INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 29-30, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Family Service and Children's Aid Society 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the personnel training records, the facility failed to have the counselor complete at least 25 clock hours of annual training in one of one record.
Employee #4 was hired as a counselor April 15, 2019 and still employed. Employee #4 documented 13.5 hours of training for July 1, 2024 to June 30, 2025 training year.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program Director and clinical supervisor reviewed the training deficiency for the identified staff. The program director and clinical supervisor will begin assigning trainings beginning January 1, 2026 for all staff to ensure they meet their 25 required hours. Both the clinical supervisor and program director will utilize resources from DDAP, SAMHSA, OMHSAS, Hazelden, county entities, and interagency training opportunities. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records, the facility failed to conduct unannounced fire drills once a month.
Reviewed fire drills from September 2024 to September 2025. No fire drills were conducted during the months of September 2024 to June 2025 and August 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The program director reviewed this deficiency with the CEO and HR manager following the exit interview on 10/2/2025. The HR manager will be resume responsibility for conducting monthly fire drills based on the guidelines of the policy. The program director and HR manager will schedule fire drills out ahead of time without telling facility staff so that both the program director and HR manager can ensure the drill is completed. The program director will follow up monthly with the HR manager to receive copies of all conducted fire drills. |
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 complete initial treatment plans according to agency policy and procedure in five of seven records.
According to agency policy and procedures, the preliminary treatment plan is completed at intake, initial treatment plan is completed within 30 days, and all additional updates are done every 60 days thereafter.
Client #1 was admitted February 4, 2025 and discharged May 27, 2025. The client ' s initial treatment plan was due March 6, 2025 but not completed until March 27, 2025.
Client #2 was admitted April 25, 2025 and discharged September 23, 2025. The client ' s initial treatment plan was due May 25, 2025 but not completed until June 10, 2025.
Client #3 was admitted March 10, 2025 and discharged September 25, 2025. The client ' s initial treatment plan was due April 9, 2025 but not completed until May 8, 2025.
Client #4 was admitted February 24, 2025 and still a current client. The client ' s initial treatment plan was due March 26, 2025 but not completed until June 6, 2025.
Client #7 was admitted June 12, 2025 and still a current client. The client ' s initial treatment plan was due July 12, 2025 but not completed until July 28, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 17, 2023 and September 24, 2024 licensing inspection.
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Plan of Correction
The program director reviewed this deficiency with the clinical supervisor and the CEO on 10/10/25. At this time, it was decided to change program policy from 'initial treatment plan is completed within 30 days,' to 'initial treatment plan will be completed by the fifth session.' This policy change will be effective as of 11/1/2025. This will account for potential missed appointments or changes in scheduled sessions.
All treatment plans will be tracked and monitored by the clinical supervisor to ensure they are done by the fifth session.
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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 complete treatment plan updates at least every 60 days in four of seven records reviewed.
Client #2 was admitted April 25, 2025 and discharged September 23, 2025. The treatment plan was completed on June 10, 2025 and an update was due by August 9, 2025 but not completed until August 26, 2025.
Client #3 was admitted March 10, 2025 and discharged September 25, 2025. The treatment plan was completed on May 8, 2025 and an update was due by July 7, 2025 but not completed until August 14, 2025.
Client #5 was admitted March 11, 2025 and still a current client. The treatment plan was completed on May 19, 2025 and an update was due by July 18, 2025 but not completed at the time of the inspection.
Client #7 was admitted June 12, 2025 and still a current client. The treatment plan was completed on July 28, 2025 and an update was due by September 26, 2025 but not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 24, 2024 licensing inspection.
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Plan of Correction
Treatment plan updates will be tracked by the clinical supervisor on an excel spreadsheet for each clinician. Clinicians will review all treatment plan updates during weekly clinical supervision the week prior to the 60-day due date. At the time of supervision the clinician will complete all treatment plan updates during the one-hour scheduled time immediately following supervision allotted specifically for treatment plan updates. This will be effective beginning 11/1/2025. |
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 document case consultations according to agency policy and procedure in three of seven records.
The facility's policy and procedure states that a case consultation must be completed 90 days following admission and then every 60 days thereafter.
Client #3 was admitted March 10, 2025 and discharged September 25, 2025. The case consultation was due by June 8, 2025 but not done until September 25, 2025.
Client #4 was admitted February 24, 2025 and still a current client. The case consultation was due by May 25, 2025 but not done until July 15, 2025.
Client #5 was admitted March 11, 2025 and still a current client. There was no case consultations in the client record.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the October 17, 2023 and September 24, 2024 licensing inspection.
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Plan of Correction
The program director and clinical supervisor reviewed this deficiency on 10/10/2025 and identified that all case consultations will be completed during the weekly supervision time and the hour designated for treatment plan updates immediately following the weekly clinical supervision time. If clinical supervision is cancelled or missed due to illness or vacation then it will be rescheduled for the next earliest available time while not disrupting the following week's clinical supervision |
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 client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for the initial comprehensive treatment plan being late was submitted and approved by the Department for the October 17, 2023 and September 24, 2024 annual licensing inspections. Initial treatment plans were again found to be a deficiency in the September 30, 2025 licensing inspection.
Additionally, a plan of correction for the case consultations being late or missing was submitted and approved by the Department for the October 17, 2023 and September 24, 2024 annual licensing inspections. Case consultations were again found to be a deficiency in the September 30, 2025 licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Program director and clinical supervisor discussed this deficiency on 10/10/25. To ensure that all corrections are followed the clinical supervisor will maintain a compliance list beginning November 1, 2025, to review with staff. The clinical supervisor will review this list on a weekly basis and provide time for counselor to complete identified tasks if extra time is needed before documents are out of compliance.
The program director will receive updates on a weekly basis from the clinical supervisor regarding compliance and will utilize progressive disciplinary steps according to policies and procedures in cases where compliance is not met as the new plan of correction protocol will become policy.
Ongoing compliance will be incentivized through monthly recognition during program staff meetings.
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