INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Berks Counseling Center, 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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709.28 (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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in one of seven client records reviewed.
Client # 5 was admitted on September 4, 2025 and was discharged on January 8, 2026. A release of information form for a social services agency signed by the client on September 4, 2025, did not specify the specific information to be disclosed.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
BCC conducted review training with the Admissions Clinical Care Coordinators on 2/2/2026.In addition, the new electronic health record, being implemented on 3/2/2026, has an improved layout for the informed consent for disclosure.
BCC's CQI Department conducts monthly chart reviews which include review of these consents. |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one of seven client records reviewed.
Client # 5 was admitted on September 4, 2025 and was discharged on January 8, 2026. A release of information form for a social services agency signed by the client on September 4, 2025, did not specify the purpose of disclosure.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
BCC conducted review training with the Admissions Clinical Care Coordinators on 2/2/2026.In addition, the new electronic health record, being implemented on 3/2/2026, has an improved layout for the informed consent for disclosure.
BCC's CQI Department conducts monthly chart reviews which include review of these consents. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of the seven records reviewed.
Client #1 was admitted on April 29, 2025 and a current client at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 29, 2025; however, the plan did not include documentation of the frequency of treatment and rehabilitation services.
Client #2 was admitted on November 7, 2025 and a current client at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 18, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client #3 was admitted on February 27, 2025 was discharged on May 9, 2025. The individual treatment and rehabilitation plan was completed on April 7, 2025 however, the plan did not include documentation of the frequency of treatment and rehabilitation services.
Client # 5 was admitted on September 4, 2025 and was discharged on January 8, 2026. The individual treatment and rehabilitation plan was completed on September 4, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
BCC is conducting mandatory training for all clinical staff with various sessions between 2/19/2026 and 2/26/26.In addition, the new electronic health record, being implemented on 3/2/2026, has an improved layout for treatment planning which contains prompts for frequency of services.
BCC's CQI Department conducts monthly chart reviews which include in depth review of the treatment plan. |
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 project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in four of seven applicable records reviewed.
Client #1 was admitted on April 29, 2025 and a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan update, documented in the client record on July 17, 2025, indicated that the client was to receive one group counseling session per week; however, there were no group counseling sessions documented in the record for the weeks of July 20, 2025 through July 26, 2025, September 14, 2025 through September 20, 2025, September 21, 2025 through September 27, 2025 and November 23, 2025 through November 29, 2025.
Client #4 was admitted on August 27, 2025 and was discharged on December 11, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on October 15, 2025, indicated that the client was to receive one group counseling session per week; however, there were no group counseling sessions documented in the record for the months of October 2025, November 2025 and December 2025.
Client #6 was admitted on February 10, 2025 and was October 1, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on February 10, 2025, indicated that the client was to receive one group counseling session per week; however, there were no group counseling sessions documented in the record for the weeks of August 10, 2025 through August 16, 2025, August 17, 2025 through August 23, 2025, August 31, 2025 through September 6, 2025 and September 7, 2025 through September 13, 2025.
Client #7 was admitted on March 4, 2025 and was discharged on July 2, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on March 4, 2025, indicated that the client was to receive one group counseling session per week; however, there were no group counseling sessions documented in the record for the months of May 2025 and June 2025.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
BCC is conducting mandatory training for all clinical staff with various sessions between 2/19/2026 and 2/26/26. This will include ensuring proper documentation of changes in treatment and/or lack of attendance at prescribed treatment.
BCC's CQI Department conducts monthly chart reviews which include in depth review of the treatment plan and associated services. |