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 18, 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 and Psychiatric Services 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 the review of client records, the facility failed to document case consultations within ninety days of admission, per the facility ' s policy and procedures manual in two out four applicable records reviewed. Client #6 was admitted on October 9, 2025 and was discharged on January 21, 2026. A case consultation was due no later than January 7, 2026; however, there is no documentation that one was completed. Client #7 was admitted on March 26, 2025 and was discharged on July 1, 2025. A case consultation was due no later than June 24, 2025; however, one was not completed until July 1, 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 regarding the requirement that a case consultation must be completed within 90 days of client admission. Local office administration will maintain a tracking system to monitor and ensure that case consultations are completed in accordance with established policies and procedures. The Quality Improvement Department will conduct random chart reviews to verify staff adherence to regulatory requirements and to confirm that the internal tracking system is effectively supporting ongoing compliance. |