D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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IMPACT COUNSELING SERVICE LLC
413 NORTH MONTGOMERY STREET
HOLLIDAYSBURG, PA 16648

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Survey conducted on 10/01/2025

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on October 1, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Impact Counseling Services LLC 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
709.28 (c) (4) 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: (4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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 contained the dated signature of client in one out of seven records reviewed. Client #3 was admitted on April 9, 2025 and was current at the time of the licensing inspection. Client #3 had informed and voluntary consent to disclose information forms signed by the client for a treatment provider and a healthcare agency that did not have the date of the signature documented. This finding was reviewed with facility staff during the licensing process.	Plan of Correction All staff will be trained on the appropriate way to correctly complete consents in order to ensure confidentiality. The facility and project directors will train the staff and monitor compliance through chart reviews.
709.34 (c) (2) LICENSURE Reporting of unusual incidents § 709.34. Reporting of unusual incidents. (c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving: (2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
Observations Based on a review of client records and unusual incident reports, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving a death or serious injury due to trauma, suicide, medication error or unusual circumstances.Client #6 was admitted on April 24, 2024 and discharged on June 11, 2025 following another client reporting that the client was decreased. The facility contacted the client ' s referring agency and it was confirmed the client had passed away. There was no documentation that the Department was made aware of the death. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The Facility Director and/or the Project Director will train staff on filing a written unusual incident report with the department within 3 business days following a serious injury/trauma/suicide, medication error or an unusual circumstance with a client. This will be monitored on an ongoing basis by Directors.
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.
Observations Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in four out of seven records reviewed. Client #1 was admitted on November 5, 2024 and was still current at the time of the licensing inspection. Client #1 ' s treatment plans dated November 22, 2024, January 22, 2025, March 22, 2025, May 22, 2025, July 22, 2025, and September 22, 2025, all indicated individual counseling sessions biweekly. There was no documentation in the record of individual counseling for the weeks of December 15 -21, 2024, December 29, 2024 -January 4, 2025, January 26, 2025 - February 1, 2025, March 9-15, 2025, April 6-12, 2025, May 4-10, 2025, July 13-19, 2025, August 10-15, 2025, September 7-13, 2025, and September 21-27, 2025.Client #2 was admitted on May 24, 2024 and was still current at the time of the licensing inspection. Client #2 ' s treatment plans dated August 12, 2024, and October 12, 2024, identified individual counseling sessions twice a month. For the months of August and September 2024 there was only one individual counseling session documented. Client #4 was admitted on March 10, 2023 and was still current at the time of the licensing inspection. Client #4 ' s treatment plan dated August 3, 2024, indicated individual counseling sessions weekly. There was no individual counseling session documented for the weeks of September 1-7, 2024, and September 8, 2024. The treatment plans dated October 3, 2024, December 3, 2024, February 3, 2025, April 3, 2025, June 3, 2025, indicated individual counseling sessions biweekly. There were no individual counseling sessions for the weeks of November 17-23, 2025, December 29, 2024 - January 4, 2025, March 2-8, 2025, March 30, 2025 - April 5, 2025, May 4-10, 2025, June 22, 2028, August 10-16, 2025, and September 21-27, 2025.Client #7 was admitted on September 27, 2024 and discharged on November 17, 2024. Client #7 ' s individual treatment plan dated September 27, 2025, indicated individual counseling sessions biweekly. There was no documentation of individual counseling sessions documented during the weeks of October 6-12, 2024, October 20-26, 2024, and November 3-9, 2024.These findings were reviewed with facility staff during the licensing process.	Plan of Correction The Project Director and/or the Facility Director will train staff on documenting the appropriate amount of therapy sessions a client will need to participate in and how to note this on their individual treatment plans. Staff will also be trained on the importance of documenting missed sessions and the reason for missed sessions. This will be monitored on an ongoing basis during chart reviews.