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 20, 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 Carlisle 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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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 two out of six applicable records reviewed.Client #1 was admitted on November 18, 2025 and was still active at the time of the inspection. The treatment plan dated December 4, 2025, indicated one group session a week and one individual session a month. There is no documentation that the client received group counseling from December 4, 2025, through January 14, 2026. Client #6 was admitted on July 15, 2025 and discharged on October 13, 2025. The treatment plan dated July 22, 2025, indicated one group session a week and one individual session a month. There was no documentation that the client received any individual counseling session in the month of September 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 |