INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Casa de Consejeria y Salud Integral, 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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to ensure the completion of annual written individual staff performance evaluations, which shall be reviewed and signed by the employee, in two of six applicable personnel records reviewed.
Employee #4 was hired as a counselor on October 31, 2022. The individual performance evaluation was signed by the clinical supervisor on October 31, 2025, but the evaluation was not signed by the employee.
Employee #7 was hired as a counselor on February 17, 2025. The individual performance evaluation was signed by the clinical supervisor on February 17, 2026, but the evaluation was not signed by the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon notification of the deficiency, the Facility Director and Human Resources Department immediately reviewed the facility's personnel file procedures and performance evaluation process to ensure compliance with DDAP personnel record requirements.
The missing employee signatures will be obtained for the identified performance evaluations, as soon as possible and maintained in the employees' personnel records.
The Facility Director and Human Resources Department will conduct an in-service training with supervisory and administrative staff regarding proper completion and review of annual employee performance evaluations. The training will emphasize:
Timely completion of annual performance evaluations
Requirement that evaluations be reviewed with the employee
Employee and supervisor signatures and dates prior to filing
Proper personnel record documentation and maintenance
Procedures for tracking evaluation due dates and completion status
Additionally, all personnel records will be audited to verify that annual performance evaluations are fully completed and include all required signatures and documentation. Any identified deficiencies will be corrected immediately.
To prevent recurrence, the facility will implement an enhanced monitoring procedure through Human Resources and Quality Assurance. A performance evaluation tracking system and checklist will be utilized to ensure evaluations are completed timely and signed by both the supervisor and employee before placement into personnel records.
The Facility Director and Human Resources Department will continue to monitor personnel records on an ongoing basis to ensure continued compliance with DDAP staffing and personnel documentation requirements.
Responsible Persons:
Facility Director and Human Resources Representative
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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 document the name of the person, agency, or organization to whom the disclosure was to be made to on consent to release information forms in four of seven client records reviewed.
Client #2 was admitted on August 28, 2025 and was active at the time of inspection. There was a blank release of information form signed by the client on August 25, 2025; however, the form did not include documentation of the name of the person, agency, or organization to whom the disclosures would be made.
Client #3 was admitted on February 10, 2026 and was active at the time of inspection. A release of information form, signed and dated by the client on February 10, 2026, indicated the name of the person to whom disclosure would be made to as "Probation/Parole Department", which is not specific enough.
Client #6 was admitted on September 19, 2025 and was discharged on November 25, 2025. There was a blank release of information form signed by the client on September 19, 2025; however, the form did not include documentation of the name of the person, agency, or organization to whom the disclosures would be made.
Client #7 was admitted on September 19, 2025 and was discharged on December 5, 2025. There was a blank release of information form signed by the client on September 19, 2025; however, the form did not include documentation of the name of the person, agency, or organization to whom the disclosures would be made.
This is a repeat citation from the April 10, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will conduct a mandatory in-service training with all clinical and administrative staff regarding the proper completion of Releases of Information. The training will emphasize:
The requirement to clearly identify the specific person, agency, or organization to whom information is being disclosed
Proper completion of all ROI fields
Client and witness signatures and dates
Providing a copy of the signed consent to the client
Timeframes and expiration dates for releases
Procedures for updating or revising releases while clients remain active in treatment
Confidentiality standards related to substance use disorder treatment records under 42 CFR Part 2 and HIPAA
In addition, all active client charts will be audited to ensure that Releases of Information contain sufficiently specific identifying information and meet all regulatory requirements. Any deficient or incomplete ROIs will be corrected immediately, and updated consents will be obtained from active clients as necessary.
Clinical staff will also continue to participate in ongoing trainings related to confidentiality, documentation standards, and client record keeping to maintain compliance with DDAP regulations and applicable federal confidentiality laws.
Responsible Persons:
Facility Director and Quality Assurance Coordinator
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