INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Christian Counseling Associates of Western Pennsylvania LLC 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of applicable staff records, the facility failed to provide a mechanism to provide feedback on a completed training in accordance with the facility policy and procedure manual in two of three records. The facility policy and procedure manual indicated that staff are to complete a feedback form after each training is completed. Staff #1 was hired as the project director on May 8, 2023 and was still in this position at the time of the inspection. The facility was unable to provide feedback collected for all trainings completed during the January 2025 through December 2025 training year.Staff #3 was hired as a counselor on May 8, 2023 and was still in this position at the time of the inspection. The facility was unable to provide feedback collected for all trainings completed during the January 2025 through December 2025 training year.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director will meet with the Executive Director by 3/2/26 to discuss this issue. By 3/2/26, the facility will be in compliance. The Quality Assurance team will audit staff files on a quarterly basis to ensure this policy is being followed. |
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 applicable staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in one of one staff records.Staff #3 was hired as a counselor on May 8, 2023 and was still in this position at the time of the inspection. A TB/STD training was completed on January 6, 2025; however it did not follow a Department-approved curriculum.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 9, 2025 annual licensing inspection.
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Plan of Correction
The Director will find a Department-approved curriculum by 3/2/26. Facility will be in compliance by 3/2/26. The Director will ensure that this staff member completes a new Department-approved training by 3/2/26. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the personnel training records, the facility failed to have the project director complete at least 12 clock hours of annual training in one of one record. Staff #1 was hired as the project director on May 8, 2023 and was still in this position at the time of the inspection. Staff #1 had documented 10.5 hours of training for the January 2025 through December 2025 training year.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director will meet with the Project Director by 3/2/26 to review these findings. Facility will be in compliance by 3/2/26. Project Director and Facility Director will meet quarterly to ensure Project Director is staying on course with his trainings for throughout the year. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on an inspection of facility fire extinguishers, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The facility was found to have a fire extinguisher that was last inspected in December, 2023. This finding was reviewed with the facility staff during the licensing process.This is a repeat citation from the January 9, 2025 annual licensing inspection.
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Plan of Correction
The Facility Director has already contacted the building manager about the fire extinguisher inspection. The building manager will confirm with Facility Director when the fire extinguishers inspections occur throughout each year. The fire extinguisher has already been inspected for 2026, the inspection occured on 1/27/26. Facility Director will consult with building manager throughout the year to ensure fire extinguisher inspection will occur. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on applicable staff records reviewed, the facility failed to provide documentation of an annual written individual staff performance evaluations reviewed and signed by the employee in one of two records. The facility's policy states that annual employee performance evaluations will be conducted yearly by the employee's anniversary date.Staff #3 was hired as a counselor on May 8, 2023 and was still in this position at the time of the inspection. The annual performance evaluation was due no later than May 8, 2025; however an annual performance evaluation has not been completed since January 23, 2024.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will ensure that all counselors receive timely annual reviews. He will audit the Counselors HR files quarterly to check for annual reviews. Facility will be in compliance by 3/2/26. |
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 client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in two of two applicable records.Client #1 was admitted on November 1, 2024 and was discharged on December 16, 2025. A treatment and rehabilitation plan was developed on January 8, 2025. A treatment and rehabilitation plan update was due no later than March 8, 2025; however, there were no treatment plan updates completed prior to discharge.Client #2 was admitted on November 4, 2024 and was discharged on July 31, 2025. A treatment and rehabilitation plan was developed on December 17, 2024. A treatment and rehabilitation plan update was due no later than February 17, 2025; however, there were no treatment plan updates completed prior to discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has already met with the QA team to create a new plan for auditing charts. The QA team will audit charts monthly to ensure compliance. Facility will be in compliance by 3/2/26. |
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 client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in two of two applicable records. The facility policy and procedure manual indicate a case consultation is to occur at admission and discharge. Client #1 was admitted on November 1, 2024 and was discharged on December 16, 2025. A case consultation was due to occur no later than December 16, 2025, however this was not completed at the time of the inspection.Client #2 was admitted on November 4, 2024 and was discharged on July 31, 2025. A case consultation was due to occur no later than July 31, 2025, however this was not completed at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will meet with the QA Team to ensure case consultations are audited. QA Team will audit for case consultations monthly. Facility will be in compliance by 3/2/26. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on applicable client records reviewed, the facility failed to complete an aftercare plan in accordance with the facility policy and procedure manual in two of two records. The facility policy and procedure manual indicated an aftercare plan will be completed with the client for all planned discharges. Client #1 was admitted on November 1, 2024 and was discharged on December 16, 2025. An aftercare plan was not completed at the time of the inspection.Client #2 was admitted on November 4, 2024 and was discharged on July 31, 2025. An aftercare plan was not completed at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will meet with QA Team to ensure aftercare plans are audited. QA Team will audit charts monthly. Facility will be in compliance by 3/2/26. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual in two of two. The policy and procedure manual indicates a discharge summary be completed within seven days of discharge.Client #1 was admitted on November 1, 2024 and was discharged on December 16, 2025. The discharge summary was to be completed no later than December 23, 2025; however, this was not completed at the time of the inspection.Client #2 was admitted on November 4, 2024 and was discharged on July 31, 2025. The discharge summary was to be completed no later than August 7, 2025; however, this was not completed at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will meet with QA Team to ensure discharge summaries are being audited and Facility Director will add this item to the Group Supervision agenda. Facility will be in compliance by 3/2/26. |
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 applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual. The policy and procedure manual indicates follow-up contact must be made within seven to ten days after discharge.Client #1 was admitted on November 1, 2024 and was discharged on December 16, 2025. Follow-up contact was due to be completed no later than December 26, 2025; however, this was not completed at the time of the inspection.Client #2 was admitted on November 4, 2024 and was discharged on July 31, 2025. Follow-up contact was due to be completed no later than August 10, 2025; however, this was not completed at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will meet with QA Team to ensure follow-up contact notes are being audited. Audits will occur monthly. Facility Director will also add this item to Group Supervision agenda. Facility will be in compliance by 3/2/26. |