INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 7, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clear Concepts Counseling 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Employee #3 was hired as a counselor on July 1, 1996 and was still in the position as of the date of the inspection. The facility's training year that was reviewed was from July 1, 2024 through June 30, 2025. Employee # 3's record only document 21 hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Our project will be in full compliance with this standard by 6/30/2026, which is the end of our current training year. By that date, all employees will have received twenty-five training hours as is required by our agency's standards.
This employee will seek out and attend training throughout the year which will address the areas set forth by the standard.
The Project Director will continually monitor all staff training hours to make sure all staff obtain the mandator 25 hours each fiscal year.
|
709.28 (c) (2) 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:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the specific information to be disclosed in one out of six applicable records reviewed.
Client #5 was admitted on September 19, 2025 and was still active at the time of the inspection. A release of information form was signed and dated October 6, 2025 to an agency did not include the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard will be reviewed during our agency staff meeting on May 21, 2026.
The proper completion of the required consent forms, including name of person/agency or organization, date, date, event, specific information disclosed and condition as well as the dated signature of a witness and the expiration date of the consent. To ensure correct completion of consent forms the Clinical Director will verify completion during monthly staff meetings.
The Project Director will also review individual counselor's client records on a weekly basis to ensure all required information is completed.
|
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.
|
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 #1 was admitted on June 6, 2025 and discharged on February 16, 2026. A comprehensive treatment plan was completed on July 25, 2025 and an update was due no later than September 25, 2025; however, none was completed.
Client #6 was admitted on July 11, 2024 and was still active at the time of the inspection. An updated treatment plan was completed on September 2, 2025 and an update was due no later than November 2, 2025; however, it was not completed until November 25, 2025.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the April 9, 2024 and April 8, 2025 licensing inspections.
|
Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard will be reviewed during our agency staff meeting on May 21, 2026.
Individual treatment plan updates will be completed at least every 60 days. To ensure completion of treatment plan updates at least every 60 days the Clinical Director will verify completion during monthly staff meetings. The Project Director will also review individual counselor's client records on a weekly basis.
|
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include aftercare information in one out of two applicable discharged records reviewed.
Client #3 was admitted on April 7, 2025 and was discharged on June 30, 2025. No aftercare plan was completed.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard will be reviewed during our agency staff meeting on May 21, 2026.
To ensure completion of aftercare care plans for all clients who have "successfully completed" treatment the Project Director will review this policy and procedure with all staff during the agency staff meeting on May 21, 2026.
The Project Director will review closed client charts to ensure aftercare plans are completed before they are filed in archive.
|
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in two out of two applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed 60 days following discharge.
Client #3 was admitted on April 7, 2025 and discharged on June 30, 2025. No follow up was completed.
Client #4 was admitted on July 21, 2025 and was discharged on February 24, 2026. No follow up was completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard will be reviewed with all counselors and support staff during our monthly staff meeting on May 23, 2026.
The proper completion of client documentation of follow-up information for all clients who have successfully completed treatment, Beginning immediately, the follow-up contact information and letter to be sent to the client after 60 days will be given to support staff who will keep information in binder and will send out letters or contact via phone at the end of 60 days.
To ensure correct completion and follow through of consent forms the Project Director will verify completion during weekly closed client record reviews.
|
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of staff training records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for treatment plan updates were submitted and approved by the Department for the April 9, 2024 and April 8, 2025 annual licensing inspections. Treatment plan updates was again found to be a deficiency in the April7, 2026 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The documentation of treatment plan updates specifically will be completed correctly and within the required timeframe of every 60 days.
This requirement will be reviewed with all staff members immediately as well as in a documented in-service training scheduled for May 21, 2026 (agency staff meeting).
This training will include a detailed review of the standard; all relevant Clear Concepts Counseling (CCC) policies; and the CCC treatment plan updates which specifies the required timeframes.
Any missing or incorrect documentation for any active client will be updated within 1 week and reviewed by the Project Director to ensure that it is accurate and comprehensive.
This will be completed no later than 5/21/26. The Project Director will begin completing bi-weekly reviews immediately to ensure that all clinical charts have completed all treatment plan updates. The Project Director will also complete ongoing monthly reviews utilizing our standard review tool which assesses for presence, timeliness and quality of each clinical chart documentation.
|