INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 4, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Christian Counseling Associates of Western Pennsylvania LLC, 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the policy and procedure, the facility failed to develop a comprehensive staff development program indicating who is responsible and the time frames for completion for a mechanism to collect feedback on completed training.This finding was reviewed with the facility staff during the licensing process.This is a repeat citation from the February 21, 2025, licensing inspection.
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Plan of Correction
The Director is responsible to ensure that training feedback forms are completed. Training feedback forms must be completed within one week of the training. Facility will be in compliance by 1/15/26. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure the FTE counselor caseload in outpatient programs did not exceed 35 active clients for one of one counselor. The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE. Employee #3 was hired as a counselor on January 15, 2024. The employee's ratio calculation was as follows: 20/40= 0.5(FTE); 21/0.5 = 42, which equals a client/counselor FTE ratio of 42:1. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director will ensure that this Counselor's FTE will be in requlation by 2/15/26. To prevent this in the future, the Director will review all Counselors caseloads during Supervision meetings. |
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 client records, the facility failed to obtain an informed and voluntary consent from the client which includes name of the person, agency, or organization to whom disclosure is made in one of seven records.Client #7 was admitted on September 2, 2025, and was still active at the time of the inspection. A release of information form was signed September 3, 2025, and did not include name of the person, agency, or organization to whom disclosure is made.This finding was reviewed with the facility staff during the licensing process.This is a repeat citation from the February 21, 2025, licensing inspection.
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Plan of Correction
The Director will add this item to the Supervision Meeting Agenda. The Director will do remedial training regarding proper completion of release of information forms by 1/15/26. The Quality Assurance Team will continue to conduct audits throughout the year. Counselors will demonstrate proper completion of the form during Supervision meetings by 1/15/26. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent will expire in two of seven records.Client #1 was admitted on April 15, 2025, and discharged on July 25, 2025. A release of information form was signed April 21, 2025, and did not document when the consent will expire.Client #7 was admitted on September 2, 2025, and was still active at the time of the inspection. A release of information form was signed September 3, 2025, and did not document when the consent will expire.These findings were reviewed with the facility staff during the licensing process. This is a repeat citation from the February 21, 2025, licensing inspection.
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Plan of Correction
Facility will be in compliance by 1/15/26. Director will ensure that Counselors are properly completing consent forms by auditing charts during Supervision meetings and the Quality Assurance team will audit charts, too. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a recordkeeping system that allowed for the identification of clients' admission and discharge dates within a specific time period. The facility provided written lists of active clients and discharged clients but was unable to produce the lists with admit and discharge dates within the requested time period. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director will meet with the person responsible for our electronic health record and discover how a we can produce a list of active and discharged clients. We will find a solution by 2/15/26. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document the disclosure of the criteria for admission to clients, during the intake process, in seven of seven records. This finding was reviewed with the facility staff during the licensing process.This is a repeat citation from the February 21, 2025, licensing inspection.
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Plan of Correction
The Director will ensure that admission criteria is added to the Client Agreement for Counseling Intake Form. This Intake Form will be updated by 1/15/26. Compliance will be maintained with the help of the Quality Assurance team. |
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 one of three applicable records.Client #4 was admitted on June 18, 2025, and was still active at the time of the inspection. The treatment plan was completed on July 16, 2025, and an update was due no later than September 16, 2025; however, it was completed on October 9, 2025.This finding was reviewed with the facility staff during the licensing process.This is a repeat citation from the February 21, 2025, licensing inspection.
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Plan of Correction
The Director will remind all Counselors of the timeliness of treatment plan updates by 1/15/26. The Quality Assurance team will audit treatment plans to ensure they are updated at least every 60 days. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in one of two applicable records.The facility's policy and procedure manual states the discharge summary is to be completed for all discharges within four weeks.Client #1 was admitted on April 15, 2025, and discharged on July 25, 2025. There was no discharge summary documented.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director will remind the Counselor of the timeliness of Discharge Summaries by 1/15/26. Facility will be in compliance by 1/15/26. Both the Director and the Quality Assurance Team will audit charts to ensure timeliness of Discharge Summaries. |