INITIAL COMMENTS
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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:
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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 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.
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Plan of Correction
The facility acknowledges the finding regarding the absence of an annual, written individual training plan for Employee #1. At the time of the inspection, Employee #1 was the only staff member on board, serving as both the project director and facility director. Because onboarding activities were still in progress, the individual training plan had not yet been developed or documented in the personnel file.
The facility will develop the required written individual training plan with input from both the employee and the supervisor. Once completed, it will be placed in the personnel record. The facility is also implementing a tracking process to ensure that all employees, including future hires, have timely and compliant annual training plans on file.
The individual training plan will be completed by January 15, 2026, and placed in the personnel record upon completion
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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.
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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.
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Plan of Correction
The agency acknowledges that there was no documentation in the personnel file showing completion of fire extinguisher training upon hire. To correct this, when staff is on board, they will complete the fire extinguisher training and will document the information in the record. To that end, all new staff will fire extinguisher instruction during onboarding, and the Executive Director will verify and document completion to ensure continued compliance once staff is on board.
To correct this, Employee #1 will complete fire‑extinguisher training by January 15, 2026, and documentation of this training will be placed in the personnel record upon completion. |
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.
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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.
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Plan of Correction
The agency did a fire drill for the first year; however, it was not documented by the Admin as was requested. §705.28(d)(1).
The facility acknowledges that unannounced monthly fire drills were not documented for the period of August 2025 through February 2026 as required under §705.28(d)(1).
Although the fire drill was conducted, the agency acknowledges that the monthly fire drill was not documented. A Fire Safety Log Binder will be created to ensure all future fire drills are properly recorded, including dates, times, evacuation details, and any corrective actions monthly. Beginning October 2026, the agency will conduct monthly unannounced fire drills and will review the fire drill log as part of ongoing Quality Assurance. The agency will also meet in January or April to review the fire drill schedule and ensure continued compliance. At this time there are no other staff members, but as the agency grows, all newly hired staff will be trained on fire drill procedures and documentation requirements during onboarding. All corrective actions will be implemented October 2026.
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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.
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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.
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Plan of Correction
The employee that was with the agency was hired as a coordinator. At the time of the agency having staff on board, it was discussed with the staff, and crisis information was reviewed but was not documented. However, moving forward, the agency will ensure that there is documentation in the personnel file showing completion of training to perform assigned tasks during emergencies when staff is on board. The agency will ensure that staff will complete the required emergency response training and will provide proof of documentation. Moving forward, all new personnel will receive emergency response training during onboarding, and documents will be verified. |
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.
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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.
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Plan of Correction
The facility acknowledges the finding regarding the absence of written policies and procedures on client rights that include all required regulatory components. At the time of the inspection, the client rights policy and procedure did not fully reflect all mandated client rights. However, it is documented in the written policy.
The facility will revise and update the client rights policy and procedure to ensure all required regulatory elements are included. Once completed, the updated policy will be incorporated into the facility's policy and procedure manual and reviewed with all staff.
To prevent recurrence, the facility will implement an annual policy review process to ensure all policies, including client rights, remain current with regulatory requirements. |