INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 13, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Al-Assist Behavioral Health Care Center 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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705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the August 2024 through July 2025 fire drill logs, the facility failed to conduct fire drills during normal staffing conditions.
The facility's posted hours of operation are Monday, Wednesday, Friday from 8:30AM to 5:00PM and Tuesday, Thursday from 8:30AM to 8:00PM. The fire drill documented for Wednesday, July 23, 2025 was conducted at 6:02PM, which was outside the posted hours of operation for Wednesdays.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to comply with standard 705.28. Fire safety. (d) Fire drills. The nonresidential facility shall: (2) Conduct fire drills during normal staffing conditions.
Following the site visit, a meeting was held with the Site's Leadership Team along with the Lead Safety and Security Officer to discuss the findings of the audit. Standard 705.28 (d)(2) was reviewed with the Site's Leadership Team and Lead Safety and Security Officer to ensure that everyone was clear on the requirements of the standard, acknowledging our failure to meet the standard, and agreed as to how failure to meet standard 705.28 (d)(2) will be avoided moving forward.
The Safety and Security Officers were instructed to continue to strategically plan drills to ensure a variation in shifts, days, and times. However, all fire drills are to occur during normal staffing conditions and hours of on-site operations. The Safety and Security Officers were instructed to continue to review the fire drill tracker before performing fire drills to ensure that drill variations are occurring within the normal staffing conditions.
Safety and Security Officers are instructed to discuss only the monthly pending fire drill with the Lead Safety and Security Officer to ensure they comply with 705.28 (d)(2) before facilitating the drills.
The Quality Assurance Manager will monitor and track drill compliance monthly. The QA Manager will present the fire drill tracking form during site leadership meetings and provide the BH leadership with a quarterly summary of the fire drill report.
Monitoring - On-going
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on review of client records, the facility failed to include, as part of the intake and admission process, documentation of a psychosocial evaluation in two of six applicable client records reviewed.
Client # 3 was admitted on June 6, 2025 and was active at the time of inspection. There was no psychosocial evaluation documented in the record as of the date of the inspection.
Client # 5 was admitted on December 4, 2024 and was discharged on February 28, 2025. There was no psychosocial evaluation documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
709.91(b)(6) LICENSURE
Intake and Admission:
In order to comply with standard 709.91. (b) Intake and Admission. (6) Psychosocial Evaluation.
Following the site visit, a meeting was held with the Site's Leadership Team to discuss the clinical findings of the audit. Standard 709.91 (b)(6) was reviewed with the Site's Leadership Team to ensure that everyone was clear on the requirements of the standard, acknowledging our failure to meet the standard, and agreed as to how failure to meet standard 709.91 (b)(6) will be avoided moving forward.
To achieve full compliance with regulation 709.91(b)(6), the following corrective action was implemented. A full case review was conducted to determine whether failure to comply with regulation 709.91 (b)(6) was sporadic for the counselor, and under what circumstance did non-compliance occur. Additionally, the DA compliance tracker was reviewed to determine accuracy in documenting non-compliance.
As a result of the full case review: 1) The Clinical Supervisor and Counselor developed a performance improvement plan to address non-compliance of Standard 709.91 (b)(6). The PIP requires bi-weekly review of progress and compliance with a 90-day end date provided that the Counselor can maintain clinical compliance. 2) An additional 30 minutes have been added to the timeframe to complete a psychosocial evaluation and clinical summary. 3) The Clinical Supervisor must fully review the clinical record and reconcile on the DA compliance tracker clinical compliance for all new admits or re-admits within 5 business days of admission.
Monitoring: Monthly DA Peer Reviews will be conducted by internal DA Clinical Supervisors from other sites to ensure safe, effective, and evidence-based quality Client care, and program compliance. The results of the peer reviews will be presented during monthly Site Leadership Meetings with the intent of identifying areas for improvement, upholding professional standards and regulatory requirements, and program integrity.
The Quality Assurance Clerk will conduct weekly audits based on scheduled intake appointments to ensure a psychosocial evaluation summary has been completed. Non-Compliance will be emailed to both the Counselor and Clinical Supervisor for immediate correction.
The Clinical Supervisor will be responsible for ensuring all infractions of non-compliance is corrected within 24 hours of notification.
Corrective Action Plan in Progress
Time Frame for Completion: November 15, 2025
? Ongoing Monitoring
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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 a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include the documentation of case consultation notes, in two of two applicable client records reviewed.
Per the facility's policy and procedure manual, case consultation notes are to be completed every 90 days.
Client # 1 was admitted on March 5, 2025 and was active at the time of inspection. A case consultation note was due to be completed by June 5, 2025, but there was no consultation note documented in the record as of the date of the inspection.
Client # 2 was admitted on March 12, 2025 and was active at the time of inspection. A case consultation note was due to be completed by June 12, 2025, but there was no consultation note documented in the record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
709.93(a)(8) LICENSURE
In order to comply with standard 709.93. (a) Client Record. (8) Case Consultations.
Following the site visit, a meeting was held with the Site's Leadership Team to discuss the clinical findings of the audit. Standard 709.93 (a)(8) was reviewed with the Site's Leadership Team to ensure that everyone was clear on the requirements of the standard, acknowledging our failure to meet the standard, and agreed as to how failure to meet standard 709.93 (a)(8) will be avoided moving forward.
To achieve full compliance with regulation 709.93(a)(8), the following corrective action was implemented. The scheduling of formal Case Consultations has been increased from monthly to weekly effective September 5, 2025, to allow an opportunity for more clinical cases to be reviewed in a timely manner.
Monitoring: Monthly DA Peer Reviews will be conducted by internal DA Clinical Supervisors from other sites to ensure safe, effective, and evidence-based quality Client care, and program compliance. The results of the peer reviews will be presented during monthly Site Leadership Meetings with the intent of identifying areas for improvement, upholding professional standards and regulatory requirements, and program integrity.
The Quality Assurance Clerk will conduct monthly KPI audits based on case consultation compliance to ensure case consultations are completed according to policy. Non-Compliance will be emailed to both the Counselor and Clinical Supervisor for immediate correction.
The Clinical Supervisor will be responsible for ensuring all infractions of non-compliance is corrected and presented at the next weekly scheduled case consultation. Additionally, the Clinical Supervisors is responsible for using the DA Tracker to accurately track regulatory and policy compliance reconciling the tracker weekly.
Corrective Action Plan Completed
? Ongoing Monitoring
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