INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Counseling Solutions of the Lehigh Valley, 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of two applicable personnel records reviewed.
Employee # 4 was hired as a counselor on June 4, 2024 and was due to have the TB/STD training no later than June 4, 2025; however, the TB/STD training was not completed at the time of the inspection.
This is a repeat citation from the August 1, 2024 and August 7, 2025 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Counseling Solutions LV recognizes that the timely completion and accurate documentation of required staff training are essential components of
ensuring staff competency, maintaining regulatory compliance, and supporting the
delivery of safe, effective, and quality services.
CSOLV will implement the following corrective actions to address the identified
deficiency and prevent recurrence:
The identified staff member will complete the required HIV and TB/STD training within
30 calendar days of the implementation of this Plan of Correction (POC).
Documentation verifying successful completion will be obtained and maintained in the
employee's training/personnel record.
All newly hired staff members will be required to complete the approved training
curriculum, including the required HIV and TB/STD training, within the first 12 months of
employment.
Staff who have completed their first year of employment will be required to maintain
compliance with HIV and TB/STD training requirements on a two-year renewal cycle.
Staff will be notified and scheduled to complete the required training at least 60 days
prior to their individual training anniversary/renewal date to ensure adequate time for
completion and documentation.
The Program Supervisor, in collaboration with the Office Manager, will monitor
upcoming training requirements and renewal deadlines.
Staff will receive notification of upcoming required training and will be expected to
complete all required or assigned training within the established timeframe. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
The project had an exception to the regulation stating that the project would be exempt from completing an audit if the project's gross income is less than $500,000. At the time of inspection, the project provided a copy of their 2025 tax return and the return indicated the gross income exceeded $500,000 for the project's previous fiscal year; therefore, the exception is no longer valid and a financial audit must be completed for the facility's 2025 fiscal year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CSOLV recognizes the importance of sound fiscal management, accountability, and financial integrity. CSOLV requested an extension from the Department of Drug and Alcohol Programs (DDAP) to complete this requirement and is currently awaiting a response.
In the interim, and in an effort to ensure timely compliance, CSOLV has retained an accounting firm to conduct the annual audit for calendar year 2025 and for ongoing annual audits thereafter. The 2025 audit is scheduled to be completed by 9/30/2026.
Upon completion, the results of the audit will be reviewed by CSOLV leadership and reported to DDAP in accordance with all applicable regulatory requirements, established best practices, and CSOLV policies and procedures. CSOLV will maintain all required audit documentation and implement any corrective actions identified through the audit process, as applicable.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a consent to release information form in one of seven client records reviewed.
Client # 2 was admitted on March 27, 2026 and was still active at the time of the inspection. A release of information form to another treatment provider was signed by the client on March 27, 2026; however, there was no purpose of disclosure documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Counseling Solutions of Lehigh Valley (CSOLV) is committed to safeguarding client confidentiality and ensuring the appropriate and secure release of Protected Health Information (PHI). Releases of Information (ROI) will be completed accurately, in their entirety, and limited to the specific purpose and use identified and authorized by the client, consistent with applicable regulatory requirements and CSOLV policies and procedures.
The case cited during the audit was presented to client #2 and reviewed with new date, since client #2 is an active client. The ROI was updated on 7/31/2026. All staff will attend a review of CSOLV confidentiality documentation on 10/31/2026 to ensure that all releases of information are complete there entirely. Quality Insurance plan is in place to review all admission documentation including Releases of Information starting on 8/1/2026 and follow up of reviews weekly by QA staff.
The Program Manager and/or Clinical Manager, or designee, will conduct monthly chart audits to monitor compliance with ROI requirements.
Any incomplete, inaccurate, expired, or otherwise deficient ROI identified through the audit process will be addressed immediately. Corrective action and additional staff education will be provided when indicated.
ROI compliance will be incorporated into CSOLV's ongoing Quality Assurance/Performance Improvement process. Audit results will be reviewed by program leadership, and trends or recurring deficiencies will be addressed through additional training, supervision, policy clarification, or other corrective action as appropriate.
CSOLV's goal is to maintain 100% compliance with all applicable ROI and PHI release requirements and to ensure that client confidentiality and privacy are protected at all times. |
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 a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client and in accordance with facility policy, in three of seven applicable client records reviewed.
The facility policy and procedure manual stated the individual treatment and rehabilitation plan is to be completed within 30 days of admission.
Client # 3 was admitted on February 11, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by March 13, 2026, according to facility policy; however, the treatment plan was not completed at the time of the inspection.
Client # 4 was admitted on January 7, 2026 and was discharged on March 17, 2026. The individual treatment and rehabilitation plan was completed on January 10, 2026; however, there was no documentation indicating the treatment plan was developed with the client.
Client # 5 was admitted on December 30, 2025 and was discharged on May 7, 2026. The individual treatment and rehabilitation plan was completed on December 31, 2026; however, there was no documentation indicating the treatment plan was developed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CSOLV recognizes that all treatment plans must be developed collaboratively with the client and reflect the client's identified needs, preferences, strengths, goals, and desired outcomes. Historically, the client's signature served as documentation of their participation in the treatment-planning process.
Effective immediately, CSOLV will strengthen documentation by including a statement in the Clinical Summary confirming that the treatment plan was developed collaboratively with the client. Clinical staff will also document client participation in the corresponding progress note, and clients will review and sign completed treatment plans.
Initial treatment plans will be developed during the first clinical session and completed within 30 days of admission. Treatment plans will be reviewed and updated at least every 60 days, or sooner when clinically indicated.
CSOLV's QA process includes weekly review of admission and treatment-planning documentation. Additionally, the Clinical Supervisor will complete a review every 45 days to verify timely completion, required documentation, client participation, and overall compliance with treatment-planning requirements. Any identified deficiencies will be addressed through supervision, retraining, corrective action, and/or increased monitoring.
For Client #3, the treatment plan was developed collaboratively with the client during the individual session on July 28, 2026. Moving forward, CSOLV will ensure that client participation is explicitly documented within the clinical record in addition to the client's signature. |
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 personnel records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe was submitted and approved by the Department for the August 1, 2024 and August 7, 2025 annual licensing inspections. Failing to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe was again found to be a deficiency in the July 8, 2026 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To comply with plans of correction that were approved by the Department during the previous inspection. This will be completed by 8/29/26.
A staff training was held on 8/8/2026 on documentation and treatment planning.
A monthly review of the Plans of Correction will continue to be completed by the Clinical Supervisor. The team member responsible for ensuring this POC is implemented is Program Supervisor, in collaboration with the Office Manager, will be responsible for monitoring staff training compliance, notifying staff of upcoming requirements, ensuring completion is documented, and addressing any identified training gaps. |