INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 10, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Central Behavioral 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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709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that they have been notified of their client rights in three of four applicable client records reviewed.
Client #4 was admitted on December 22, 2025 and discharged on April 10, 2025. There was no documentation of written acknowledgement by the client documented in the record at the time of the inspection.
Client #5 was admitted on January 12, 2026 and discharged on May 30, 2026. There was no documentation of written acknowledgement by the client documented in the record at the time of the inspection.
Client #6 was admitted on January 19, 2026 and discharged on April 17, 2026. There was no documentation of written acknowledgement by the client documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director reviewed the citation with the counseling and intake coordinator staff on September 23 2026. It was reiterated that the client rights and responsibilities form needs to be reviewed, signed, and completed at the intake/assessment appointment as per the policy and procedure manual. As there are occasions in which this might be difficult (client must leave early, issues with computer system), it was identified that in those cases the form will need to be completed no later than the first individual counseling appointment.
The facility director will review new admissions weekly to ensure that this plan is being followed and coordinate with the intake and counseling staff immediately if the form needs to be completed.
As the clients who were reviewed for inspection are already closed to the program, no further action was taken regarding their treatment. |
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, treatment, completion and discharge to the client, during the intake and admission process, in three of four applicable records reviewed.
Client #4 was admitted on December 22, 2025 and discharged on April 10, 2026. There was no criteria for admission, treatment, completion and discharge disclosure documented in the record at the time of the inspection.
Client #5 was admitted on January 12, 2026 and discharged on May 30, 2026. There was no criteria for admission, treatment, completion and discharge disclosure documented in the record at the time of the inspection.
Client #6 was admitted on January 19, 2026 and discharged on April 17, 2026. There was no criteria for admission, treatment, completion and discharge disclosure documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director reviewed the citation with the counseling and intake coordinator staff on September 23 2026. It was reiterated that the admission, treatment, completion and discharge forms need to be reviewed, signed, and completed at the intake/assessment appointment as per the policy and procedure manual. As there are occasions in which this might be difficult (client must leave early, issues with computer system), it was identified that in those cases the forms will need to be completed no later than the first individual counseling appointment.
The facility director will review new admissions weekly to ensure that this plan is being followed and coordinate with the intake and counseling staff immediately if the forms need to be completed.
As the clients who were reviewed for inspection are already closed to the program, no further action was taken regarding their treatment. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on the review of client records, the facility failed to document client orientation to the project, which is to include project policies, hours of operation, fee schedule, and services provided, during the intake and admission process, in three of four applicable client records reviewed.
Client #4 was admitted on December 22, 2025 and discharged on April 10, 2025. There was no client orientation documented in the record at the time of inspection.
Client #5 was admitted on January 12, 2026 and discharged on May 30, 2026. There was no client orientation documented in the record at the time of inspection.
Client #6 was admitted on January 19, 2026 and discharged on April 17, 2026. There was no client orientation documented in the record at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director reviewed the citation with the counseling and intake coordinator staff on September 23 2026. It was reiterated that the program policies, hours, fees, services, and intake/admission policies forms need to be reviewed, signed, and completed at the intake/assessment appointment as per the policy and procedure manual. As there are occasions in which this might be difficult (client must leave early, issues with computer system), it was identified that in those cases the forms will need to be completed no later than the first individual counseling appointment.
The facility director will review new admissions weekly to ensure that this plan is being followed and coordinate with the intake and counseling staff immediately if the forms need to be completed.
As the clients who were reviewed for inspection are already closed to the program, no further action was taken regarding their treatment. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to ensure the documentation of a consent to treatment was signed by the client, during the intake and admission process, in two of four applicable records.
Client #5 was admitted on January 12, 2026 and discharged on May 30, 2026. There was no documentation of a client-signed consent to treatment in the record at the time of the inspection.
Client #6 was admitted on January 19, 2026 and discharged on April 17, 2026. There was no documentation of a client-signed consent to treatment in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director reviewed the citation with the counseling and intake coordinator staff on September 23 2026. It was reiterated that the consent to treatment form needs to be reviewed, signed, and completed at the intake/assessment appointment as per the policy and procedure manual. As there are occasions in which this might be difficult (client must leave early, issues with computer system), it was identified that in those cases the form will need to be completed no later than the first individual counseling appointment.
The facility director will review new admissions weekly to ensure that this plan is being followed and coordinate with the intake and counseling staff immediately if the form needs to be completed.
As the clients who were reviewed for inspection are already closed to the program, no further action was taken regarding their treatment. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were provided to the client according to the individual treatment and rehabilitation plan in two of six applicable client records reviewed.
Client #5 was admitted on January 12, 2026 and discharged on May 30, 2026. The individual treatment and rehabilitation plan was completed January 12, 2026 and indicated weekly counseling sessions. There was no documentation, in the record, of individual counseling sessions occurring during the weeks of January 11, 2026 through January 31, 2026.
Client #6 was admitted on January 19, 2026 and discharged on April 17, 2026. The individual treatment and rehabilitation plan was completed on January 19, 2026 and indicated weekly individual counseling sessions. There was no documentation, in the record, of individual counseling sessions occurring during the weeks of January 18, 2026 through February 14, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director met with counseling staff on September 23, 2026, to discuss the development and adherence to the treatment plan as per the citation.
The treatment plans for each of the client's records cited were reviewed, and it was identified that the meeting frequency listed on the initial treatment plans were more regular than what the clients were able to complete. The importance of making sure the frequency of treatment listed on plans were indicative of client need was discussed, as well as updating the treatment plan if that frequency needs to be altered.
In addition, if a client requires a frequency of treatment that this program cannot meet, a timely referral to another program will be made to ensure that the client's treatment needs are met.
The facility director will review treatment plans and frequency of treatment with counselors during weekly supervision to ensure that this plan is being implemented.
As the clients who were reviewed for inspection are already closed to the program, no further action was taken regarding their treatment. |