruction.
The Facility/Project Director is responsible for implementing and monitoring this Plan of Correction.
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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 records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one out of seven records reviewed.
Client #2 was admitted on April 28, 2026, and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to a legal entity signed by the client on April 28, 2026, that had no purpose identified.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Keystone Drug and Alcohol acknowledges that Client #2's consent to release information to a legal entity did not identify the purpose of the disclosure as required by 28 Pa. Code § 709.28(c)(3).
The facility determined that the deficiency occurred because an incomplete consent was accepted during intake without verification that all required fields were completed.
Effective 7/24/2026, Client #2 completed a new informed and voluntary consent identifying the specific purpose of the disclosure. The original consent was not altered or backdated. No additional information will be disclosed with an incomplete consent.
All consent forms must identify the specific purpose for releasing information. General or blank entries will not be accepted. Examples may include coordination of care, verification of treatment attendance, submission of progress reports, legal compliance, or payment and authorization, as applicable to the recipient and authorized disclosure.
The staff member completing the consent with the client will review all required fields before the consent is signed. The Facility/Project Director will complete a one-time review of all active client consent forms and will review 100% of new admission consents weekly for 90 days.
Any incomplete consent identified during review will be replaced using the actual date before additional information is disclosed. The Facility/Project Director is responsible for implementing and monitoring this Plan of Correction
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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 an individual treatment plan within three sessions or 14 days of admission, per facility policy, in four out of seven records reviewed.
Client #1 was admitted on August 13, 2025, and was still active at the time of the inspection. A treatment plan was due no later than August 27, 2025; however, it was not completed until September 30, 2025.
Client #2 was admitted on April 28, 2026, and was still active at the time of the inspection. A treatment plan was due no later than May 12, 2026; however, it was not completed until June 10, 2026.
Client #3 was admitted on January 2, 2026, and was still active at the time of the inspection. A treatment plan was due no later than January 16, 2026; however, it was not completed until February 15, 2026.
Client #5 was admitted on October 6, 2025, and was discharged on February 23, 2026. A treatment plan was due no later than October 20, 2025; however, it was not completed until January 28, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Keystone Drug and Alcohol acknowledges that four of seven client records did not contain an individual treatment and rehabilitation plan within three sessions or 14 days of admission as required by the facility's policy in effect at the time of the inspection.
The facility determined that the deficiency resulted from inconsistent monitoring of treatment-plan due dates and the absence of a reliable secondary review process.
Effective 7/24/2026, Keystone revised its Treatment and Rehabilitation Services Policy to require that the master treatment plan be developed with the client and completed within 30 calendar days of admission. This revised timeframe applies prospectively and does not alter the due dates that were applicable to the records cited by the Department.
The counselor will initiate treatment planning during the admission process and complete the master treatment plan with the client no later than the 30th calendar day following admission. Treatment plans will continue to be reviewed and updated at least every 60 days.
The Facility/Project Director or Clinical Supervisor will maintain a treatment-plan due-date tracker and review upcoming and overdue plans weekly. Counselors will receive notification before each plan is due. Any plan approaching its due date will be addressed during supervision.
The Facility/Project Director is in the midst of reviewing all active client records to verify that each client has a current treatment plan. Missing or overdue plans will be completed with the client and primary counselor using the actual completion date and will not be backdated. All treatment plans will be in compliance no later than 8/4/2026
The Facility/Project Director or Clinical Supervisor will review 100% of new admissions weekly for 90 days to verify that treatment plans are completed within 30 calendar days. Following the initial 90-day period, treatment-plan compliance will be reviewed monthly for twelve months.
Any late treatment plan identified during monitoring will be corrected immediately and addressed with the responsible counselor. The Facility/Project Director is responsible for implementing and monitoring this Plan of Correction.
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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 ensure that an individual treatment and rehabilitation plan was developed with the client and included written documentation of the type and frequency of treatment and rehabilitation services in seven out of seven records reviewed.
Client #1 was admitted on August 13, 2025, and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 30, 2025, that did not include the type and frequency of treatment and rehabilitation services.
Client #2 was admitted on April 28, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 10, 2026, that did not include the type and frequency of treatment and rehabilitation services.
Client #3 was admitted on January 2, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was developed on February 15, 2026, that did not include the type and frequency of treatment and rehabilitation services.
Client #4 was admitted on August 25, 2025, and discharged on March 4, 2026. A comprehensive treatment plan was developed on September 8, 2025, that did not include the type and frequency of treatment and rehabilitation services.
Client #5 was admitted on October 6, 2025, and discharged on February 23, 2026. A comprehensive treatment plan was developed on January 28, 2026, that did not include the type and frequency of treatment and rehabilitation services.
Client #6 was admitted on January 6, 2026, and was discharged on March 23, 2026. A comprehensive treatment plan was developed on January 20, 2026, that did not include the type and frequency of treatment and rehabilitation services.
Client #7 was admitted on March 26, 2026, and discharged on May 4, 2026. A comprehensive treatment plan was developed on April 8, 2026, that did not include the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Keystone Drug and Alcohol acknowledges that seven out of seven treatment plans reviewed did not document the type and frequency of treatment and rehabilitation services as required by 28 Pa. Code § 709.92(a)(2).
The facility determined that the Master Treatment Plan template did not clearly require counselors to identify each service and its specific frequency. As a result, plans contained treatment goals and interventions but did not consistently state how often each service would be provided.
Effective 7/24/2026, Keystone revised its Treatment and Rehabilitation Services Policy and Master Treatment Plan process to require written documentation of the individualized type and frequency of each treatment and rehabilitation service.
Examples include individual counseling once weekly, group counseling three times weekly, family counseling monthly, medication-management appointments monthly or as clinically indicated, and case-management or recovery-support services as identified in the client's plan. The services and frequencies will be individualized according to each client's assessed needs and level of care.
The Facility/Project Director or Clinical Supervisor are in the midst of reviewing all active client treatment plans. Any active plan missing the type or frequency of services will be updated with the client using the actual date of completion. The review on all active clients is to be completed by 8/4/2026. Previously completed records will not be altered or backdated.
Applicable clinical staff were instructed in all staff meeting held on 7/23/2026 that general language such as "outpatient treatment," "IOP services," or "counseling as needed" does not adequately document type and frequency.
The Facility/Project Director or Clinical Supervisor will review 100% of newly completed and updated treatment plans weekly for 90 days. Plans missing the type or frequency of services will be returned to the counselor for immediate correction. Following the initial 90-day period, treatment plans will be reviewed monthly for twelve months.
The Facility/Project Director is responsible for implementing and monitoring this Plan of Correction.
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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 the review of client records, the facility failed to document case consultations on a quarterly basis or sooner, per the facility's policy, in two out five applicable records reviewed.
Client #1 was admitted on August 13, 2025, and was still active at the time of the inspection. A case consultation was completed on November 13, 2025, and the next update was due no later than February 11, 2026; however, it was not completed until March 11, 2026.
Client #4 was admitted on August 25, 2025, and was discharged on March 4, 2026. A case consultation was completed on November 25, 2025, and the next update was due no later than February 25, 2026; however, there was no documentation in the record that it was completed.
This is a repeat citation from August 29, 2024, and June 13, 2025, licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Keystone Drug and Alcohol acknowledges that case consultations were not documented every 90 days or sooner, as required by the facility's policy, in two of five applicable client records reviewed.
The facility determined that the deficiency resulted from inconsistent tracking of case-consultation due dates and the absence of a secondary supervisory review to identify approaching or overdue case consultations.
Effective 7/20/2026, the Facility/Project Director and Clinical Supervisor started reviewing all active client records to identify the date of the most recent case consultation and calculate the next required due date. Any overdue case consultation for an active client will be completed using the actual completion date and will not be backdated.
Facility/Project Director and Clinical Supervisor are creating a Case Consultation Due-Date Tracker identifying each active client, assigned counselor, date of the most recent case consultation, and next due date to be completed by 8/4/2026. Case consultations will be completed and documented in EMR every 90 days or sooner, in accordance with the facility's existing policy.
Counselors are responsible for reviewing their case-consultation due dates weekly and completing each consultation before the due date. The Clinical Supervisor will review the tracker during weekly clinical supervision and notify the responsible counselor of consultations due within the next 30 days.
The Facility/Project Director will review the tracker weekly for 90 days to verify that all case consultations are completed on time. Following the initial 90-day period, the tracker will be reviewed monthly for twelve months.
Any missed or overdue case consultation will be completed immediately using the actual date and addressed with the counselor responsible through supervision and corrective instruction. The Facility/Project Director and Clinical Supervisor are responsible for implementing and monitoring this Plan of Correction.
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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 included follow-up information within one month of discharge, per facility policy, in two out of four applicable records reviewed.
Client #6 was admitted on January 6, 2026, and discharged on February 17, 2026. A follow up contact was due no later than March 19, 2026; however, it was not documented until April 23, 2026.
Client #7 was admitted on March 26, 2026, and discharged on May 4, 2026. A follow-up contact was due no later than June 5, 2026; however, it was not documented until June 15, 2026.
This is a repeat citation from the June 13, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Keystone Drug and Alcohol acknowledges that follow-up information was not documented within one month of discharge, as required by facility policy, in two of four applicable client records reviewed.
The facility determined that the deficiency resulted from inconsistent tracking of follow-up due dates after discharge and the absence of a secondary review process to identify approaching or overdue follow-up contacts.
Effective 7/20/2026, Keystone implemented a Discharge Follow-Up Tracking Log. At the time of discharge, the Clinical Supervisor will enter the client's discharge date, assigned staff member, and follow-up due date. The Clinical Supervisor will review the list of clients that need to be contacted for their Discharge Follow-Up weekly with clinical staff in the supervisor role and then conduct chart audits weekly to ensure the client has been contacted and documentation is in each chart.
Follow-up contact will be attempted and documented within one month of discharge. When the client cannot be reached, all attempts to contact will be documented, including the date, method of contact, and outcome. Documentation will not be backdated.
The Facility/Project Director will review the tracker weekly for 90 days to verify that all follow-up contacts are completed or attempted within the required timeframe. Following the 90-day period, the tracker will be reviewed monthly for twelve months.
Any overdue follow-up identified during monitoring will be completed or attempted immediately using the actual date and addressed with the staff member responsible. The Facility/Project Director is responsible for implementing and monitoring this Plan of Correction.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting case consults was submitted and approved by the Department for the August 29, 2024, and June 13, 2025, annual licensing inspections. Completing and documenting case consults was again found to be a deficiency in the June 16, 2026, licensing inspection.
A plan of correction for obtaining an informed and voluntary consent from the client for the disclosure of information in the client record was submitted and approved by the Department for the August 29, 2024, and June 13, 2025, annual licensing inspections. Obtaining an informed and voluntary consent from the client for the disclosure of information in the client record was again found to be a deficiency in the June 16, 2026, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Keystone Drug and Alcohol acknowledges that the facility did not sustain compliance with previously approved Plans of Correction
The facility determined that prior corrective actions relied primarily on staff training and individual staff responsibility but did not include a centralized tracking system, consistent administrative verification, or documented follow-up to ensure continued compliance.
Effective 7/24/2026, Keystone implemented a Master Plan of Correction Tracking Log that identifies each citation, required corrective action, responsible staff member, implementation date, monitoring frequency, supporting documentation, identified deficiencies, and the date corrective action was verified.
The Facility/Project Director will review the Master Plan of Correction Tracking Log weekly. Compliance with all plan-of-correction requirements will be a standing item during the facility's clinical and administrative review process.
The Clinical Supervisor will review plan of correction due dates weekly to ensure that the facility is maintaining plan of correction guidelines and facility policy. The Facility/Project Director will verify completion through monthly client-record audits.
The Facility/Project Director will review all active client charts to ensure all plans of correction are followed. For 90 days, our intake and billing staff will verify that all plan-of-correction requirements are completed and will inform the clinical supervisor of any information that may require correction.
After the initial 90-day period, the Facility/Project Director will conduct monthly compliance audits for twelve months.
Any missing, incomplete, or overdue documentation will be addressed immediately. Documentation will be completed using the actual date and will not be backdated. The staff member responsible will receive corrective instruction, and repeated noncompliance will result in increased supervision or additional administrative action.
Audit findings and corrective actions will be documented and maintained with Keystone's Plan of Correction records. The Facility/Project Director is responsible for implementing, monitoring, and verifying continued compliance with all approved Plans of Correction.
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