INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 20, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Casa De Consejeria Drug and Alcohol Counseling Program, 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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705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to ensure a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer were provided in each bathroom.
At the time of the inspection, conducted on April 20, 2026 at approximately 12:30pm, there was no wall mirror provided in the first-floor bathroom.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon notification of the deficiency during the licensing inspection process, the facility immediately reviewed all bathroom requirements outlined under applicable DDAP physical plant standards.
The facility has purchased a wall mirror for the first-floor bathroom, and installation occurred immediately to ensure compliance with the regulation requiring all bathrooms to contain the necessary fixtures and hygiene accommodations.
Additionally, the Facility Director and Maintenance Department conducted a walkthrough of all bathrooms within the facility to verify that each bathroom contains:
A functioning sink
An operable soap dispenser
A wall mirror
Individual paper towels or a mechanical hand dryer
The facility director has also implemented ongoing environmental monitoring procedures, including routine physical plant inspections, to ensure continued compliance with DDAP physical plant standards and prompt correction of any identified deficiencies. |
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 document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information form in one of seven client records reviewed.
Client #2 was admitted on October 3, 2025 and was active at the time of inspection. A release of information form, signed and dated by the client on October 3, 2025, indicated the name of the agency to whom disclosure would be made to as "Probation/Parole Department", which is not specific.
This is a repeat citation from the April 8, 2026 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will conduct a mandatory in-service training with all clinical and administrative staff regarding the proper completion of Releases of Information. The training will emphasize:
The requirement to clearly identify the specific person, agency, or organization to whom information is being disclosed
Proper completion of all ROI fields
Client and witness signatures and dates
Providing a copy of the signed consent to the client
Timeframes and expiration dates for releases
Procedures for updating or revising releases while clients remain active in treatment
Confidentiality standards related to substance use disorder treatment records under 42 CFR Part 2 and HIPAA
In addition, all active client charts will be audited to ensure that Releases of Information contain sufficiently specific identifying information and meet all regulatory requirements. Any deficient or incomplete ROIs will be corrected immediately, and updated consents will be obtained from active clients as necessary.
Clinical staff will also continue to participate in ongoing trainings related to confidentiality, documentation standards, and client record keeping to maintain compliance with DDAP regulations and applicable federal confidentiality laws.
Responsible Persons:
Facility Director and Quality Assurance Coordinator
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent to release information form was offered to the client in one of seven client records reviewed.
Client # 5 was admitted on November 18, 2025 and was discharged on February 6, 2026. There were release of information forms to a government agency and a funding source signed by the client on November 18, 2025; however, there was no documentation indicating if a copy of either consent form was offered to the client.
This is a repeat citation from the April 8, 2026 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and Quality Assurance Coordinator will conduct a mandatory in-service training for all clinical and administrative staff regarding the proper completion, review, and maintenance of Releases of Information. The training will specifically emphasize:
-The requirement to offer a copy of each signed consent to the client
-Proper documentation indicating that a copy was offered and/or provided
-Completion of all required ROI elements, including specific identification of the person, agency, or organization receiving the information
-Client and witness signatures and dates
-Expiration dates and timely renewal of releases
-Procedures for revising or updating releases while clients remain active in treatment
-Confidentiality requirements under DDAP regulations, 42 CFR Part 2, and HIPAA
The facility will also revise its internal ROI review procedures to include an additional compliance verification step ensuring documentation is completed indicating whether a copy of the consent was offered to the client prior to the form being filed in the chart.
Additionally, all active client charts will be audited to identify and correct any deficient Releases of Information. When documentation is incomplete or missing, updated releases will be obtained from active clients as appropriate.
Quality Assurance staff will complete monthly chart audits focusing specifically on confidentiality documentation and ROI compliance requirements, including verification that documentation exists indicating copies of consents were offered to clients. Findings will be reviewed with supervisory staff and corrective action will be implemented immediately when deficiencies are identified.
Clinical staff will continue to attend Department of Health and other recommended trainings related to confidentiality, documentation standards, and client record keeping to maintain ongoing compliance with DDAP regulations and federal confidentiality laws.
Responsible Persons:
Facility Director and Quality Assurance Coordinator
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