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 Lancaster 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:
|
Plan of Correction
|
Observations
Based on a physical plant inspection on February 11, 2026, the facility failed to ensure that exits from the nonresidential facility were unobstructed. The emergency exit door located in the basement was obstructed, as it would not open due to snow blocking the door.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Maintenance will ensure that all facility exits remain unobstructed at all times. The Director of Maintenance will also ensure that any subcontracted snow removal vendors are instructed to thoroughly clear snow and ice from all building exits. The Director of Outpatient Administration will ensure that local office staff are re-trained to routinely monitor exits for obstructions and to immediately notify the Maintenance Department of any identified concerns. |
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 four out of seven records reviewed.Client #2 was admitted on November 24, 2025 and was still active at the time of the inspection. The treatment plan dated December 2, 2025, indicated one individual session a week. There was no documentation that the client received individual sessions in the weeks of December 21, 2025, December 28, 2025, and January 12, 2026. Client #3 was admitted on January 19, 2026 and was still active at the time of the inspection. The treatment plan dated January 28, 2026, indicated one individual session and one group session a week. There was no documentation that the client received any group counseling. Client #4 was admitted on March 12, 2025 and discharged on July 9, 2025. The treatment plan dated April 8, 2025, indicated one individual session a week. There was no documentation that the client received individual counseling during the weeks of April 20, 2025, and May 11, 2025. Client #6 was admitted on October 1. 2025 and discharged on December 4, 2025. The treatment plan dated October 6, 2025, indicated one group session a week. There was no documentation that the client received group counseling during the weeks of October 12, 2025, and October 19, 2025. These findings were reviewed with facility staff during the licensing process.
|
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. |