INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 7, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Fayette County Drug and Alcohol Commission, Inc. 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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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 applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in two of four records.
Client #3 was admitted on September 23, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on March 27, 2026. The next treatment and rehabilitation plan update was due no later than May 27, 2026; however, this was not completed until May 28, 2026.
Client #6 was admitted on March 11, 2026 and was discharged on June 16, 2026. A treatment and rehabilitation plan was developed on April 7, 2026. A treatment and rehabilitation plan update was due no later than June 7, 2026; 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 August 12, 2025 annual licensing inspection.
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Plan of Correction
709.92(b) Treatment and rehabilitation services:
In order for FCDAC to be in compliance with DDAP regulation 709.92(b). On July 16th, 2025, the Lead Counselor, Assistant Director and the Information Technology Generalist met and developed a folder within our electronic health records system to easily access Treatment Plans to ensure that they are updated at least every 60 days. In order for the counselors to easily track dates they will utilize the Face Sheet tab and the folder will be located on the left side of the screen. Counselors will also enter on the Face Sheet the development date of the primary treatment plan and subsequent update dates (60 days). At the beginning of each session the counselor will refer to the FACE SHEET to ensure compliance. The Lead Counselor will be responsible for monitoring compliance through monthly quality assurance monitoring checks.
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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 manual in three of four applicable records. The facility policy and procedure manual indicate a case consultation to be completed at discharge.
Client #4 was admitted on December 18, 2025 and discharged on February 26, 2026. A case consultation was due to occur no later than February 26, 2026; however, this was not completed at the time of the inspection.
Client #5 was admitted on October 7, 2025 and discharged on November 20, 2025. A case consultation was due to occur no later than November 20, 2025; however, this was not completed at the time of the inspection.
Client #6 was admitted on March 11, 2026 and was discharged on June 16, 2026. A case consultation was due to occur no later than June 16, 2026; however, this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.93(a)(8) Client records:
In order for FCDAC to be in compliance with DDAP regulations 709.93(a)(8). The Assistant Director met with the Lead Counselor on July 8th, 2026, and developed a plan for discharges. The plan includes that each counselor will be required to meet with the Lead Counselor or Treatment Supervisor (once position is filled) or Assistant Director prior to discharging a client compliant or non-compliant to review discharge, and to ensure all required documentation is complete. This meeting will also serve as the discharge Case Consultation. The counselor will indicate on the Case Consultation note. To ensure compliance, Lead Counselor will be responsible with meeting with counselors to review all discharges to ensure Case Consultations are completed.
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