INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 14, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Fayette County Drug and Alcohol Commission, 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records, the facility failed to give a counselor assistant a written semiannual performance evaluation in one of one applicable record.
Staff #6 was hired as a counselor assistant on January 6, 2025, and was still employed at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
In order for FCDAC to be in compliance with 704.9(b), the Facility Director and Lead Counselor conducted a performance evaluation with the counselor assistant on August 22, 2025. To ensure that FCDAC is in compliance with conducting written semiannual and annual performance evaluations they will be completed at least one week prior to the anniversary date. The evaluations will be completed by the Facility Director, Lead Counselor or Treatment Supervisor once that position is filled. To ensure that ongoing compliance is met, the Facility Director and Administrative Assistant will conduct random audits of the personal charts. |
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 a review of personnel records, the facility failed to include an annual written individual staff performance evaluation in two of five applicable records.
Facility policy and procedure states performance evaluations are to be conducted annually.
Staff #3 was hired as a counselor on April 5, 2021, and was still employed at the time of the inspection. The last evaluation was completed May 2, 2024.
Staff #5 was hired as a counselor on July 15, 2024, and was still employed at the time of the inspection. There was no annual performance review in staff #5 ' s record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In order for FCDAC to be in compliance with 709.26(b)(3) annual written performance plans. The Facility Director conducted the annual performance evaluation with staff #5 on 8/22/25. On 8/27/25 the Facility Director and Lead Counselor conducted the annual performance evaluation with staff #3. To ensure ongoing compliance, annual performance evaluations they will be completed at least one week prior to the anniversary date. The evaluations will be completed by the Facility Director, Lead Counselor or Treatment Supervisor once that position is filled. To ensure that ongoing compliance is met, the Facility Director and Administrative Assistant will conduct random audits of the personal charts.
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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 every 60 days in four of seven records.
Client #1 was admitted on December 9, 2024, and discharged on May 15, 2025. A treatment plan update was completed on February 14, 2025, and the next update was due no later than April 14, 2025; however, there were no further updates in client #1 ' s record.
Client #3 was admitted on November 21, 2024, and discharged on March 25, 2025. A treatment plan was developed on December 23, 2024, and an update was due no later than February 23, 2025; however, there were no further updates in client #3 ' s record.
Client #6 was admitted on April 30,2025 and was still active at the time of the inspection. A treatment plan was developed on May 14, 2025, and an update was due no later than July 14, 2025; however, it was completed July 18, 2025.
Client #7 was admitted on April 14,2025 and was still active at the time of the inspection. A treatment plan was developed on April 28, 2025, and an update was due no later than June 28, 2025; however, it was completed July 21, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In order for FCDAC to be in compliance with DDAP regulation 709.92(b). On August 25,2025, the Facility Director changed FCDAC's policy regarding Comprehensive Treatment Plan Update. The new policy went into effect as of the above-mentioned date. The policy states that the primary therapist will complete a written update at least once every 60 days, beginning from the date of the Comprehensive Treatment plan. The new policy no longer requires obtaining the client's signature. The written update will be entered into the client's chart. To ensure compliance, the Lead Counselor and or Treatment Supervisor (once position is filled) will conduct monthly quality assurance checks on active charts. |
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.
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Observations
Based on a review of client records, the facility failed to document follow-up information in four of four applicable records.
The facility's policy and procedures state follow-up contact is to be completed for all discharges within one month.
Client #1 was admitted on December 9, 2024, and discharged on May 15, 2025. The follow-up was due no later than June 15, 2025; however, it was completed June 26, 2025.
Client #2 was admitted on January 14, 2025, and discharged on May 16, 2025. The follow-up was due no later than June 16, 2025; however, it was completed June 26, 2025.
Client #3 was admitted on November 21, 2024, and discharged on March 25, 2025. There was no follow-up in client #3 ' s record.
Client #4 was admitted on December 4, 2024, and discharged on April 4, 2025. The follow-up was due no later than May 4, 2025; however, it was completed May 13, 2025.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the June 26, 2024, licensing inspection.
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Plan of Correction
On August 19,2025, the Facility Director, Administrative Assistant and Lead Counselor met to discuss the process of documentation of the 30 day follow up letters that are sent to clients that are successfully discharged from FCDAC. To ensure that FCDAC is in compliance with 709.93(a)(11) Licensure Client records, FCDAC has changed the procedure of how discharge letters are generated and mailed out. As of the above date, follow-up letters will be completed and dated by the counselor at discharge through our EHR system. The letters will be printed off and placed into sealed envelopes and placed in a secure location at the front desk. There will now be two identified clerical staff responsible for ensuring that the letters will be mailed out based on the discharge dates. If the follow up date occurs over a weekend, then the identified staff member will send the letters prior to the weekend date. Both the Facility Director and Administrative Assistant will ensure that compliance with this process is occurring through monthly quality assurance checks. |