INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 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, Brighter Visions Counseling 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of three personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #3 was hired on August 4, 2025 as a counselor assistant. Employee #3 has a high school diploma and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Employee #3 ' s personnel record did not have documentation of direct observation occurring from August 4, 2025, through November 4, 2025, or close supervision documented from November 5, 2025, to the time of the inspection.
Direct observation is defined by regulation as follows: " In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities " .
Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " .
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Brighter visions counseling is committed to the fulfillment of all requirements of 704.9 supervision of a counselor assistant. The counselor assistant position was vacated on January 21, 2026.
The Facility Director is responsible for staff hiring and promotion decisions. As such it is his duty to verify each employee's educational record and experience. To correct the deficiency, the Facility Director will review the educational requirements of 704.7, 704.8, 704.9 before hiring a candidate for position of either counselor assistant or counselor. In the case someone is hired the Facility Director will review requirements of supervision for each position on a weekly basis and ensure that it is being provided according to the law. The Facility Director is responsibile for the implementation of this plan of correction. This plan of correction is in place February 14, 2026.
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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 and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired on November 1, 2023 as a certified recovery specialist and receptionist and promoted to a counselor assistant on August 4, 2025, and still is employed in that position at the time of inspection. Employee # 3 was due to have the communicable disease training no later than November 1, 2025. According to the documentation in the personnel file, completion of the HIV/AIDS training occurred on November 3, 2025, and there is no documentation that the employee completed the TB/STD training as of the date of the inspection.
This finding was discussed with facility staff during the licensing process.
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Plan of Correction
The employee who could not demonstrate proof of training in communicable diseases resigned from the agency on January 21, 2026.
The Facility Director is responsible for explaining and monitoring staff training according to licensing requirements. These requirements will be explained at time of hiring, and by an annual training plan for each staff person to be completed jointly between the staff person and the Director in January. The plan will include any mandatory training requirements based on their tenure, but also training goals fitted to their position, education, and goals. A log of completed and required trainings including completion certificates will be maintained in each personnel file. This training plan will be reviewed between the employee and the Director monthly at a meeting for staff supervision. The implementation of this plan of correction is the responsibility of the Facility Director. The plan of correction is in place on February 22, 2026. |
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 obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to who disclosure is made in one of seven records reviewed.
Client #2 was admitted on October 15, 2025 and is still active at the time of the inspection. The record contained one informed and voluntary consent to release information to an emergency contact signed by the client on October 15, 2025, that did not identify the name of the person to whom the disclosure is made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
It is policy for Brighter Visions Counseling to obtain from each client an informed and voluntary consent for the disclosure of information. This is in writing and shall include but not be limited to: (dated signature of client or guardian as provided for under 42 CFR 2.14 (a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients). The consent for release of information must include the person or entity to whom it will be released, the purpose and scope of the release, and the date range during which the release is in effect.
To correct this deficiency the Facility Director will review this form with all staff. Each chart will be reviewed during 60-day treatment plan consultations to verify compliance. In the case of client #2, the ROI form for emergency notification has been corredted naming the specific person for the release. This has been corrected on January 27, 2026.
The Facility Director is responsible for the fulfillment of this plan of correction. This plan of correction is in place as of March 1, 2026.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow up information within sixty days of discharge, per facility policy, in one out of three applicable records reviewed.
Client #6 was admitted on July 3, 2025 and discharged on September 3, 2025. A follow up contact was due no later than November 3, 2025; however, there was no documentation that one was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Brighter visions counseling is committed to compliance with all aspects of client records requirements including a follow up telephone interview or letter 60 days after the date of discharge.
In order to prevent a recurrence of this deficiency in record keeping, the Facility Director will review cases weekly with each counselor. Closed charts will remain on the list for consultation until after the 60-day follow-up call or letter has been completed. The Facility Director is responsible for the enactment of this plan of correction. The plan of correction is in place February 14, 2026.
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