INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 13, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Ascend Counseling Services Inc. 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure an annual, written individual training plan was developed for each employee, with input from both the employee and the supervisor, in one of one personnel records reviewed.
Employee # 1 was hired as the project director and facility director on July 1, 2025. There was no individual training plan documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of fire extinguishers upon staff employment in one of one applicable personnel records reviewed.
Employee # 1 was hired as the project director and facility director on July 1, 2025. There was no documentation, in the personnel record, indicating the employee received training in the use of fire extinguishers upon hire as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the August 2025 through February 2026 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, there was no documentation provided indicating any fire drills were conducted during the reviewed period.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies in one of one applicable personnel records reviewed.
Employee # 1 was hired as the project director and facility director on July 1, 2025. There was no documentation, in the personnel record, indicating the employee received training to perform assigned tasks during emergencies as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
Based on a review of the facility policy and procedure manual, the facility failed to develop written policies and procedures on client rights, which included all the required components.
At the time of the inspection, the client rights policy and procedure did not include all the required regulatory client rights.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
An approved Plan of Correction is not on file. |