INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection. The physical plant inspection was conducted on February 12, 2026, and the client record review was conducted February 19, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the annual inspection, Pennsylvania Counseling Services 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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709.92(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 document treatment plan updates within the regulatory timeframe in two out of five applicable records reviewed.Client #6 was admitted on June 6, 2025 and was discharged on October 14, 2025. A treatment plan was completed on June 20, 2025, and the next update was due no later than August 19, 2025; however, it was not completed until September 3, 2025. Client #7 was admitted on June 5, 2025 and discharged on October 3, 2025. A treatment plan was completed on June 13, 2025, and the next update was due no later than August 12, 2025; however, it was not completed until September 4, 2025. This is a repeat citation from the January 14, 2025 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will ensure that all staff receive re-education regarding the requirement that treatment plan updates must be completed within regulatory timeframes (every 60 days). Local office administration will maintain a tracking system to monitor and ensure treatment plan updates are submitted within the required 60-day period. The Quality Improvement Department will conduct random chart reviews to verify that staff are adhering to regulatory requirements and that the internal tracking system is effectively maintaining compliance. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of seven records reviewed.Client #2 was admitted on November 4, 2025 and was still active at the time of the inspection. The treatment plans dated November 13, 2025, and December 16, 2025, indicated one individual session and one group session a week. There was no documentation that the client received individual session in the week of December 28, 2025. Client #7 was admitted on June 5, 2025 and discharged on October 3, 2025. The treatment plan dated June 13, 2025, indicated one individual session a month and one group session a week. There was no documentation that the client received individual counseling session in the month of August 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will ensure that all staff receive re-education emphasizing that each client must receive counseling services in accordance with their individualized treatment plan. Programming staff have added a designated field within the client's electronic health record to clearly display the recommended frequency of services. Staff will be reminded to consistently utilize this feature as a reference to support compliance. The Quality Improvement Department will conduct random chart reviews to verify adherence to regulatory requirements and to ensure documentation accurately reflects any changes to the type or frequency of services provided. |