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 12, 2026, and the client record review was conducted February 20, 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(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 document that a comprehensive treatment plan was developed with the client in two out of six applicable records reviewed. Client #1 was admitted on November 24, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on November 24, 2025; however, did not have documentation it was developed with the client. Client #7 was admitted on August 7, 2025 and discharged on November 4, 2025. A comprehensive treatment plan was completed on September 17, 2025; however, did not have documentation it was developed with the client. These findings were reviewed with the 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 comprehensive treatment plans be developed collaboratively with the client. Local office administration will maintain a tracking system to monitor and ensure that comprehensive treatment plans are completed with client participation. The Quality Improvement Department will conduct random chart reviews to verify staff adherence to regulatory requirements and to ensure that the internal tracking system is effectively maintaining compliance.
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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 document treatment plan updates within the regulatory timeframe in three out of four applicable records reviewed.Client #1 was admitted on November 24, 2025 and was still active at the time of the inspection. A treatment plan was completed on November 24, 2025, and the next update was due no later than January 23, 2026; however, there is no documentation that one was completed. Client #2 was admitted on December 3, 2025 and was still active at the time of the inspection. A treatment plan was completed on December 10, 2025, and the next update was due no later than February 8, 2025; however, it was not completed until February 17, 2026. This is a repeat citation from the January 13, 2025 licensing inspection. 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 regarding the requirement that treatment plan updates must be completed within regulatory timeframes (every 60 days). Local office administration will maintain a tracking system to monitor and ensure treatment plan updates are submitted within the required 60-day period. The Quality Improvement Department will conduct random chart reviews to verify that staff are adhering to regulatory requirements and that the internal tracking system is effectively maintaining compliance. |