INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 2, 2026 through March 3, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Ascend Clinical Services 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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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 a physical plant inspection, the facility failed to ensure all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
On March 3, 2026, at approximately 2:27 p.m., there was a fire extinguisher, located in the loading dock area, that was last inspected by the fire extinguisher company in May 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Prior to inspector leaving the site on March 3rd, 2026, the fire extinguisher from the loading Dock that was not inspected since 5/21 was immediately removed and replaced with a fire extinguisher with a current inspection.
We reviewed this citation with the VP Facilities and by 4/1/2026 a full training regarding the citation will be completed with the facilities team. The facility map containing all locations of fire extinguishers was updated on 3/5/2026 to ensure awareness of all fire extinguishers needing routine inspection.
The Facilities Director (or designee) will conduct quarterly inspections to ensure all fire extinguisher are current.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's February 2025 through February 2026 fire drill logs, the facility failed to ensure unannounced fire drills were conducted at least once a month.
At the time of the inspection, there were no fire drills conducted and documented during the months of February 2025 through September 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to the onsite inspection the facility was aware of the missing fire drills from February 2025 through September 2025.
The individual responsible for the non-compliance was addressed on September 25,2025 and was placed on a Performance Improvement Plan.
VP of Facilities is monitoring the fire drill logs monthly to ensure ongoing compliance.
Overall Training regarding 705.10 (d) (1) will be completed for staff responsible for overseeing fire drill completions by 4/1/2026.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on a consent to release information form in one of seven client records reviewed.
Client # 7 was admitted on August 20, 2025 and was discharged on November 1, 2025. A release of information form to another service provider was signed by the client on August 27, 2025; however, there was no documentation, on the consent form, indicating what specific information was to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Training regarding 709.28 (c) (3) will be completed by 4/01/2026 for all direct-care staff.
Monthly audits will be conducted by the Executive Director (or designee) to ensure ongoing compliance with the standard referenced above.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a consent to release information form in one of seven client records reviewed.
Client # 1 was admitted on June 5, 2025 and was still active at the time of the inspection. A release of information form to a funding source was signed by the client on May 6, 2025; however, there was no documentation, on the consent form, indicating what the purpose of the disclosure was.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
TPO Release was reviewed for client #10 and a new release was completed on 3/17/2026.
Training regarding 709.28 (c) (3) will be completed by 4/01/2026 for all direct-care staff.
Monthly audits will be conducted by the Executive Director (or designee) to ensure ongoing compliance with the standard referenced above.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's February 2025 through February 2026 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility.
At the time of the inspection, there was a documented incident, dated February 18, 2026, which required police and/or ambulance personnel to be called to the facility; however, the incident was not reported to the Department until March 2, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training will be provided to supervisory staff and members of the QA & Compliance team related to timeframes outlined in 709.34 related to incident reporting timeframes.
The Corporate Compliance Officer will conduct quarterly review of incident submissions to ensure incident reports are submitted in accordance with the timeframes outlined in 709.34
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