INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection. The physical plant inspection was conducted on February 11, 2026, and the client record review was conducted February 17, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the annual inspection, Pennsylvania Counseling Services, 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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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 ensure that the clients received counseling services according to their individual treatment plan in three out of seven applicable records reviewed.Client #1 was admitted on December 10, 2025 and was still active at the time of the inspection. The treatment plan dated December 22, 2025, indicated one individual session a week. There is no documentation that the client received individual sessions in the weeks of January 11, 2026, February 1, 2026, and February 8, 2026. Client #3 was admitted on November 14, 2025 and was still active at the time of the inspection. The treatment plan dated November 25, 2025, indicated one individual session a week. There was no documentation that the client received individual counseling sessions in the weeks of December 21, 2025 and January 11, 2026. Client #5 was admitted on November 18, 2025 and discharged on January 31, 2026. The treatment plan dated December 1, 2025, indicated two group sessions a week and one individual session a month. There was no documentation that the client received any group counseling from December 1, 2025 through January 31, 2026. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will ensure that all staff receive re-education emphasizing that each client must receive counseling services in accordance with their individualized treatment plan. Programming staff have added a designated field within the client's electronic health record to clearly display the recommended frequency of services. Staff will be reminded to consistently utilize this feature as a reference to support compliance. The Quality Improvement Department will conduct random chart reviews to verify adherence to regulatory requirements and to ensure documentation accurately reflects any changes to the type or frequency of services provided. |
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 the review of client records, the facility failed to document case consultations within ninety days of admission, per the facility ' s policy and procedures manual in one out three applicable records reviewed. Client #2 was admitted on October 22, 2025 and was still active at the time of the inspection. A case consultation was due no later than January 20, 2026; however, one was not completed until January 30, 2026. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will ensure that all staff receive re-education regarding the requirement that a case consultation must be completed within 90 days of client admission. Local office administration will maintain a tracking system to monitor and ensure that case consultations are completed in accordance with established policies and procedures. The Quality Improvement Department will conduct random chart reviews to verify staff adherence to regulatory requirements and to confirm that the internal tracking system is effectively supporting ongoing compliance. |