INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 17, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Western PA Counseling Services LLC dba Forge Health 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on review of personnel records, the facility failed to have a written individual training plan for each employee, appropriate to that employee's skill level, developed annually with input from both the employee and the supervisor by March of the training year, per the facilities policy, in two of three applicable records reviewed.
Employee # 3 was hired as a counselor on September 11, 2023 and was current in that position at time of licensing inspection. Employee #3 did not have an individual training plan until August 2025.
Employee # 4 was hired as a counselor on June 24, 2024 and was current in that position at time of licensing inspection. Employee #3 did not have an individual training plan until August 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
All current employees will have their individual training plans updated with direct input from their supervisors. An annual deadline of March 15 has been established to ensure timely completion, and this requirement has been incorporated into the Human Resources compliance checklist. The Clinical Director and HR Manager are responsible for overseeing the implementation of this corrective action. Compliance will be monitored through quarterly personnel file audits, with corrective supervision applied in cases where deadlines are missed. The full implementation of this action is to be completed by October 31, 2025. |
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 review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee in two of three applicable records reviewed.
Employee # 3 was hired as a counselor on September 11, 2023 and was current in that position at time of licensing inspection. The annual staff performance evaluation documented in the record did not contain the employee signature.
Employee # 4 was hired as a counselor on June 24, 2024 and was current in that position at time of licensing inspection. The annual staff performance evaluation documented in the record did not contain the employee signature.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A new employee evaluation form has been implemented, requiring signatures from both the supervisor and the employee to confirm review and acknowledgment. The Human Resources department will be responsible for tracking evaluation due dates and verifying that all forms are completed on time. Oversight of this process will be shared between the Clinical Director and the HR Manager. To ensure compliance, evaluations will be reviewed through a semi-annual audit. This corrective action is scheduled for full implementation by October 31, 2025. |
709.28 (c) 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.
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Observations
Based on a review of outpatient records, the facility failed to obtain informed and voluntary consent from the client for the disclosure of information contained in the client record in seven out of seven records reviewed.
Client #1 was admitted to the outpatient program on September 16, 2024 and was discharged February 19, 2025. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
Client #2 was admitted to the outpatient program on February 18, 2025 and was discharged April 11, 2025. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
Client #3 was admitted to the outpatient program on October 14, 2024 and was discharged February 28, 2025. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
Client #4 was admitted to the outpatient program on November 15, 2024 and was discharged February 18, 2025. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
Client #5 was admitted to the outpatient program on July 14, 2025 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
Client #6 was admitted to the outpatient program on June 13, 2025 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
Client #7 was admitted to the outpatient program on April 3, 2025 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Consent forms have been revised to include clear identification of each client's funding source or insurance provider. This revision was implemented on September 9, 2025. The updated form ensures that informed and voluntary consent is obtained from the client for the disclosure of information contained in their record specific to their individual insurance provider.
Beginning on the date of implementation, all benefit verifications have been completed utilizing the revised form. All staff have been retrained on the updated documentation requirements to ensure consistent and complete compliance with disclosure regulations. Supervisors will conduct weekly reviews of new admissions to confirm proper completion of the consent forms.
Ongoing oversight will be provided by the Clinical Director and Compliance Officer. Monitoring will occur through monthly random chart audits for the first six months following implementation, transitioning to quarterly audits thereafter. Replacement of all outdated consent forms in existing client records with the revised consent form will be completed by November 6, 2025.
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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 outpatient 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 was in writing and included the name of the person, agency or organization to whom disclosure is made in one out of seven client records reviewed.
Client #4 was admitted to the outpatient program on November 15, 2024 and was discharged February 18, 2025. There was an informed and voluntary consent to release information form signed by the client on October 10, 2024, that did not include the name of the person, agency or organization to whom disclosure was to be made to.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake staff have been directed to remove and replace any incomplete consent forms at the time of admission to ensure accuracy and compliance. The Office Manager and Clinical Director are responsible for overseeing this process. Supervisors will review all new consent forms during the admission phase to confirm completeness and proper documentation. This corrective action will be fully implemented by October 15, 2025. |
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).
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Observations
Based on a review of outpatient 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 included a dated signature of the client in one out of seven records reviewed.
Client #1 was admitted into the outpatient program on September 16, 2024 and was discharged February 19, 2025. There was an informed and voluntary consent form in the record for an outside provider that did not include the client signature. There was documentation that information was disclosed to the outside provider on January 1, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from September 12, 2024 licensing inspection.
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Plan of Correction
Office Management and Administrative staff will verify that all required documents are properly signed following each client's initial session. Any missing or incomplete documentation will be addressed during the weekly mandatory clinical rounds meeting. Oversight of this process will be shared by the Clinical Director and Office Manager. To ensure sustained compliance, monthly chart audits focusing on release forms will be conducted for six months. Full implementation of this corrective action is scheduled for completion by October 15, 2025. |
709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection on September 17, 2025, the facility failed to display the hours of project operation conspicuously to the general public.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Hours of operation signage has been posted at the facility entrance to ensure visibility and accessibility for clients and visitors. The Facility Manager is responsible for maintaining this requirement and verifying the signage during monthly safety rounds. Compliance will be monitored through ongoing monthly plant inspections. Full implementation of this corrective action is to be completed by October 15, 2025. |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection on September 17, 2025, the facility failed to display a telephone number conspicuously to the general public for emergency purposes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Emergency contact signage has been installed at the facility entrance to ensure that critical contact information is clearly visible to staff, clients, and visitors. The Facility Manager is responsible for maintaining and verifying the signage during monthly safety rounds. Ongoing monthly plant inspections will be used to monitor compliance and ensure the signage remains accurate and accessible. Full implementation of this corrective action will be completed by October 15, 2025. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of outpatient client records, the facility failed to follow their written procedures to complete progress notes within 24 hours of counseling sessions in three out of seven client records reviewed.
Client #1 was admitted to the outpatient program on September 16, 2024 and was discharged February 19, 2025. The record identified individual sessions occurring on September 18, 2024, October 10, 2024, October 31, 2024, and November 7, 2024, that were not documented until September 25, 2024, October 16, 2024, and November 11, 2024, respectively.
Client #4 was admitted to the outpatient program on November 15, 2024 and was discharged February 18, 2025. The record identified individual sessions occurring on November 19, 2024, and December 13, 2024, that were not documented until November 24, 2024, and December 31, 2024, respectively.
Client #5 was admitted to the outpatient program on July 14, 2025 and was still active at the time of the inspection. The record identified individual sessions occurring on July 21, 2025, August 4, 2025, August 11, 2025, and September 8, 2025, that were not documented until July 29, 2025, August 8, 2028, August 15, 2025, and September 12, 2025, respectively.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The documentation policy has been revised to allow a 48-hour timeframe for completion of progress notes. All clinicians have been retrained on the updated standard to ensure consistent compliance. Supervisors will review the timeliness of documentation during weekly supervision sessions. The Clinical Director will oversee implementation, with monitoring conducted through monthly random chart audits. Full implementation of this corrective action is expected by October 31, 2025. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of outpatient client records, the project failed to document a complete client record on an individual that included case consultation notes within the first seven days, per the facilities policy, in seven of seven records reviewed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from September 12, 2024 licensing inspection.
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Plan of Correction
Case consultation tracking sheets have been implemented to ensure consistent documentation and oversight of clinical discussions. Supervisors will review and monitor these tracking sheets during weekly clinical rounds meetings to verify completion and accuracy. Oversight of this process will be managed by the Clinical Director and Supervisors. Compliance will be monitored through monthly audits of consultation logs, with full implementation to be achieved by October 31, 2025. |
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 the review of outpatient client records, the project failed to document a complete client record on an individual that included follow-up information within ninety days of discharge, per the facilities policy, in four of four applicable client records reviewed.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from September 12, 2024 licensing inspection.
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Plan of Correction
All follow-up contacts and outcomes will be documented in the Salesforce CRM system, which functions as the organization's centralized client management platform to ensure consistency and data integrity. Oversight of this process will be jointly managed by the Clinical Director and Office Manager. Compliance and accuracy of documentation will be verified through quarterly chart audits. Full implementation of this corrective action is scheduled for completion by October 15, 2025. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection on September 17, 2025, the facility failed to display the hours of project operation conspicuously to the general public.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Hours of operation signage has been posted at the facility entrance to ensure visibility and accessibility for clients and visitors. The Facility Manager is responsible for maintaining this requirement and verifying the signage during monthly safety rounds. Compliance will be monitored through ongoing monthly plant inspections. Full implementation of this corrective action is to be completed by October 15, 2025. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection on September 17, 2025, the facility failed to display a telephone number conspicuously to the general public for emergency purposes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Emergency and telephone contact information, including after-hours and emergency numbers, has been posted at the facility entrance to ensure accessibility for staff, clients, and visitors. The Facility Manager is responsible for maintaining and verifying the accuracy and visibility of this signage during monthly safety rounds. Compliance will be monitored through ongoing monthly plant inspections. Full implementation of this corrective action will be completed by October 15, 2025. |