INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 12, 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 Pennsylvania 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(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.
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Observations
Based on a review of applicable staff records, the facility failed to provide documentation of at least 25 clock hours of annual training required for a counselor for the training year March 2024-March 2025 in one of one records.
Staff #5 was hired as a counselor on August 1, 2023 and was still in this position at the time of the inspection. During the review of the staff record, 17.15 training hours were documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The job title for employee #5 was reviewed on 11/12/2025 to confirm that this was updated for the current training year 03/2025-03/2026. They are correctly listed as a clinician and have been assigned the appropriate courses and training hours for this training year for the role of clinician.
The Senior Director of Training and Development will develop and implement a training crosswalk that will match job role and department with the correct training plan within the Relias platform. The Senior Director of Training and Development will monitor this tool to ensure new hires and anyone with position changes will receive the appropriate training plans within 2 weeks of hire or position change. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the facility's fire drill log for the months of October 2024 through October 2025, the facility failed to prepare alternate exit routes to be used during fire drills. All exits documented were the "front door".
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Clinical Director/Facility Director will randomly select a day and time each month to conduct a fire drill. Drills will include the use of all building exits. ECD/Facility Director will ensure that each exit is used for the fire drill at least once per quarter. Fire drills will be logged within the facility compliance folder. Clinical Director/Clinical Supervisor will review this log monthly to track utilization of all exits as well as varying times and days. If CD/Clinical Supervisor discovers the absence of each exit during the quarter, they will implement an addition drill utilizing the missing exit. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on applicable client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client per the facility ' s policy and procedure in four of seven records.
The facility ' s policy and procedure states an individual treatment and rehabilitation plan will be completed by the second counseling session.
Client #1 was admitted to outpatient on May 19, 2025 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed on June 2, 2025 did not have documentation that it was developed with client input.
Client #2 was admitted to outpatient on April 3, 2025 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed on April 9, 2025 did not have documentation that it was developed with client input until June 6, 2025.
Client #4 was admitted to outpatient on December 9, 2024 and was discharged on April 25, 2025. The comprehensive treatment and rehabilitation plan developed on December 16, 2024 did not have documentation that it was developed with client input.
Client #7 was admitted to outpatient on January 14, 2025 and was discharged on May 9, 2025. The comprehensive treatment and rehabilitation plan was to be developed no later than February 12, 2025; however this was not completed April 11, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Clinical Director/Facility Director will review proper treatment plan procedures and timely completion expectations during clinical rounds. Clinical Director/Clinical Supervisor will perform weekly chart audits to ensure session date correlates with the date of the initial treatment plan to ensure client input and collaboration in treatment planning. CD/Clinical Supervisor will review findings in monthly meetings with ECD/Facility Director. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services in seven of seven records.
Client #1 was admitted to outpatient on May 19, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed on June 2, 2025; however, there was no documentation of type and frequency of services.
Client #2 was admitted to outpatient on April 3, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed on April 9, 2025; however, there was no documentation of type of services.
Client #3 was admitted to outpatient on June 16, 2025 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on July 1, 2025; however, there was no documentation of type of services.
Client #4 was admitted to outpatient on December 9, 2024 and was discharged on April 25, 2025. A comprehensive treatment and rehabilitation plan was developed on December 16, 2024; however, there was no documentation of type of services.
Client #5 was admitted to outpatient on March 26, 2025 and was discharged on July 23, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on March 26, 2025; however, there was no documentation of type of services.
Client #6 was admitted to outpatient on April 21, 2025 and was discharged on October 30, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on May 16, 2025; however, there was no documentation of type of services.
Client #7 was admitted to outpatient on January 14, 2025 and was discharged on May 9, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on April 11; however, there was no documentation of type of services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During clinical rounds, Executive Clinical Director/Facility Director will review the appropriate documentation of type and frequency of services as pertaining to treatment planning. Clinical Director/Clinical Supervisor will complete random chart audits monthly to ensure compliance with identifying type and frequency within treatment plans. CD/Clinical Supervisor will review findings with ECD/Facility Director at monthly meetings. |
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 client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in three of six applicable records.
Client #1 was admitted to outpatient on May 19, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on June 2, 2025. A treatment and rehabilitation plan update was due no later than August 2, 2025; however this was not completed at the time of the inspection.
Client #3 was admitted to outpatient on June 16, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on August 22, 2025. A treatment and rehabilitation plan update was due no later than October 22, 2025; however this was not completed until October 27, 2025.
Client #4 was admitted to outpatient on December 9, 2024 and was discharged on April 25, 2025. A treatment and rehabilitation plan was developed on December 16, 2024. A treatment and rehabilitation plan update was due no later than February 16, 2025; however this was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 11, 2024 and November 21, 2023 annual licensing inspections.
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Plan of Correction
Executive Clinical Director/Facility Director will implement the use of an Excel spreadsheet to track treatment plan due dates and review due dates. During weekly clinical rounds, ECD/Facility Director will review due dates for the upcoming week. Clinical Director/Clinical Supervisor will review with individual clinicians weekly to ensure compliance. Failure to comply will result in corrective action planning with the individual clinician. |
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 applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure in six of seven applicable records.
The facility policy and procedure indicates a case consultation to occur within seven days of admission, then every ninety days thereafter.
Client #1 was admitted to outpatient on May 19, 2025 and was still active at the time of the inspection. The seven-day case consultation was due to occur no later than May 26, 2025; however this was not completed until May 27, 2025.
Client #2 was admitted to outpatient on April 3, 2025 and was still active at the time of the inspection. The seven-day case consultation occurred on April 4, 2025. The ninety-day update was due no later than July 4, 2025; however this was not completed until August 1, 2025.
Client #3 was admitted to outpatient on June 16, 2025 and was still active at the time of the inspection. The seven-day case consultation occurred on June 20, 2025. The ninety-day update was due no later than September 20, 2025; however this was not completed at the time of the inspection.
Client #4 was admitted to outpatient on December 9, 2024 and was discharged on April 25, 2025. The seven-day case consultation occurred on December 9, 2024. The ninety-day update was due no later than March 11, 2025; however this was not completed prior to discharge.
Client #6 was admitted to outpatient on April 21, 2025 and was discharged on October 30, 2025. The seven-day case consultation occurred on April 22, 2025. The ninety-day update was due no later than July 22, 2025; however this was not completed until August 15, 2025.
Client #7 was admitted to outpatient on January 14, 2025 and was discharged on May 9, 2025. The seven-day case consultation was due to occur no later than January 21, 2025; however this was not completed prior to discharge.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the October 11, 2024 annual licensing inspection.
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Plan of Correction
Executive Clinical Director/Facility Director will implement the use of an Excel spreadsheet to track due dates for consults. ECD/Facility Director will review upcoming due dates at weekly clinical rounds. Clinical Director/Clinical Supervisor will review weekly with each individual clinician to ensure compliance. Failure to comply will result in corrective action planning with the individual clinician. |
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.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for treatment plan updates was submitted and approved by the Department for the October 11, 2024 and November 21, 2023 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the November 12, 2025 annual licensing inspection.
This was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Clinical Director and Clinical Director will meet monthly with the Executive Director to review compliance with the current year plans of correction. During these meetings, compliance folders will be reviewed with the Executive Director to ensure adherence to the plans of correction. Plans of correction will also be reviewed at quarterly compliance meetings with Senior Director of Training and Leadership Development. Any noncompliance discovered in these meetings will prompt immediate action in the form of an updated corrective action plan. These deficiencies will also be documented in the annual performance reviews of the Executive Clinical Director and Clinical Director. All minutes from these meetings will be housed within the facility's compliance folders. |