INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 9, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Guidance 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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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days. The facility received notification of a client death on September 21, 2025 but has not submitted a written unusual incident report to the Department at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Department staff will meet on 2/18/2026 and review the identified deficiency. Staff will also review PA Reg 709.34 which identifies what qualifies as an unusual incident. Staff will identify that any qualification of an unusual incident will require a direct report to the Project Director. The Project Director, in coordination with staff will ensure client and staff safety immediately. The Project Director will notify the Executive Director of the incident. The Project Director, in coordination with the clinical staff, will complete the unusual incident report within 3 days of the program being notified. A copy of the incident report will be maintained by the Project Director. The Executive Director and Project Director will determine the need for any policy review, training, or corrective action that is necessary to prevent further incidents of the same nature. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to include the type and frequency of treatment and rehabilitation services on the treatment plan in one of two applicable records.
Client #2 admitted January 9, 2026 and still a current client. The comprehensive treatment plan completed on January 9, 2026 did not include type or frequency of services.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Department Staff will meet on 2/18/2026 and review how to identify the type and frequency of treatment recommended and where the documentation is completed at in the electronic health record.
Weekly, the Project Director will individually review notes completed by clinical staff to ensure that the type and frequency of services is documented accurately in each note.
Quarterly the compliance department will review charts to ensure that the type and frequency of treatment recommended is documented as required. This report will be provided to the Project Director for further review with staff. |
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 a review of client records, the facility failed to document treatment plan updates every 60 days in three of three records.
Client #1 admitted April 24, 2025 and still a current client. A treatment plan was completed on August 20, 2025 and the update was due by October 19, 2025 but not completed until December 3, 2025. Additionally, another update was due by February 1, 2026 but not completed at the time of the inspection.
Client #3 admitted April 29, 2024 and discharged December 16, 2025. A treatment plan was completed on August 8, 2025 and the update was due by October 7, 2025 but not completed until October 29, 2025.
Client #4 admitted June 11, 2025 and discharged September 22, 2025. A treatment plan was completed on June 11, 2025 and the update was due by August 10, 2025 but not completed until August 18, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Department staff will meet on 2/18/2026 and review the deficiencies identified in the on site inspection from DDAP. Department staff will review the policies and procedures that relate to this identified deficiency.
The Project Director will be responsible for generating a caseload report on Mondays to identify treatment plan time frames and deadlines for each staff member. The caseload report will be provided to the clinical staff for updates and review with client. The clinician will be responsible for updating the treatment plan within the identified time frame.
The Project Director will be responsible for ensuring that treatment plans are completed as identified by the end of the business week. Any barriers to these time frames will be clearly documented in a written supervision note that both the clinician and the Project Director have access to.
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