INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 9, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, A.L. Mental Health Counseling PC 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 (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 fire drill logs from April 2025 - March 2026, the facility failed to conduct unannounced fire drills at least once a month in ten out of eleven months reviewed.
The facility only provided documentation of a fire drill conducted by the building manager for the month of June 2025. The facility does not have an exception to conducting unannounced monthly fire drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Tag P273 ? Plan of Correction
1. Corrective Action Taken:
The facility has reviewed its fire safety procedures and documentation practices. A standardized Fire Drill Log has been developed and implemented to ensure compliance with regulatory requirements under 705.28(d)(4). All staff have been re-educated on proper fire drill procedures and documentation requirements.
2. Plan to Prevent Recurrence:
To ensure this deficiency does not recur, the facility will:
Implement a standardized Fire Drill Log form that includes:
Date of drill
Time of drill
Total evacuation time
Exit route(s) used
Number of persons present at time of drill
Problems encountered (if any)
Whether fire alarm and/or smoke detectors were operational
Conduct monthly fire drills in accordance with DDAP regulations
Require immediate documentation of each drill by designated staff
Perform monthly supervisory review of all fire drill logs for completeness and compliance
Provide ongoing staff training during orientation and annually regarding fire safety procedures and documentation requirements
3. Person Responsible:
Program Director
4. Date of Compliance:
Immediately implemented and ongoing compliance as of April 24, 2026
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of documented fire drill records from April 2025 - March 2026, the facility failed to include the amount of time it took for evacuation, the exit route used and whether the fire alarm or smoke detector was operative in one of one fire drill record documented.
The facility only had a fire drill record documented for the month of June 2025. That fire drill record failed to include the amount of time it took for evacuation, the exit route used and whether the fire alarm or smoke detector was operative.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction for Tag P279
The facility has implemented corrective actions to address the cited deficiency.
A compliant fire drill was conducted on April 27,2026, ensuring adherence to all regulatory requirements. Documentation of the fire drill has been completed and maintained on-site.
The Program Director is responsible for ensuring that all fire drills are conducted in accordance with Department of Drug and Alcohol Programs (DDAP) regulations and that proper documentation is maintained.
All staff have been re-educated on fire drill procedures and documentation requirements as of April 27, 2026
Ongoing compliance will be monitored by the Program Director through routine review of fire drill records on a monthly basis.
Corrective Action Date: April 27, 2026
A complete written fire drill record was created and includes:
Date and time of the drill
Time required for full evacuation
Exit route(s) utilized
Total number of individuals present at the time of the drill
Any problems encountered during the drill
Verification that fire alarm and/or smoke detectors were operational
The fire drill documentation has been reviewed for completeness and accuracy and is maintained in the on-site Fire Safety Compliance Binder.
Staff Training
All staff have been re-trained on:
Fire safety procedures and evacuation protocols
Proper completion of fire drill documentation per DDAP regulations
Training was conducted on April 27, 2026
Attendance was documented and maintained in personnel training files.
New staff will receive this training during orientation.
Monitoring and Quality Assurance
To ensure sustained compliance:
Fire drill logs will be reviewed monthly by the Program Director.
A quarterly internal audit will be conducted to verify:
Completion of fire drills
Accuracy and completeness of documentation
Any identified deficiencies will be corrected immediately, with additional staff retraining if needed.
Compliance with fire drill documentation will be included in the facility's ongoing Quality Improvement (QI) proces
Person Responsible
Program Director
Responsible for implementation, monitoring, and ongoing compliance
Completion Date
April 27. 2026
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709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three out of four records reviewed.
Client #2 was admitted to the outpatient program on February 9, 2026 and was discharged on March 18, 2026. A release of information form for the funding source was not documented in the client record. The facility confirmed billing had occurred.
Client #3 was admitted to the outpatient program on February 27, 2026 and was active at the time of the licensing inspection. A release of information form for the funding source was not documented in the client record. The facility confirmed billing had occurred.
Client # 4 was admitted to the outpatient program on March 16, 2026 and was active at the time of the licensing inspection. A release of information form for the funding source was not documented in the client record. The facility confirmed billing had occurred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Tag 0276
Corrective Action Taken:
The facility has reviewed and updated its policy to ensure compliance with DDAP regulations. Staff were re-educated on proper procedures related to issue?billing/documentation/etc.
No billing will occur without:
completed and properly documented services in the client record, including required clinical documentation and authorization, in accordance with DDAP regulations.
Steps to Prevent Recurrence
The facility has implemented a monthly internal audit process to review documentation and billing compliance.
All staff will receive ongoing training and supervision regarding proper procedures.
The Clinical Supervisor will conduct random chart reviews.
Any deficiencies identified will be addressed immediately with corrective training.
Person Responsible:
Program Director
The facility has identified that informed and voluntary consent for the disclosure of client information, including to funding sources, was not consistently obtained and documented as required.
1. Immediate Correction:
All current client records were reviewed. Any missing or incomplete consent forms were corrected immediately. Clients were contacted as needed, and properly informed, and voluntary written consent for release of information was obtained and placed in their records.
2. Systemic Correction:
The facility has implemented a revised Release of Information (ROI) policy to ensure compliance. A standardized consent form is now required prior to any disclosure of client information, including disclosures to funding sources.
The intake process has been updated to include mandatory completion of informed consent forms before services begin.
3. Staff Training:
All clinical and administrative staff have been retrained on
Confidentiality regulations
Proper use of the Release of Information forms
Requirements for informed and voluntary consent
Training was completed and documented.
1. Monitoring:
The Clinical Director will conduct monthly chart audits to ensure all client records contain properly completed consent forms prior to any disclosure. Any deficiencies will be corrected immediately and addressed with the staff.
2. Responsible Person:
Program Director
3. Date of Completion:
May 5, 2026
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709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on the review of outpatient client records, the facility failed to include documentation of disclosure to the client of the criteria for admission, treatment, completion and discharge in four out of four records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Intake Disclosure (709.91(b)(1))
1. Corrective Action Taken:
A.L. Mental Health Counseling has implemented a standardized Intake Disclosure Form that documents that each client is informed of:
Admission criteria
Treatment expectations
Completion criteria
Discharge process
All active client records have been reviewed and:
Missing documentation has been obtained, OR
Addendum notes have been entered where appropriate
2. Systemic Changes:
Intake packet updated to include:
Client Disclosure & Acknowledgment Form (signed at intake)
No client will be admitted without:
Completed intake packet
Signed disclosure form
Staff retrained on intake documentation requirements
3. Person Responsible:
Clinical Director
4. Monitoring Plan:
Weekly chart audits initially
Monthly compliance reviews
An intake checklist was implemented to ensure completeness before admission
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on review of client records, the facility failed to provide intake procedures that included documentation of a drug and/or alcohol history in four out of four records reviewed.
There was no documentation that a drug and/or alcohol history was completed for any of the clients reviewed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Substance Use History (709.91(b)(3)(ii))
1. Corrective Action Taken:
A.L. Mental Health Counseling has implemented a standardized biopsychosocial assessment that includes a required section documenting drug and/or alcohol history for all clients.
All active client records have been reviewed and:
Substance use history has been documented
Addendum notes added where necessary
2. Systemic Changes:
Intake process updated to include Mandatory substance use history assessment
Standard biopsychosocial form implemented, including:
Substance use (past/current)
Frequency, duration, last use
Treatment history (if applicable)
Staff retrained on documentation requirements
3. Person Responsible:
Program Director
4. Monitoring Plan:
Weekly chart audits initially
Monthly compliance checks
Intake checklist to ensure completion before admission finalized
5. Completion Date:
Immediately implemented as of: April 24, 2026
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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 develop an individual treatment and rehabilitation plan with the client to include written documentation of the type and frequency of treatment and rehabilitation services in three out of four records reviewed.
Client #1 was admitted to the outpatient program on October 1, 2025 and was discharged on February 3, 2026. The individual treatment plan dated October 1, 2025, did not include written documentation of the type and frequency of treatment and rehabilitation services.
Client #2 was admitted to the outpatient program on February 9, 2026 and discharged March 18, 2026. The individual treatment plan dated February 9, 2026, did not include written documentation of the type and frequency of treatment and rehabilitation services.
Client # 4 was admitted to the outpatient program on March 16, 2026 and was active at the time of the licensing inspection. The individual treatment plan dated March 16, 2026, did not include written documentation of the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction ? Treatment Plan (709.92(a)(2))
1. Corrective Action Taken:
A.L. Mental Health Counseling has revised its Individual Treatment Plan template to include required documentation of:
Type of treatment services
Frequency of services
All active client records have been reviewed and updated to include this information.
2. Systemic Changes:
New standardized Treatment Plan template implemented
All treatment plans must include:
Type (individual, group, etc.)
Frequency (e.g., weekly, biweekly)
Staff retrained on treatment planning requirements
Treatment plans are reviewed at the time of creation and during supervision
3. Person Responsible:
Program Director
The Program Director is responsible for ensuring that all corrective actions are implemented and maintained in compliance with DDAP regulations
4. Monitoring Plan:
Weekly chart audits initially
Monthly compliance review
Supervisor approval required for all treatment plans
5. Completion Date:
Immediately implemented as of: 05/05/2026
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with the client to include written documentation of proposed type of support services in two out of four records reviewed.
Client #2 was admitted to the outpatient program on February 9, 2026 and discharged March 18, 2026. The individual treatment plan dated February 9, 2026, did not include written documentation of the proposed type of support services.
Client #3 was admitted to the outpatient program on February 27, 2026 and was active at the time of the licensing inspection. The individual treatment plan dated February 27, 2026, did not include written documentation of the proposed type of support services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction ? Tag 1881
1. Corrective Action Taken:
The facility has reviewed the identified deficiency and implemented corrective actions to ensure compliance with DDAP regulations. Staff have been re-educated on applicable policies and procedures related to this requirement.
2. Method of Monitoring:
Ongoing compliance will be monitored through regular chart audits and supervisory review conducted on a monthly basis. Any deficiencies identified will be addressed immediately through corrective action and staff retraining.
3. Person Responsible:
Program Director
4. Corrective Action Date:
April 27, 2026
The facility has conducted a full review of all active client records to ensure compliance with 709.92(a)(3). Any records identified as incomplete or missing required elements were immediately corrected.
All clinical staff were re-educated on documentation requirements, including timely, complete, and accurate recordkeeping in accordance with state regulations.
A standardized documentation checklist has been implemented and is now required for every client record to ensure all required elements are present.
The facility has implemented the following corrective measures:
- A mandatory documentation checklist is now used for every client file.
- Weekly supervisory chart audits will be conducted to ensure compliance.
- Staff will receive ongoing training and supervision related to documentation standards.
- Any deficiencies identified will be corrected immediately and addressed with the staff through additional training.
Director will conduct:
- Weekly chart audits (minimum 10% of active charts) for 60 days
- After 60 days, audits will transition to monthly reviews.
- Audit results will be documented and maintained on-site.
- Non-compliance will result in corrective action and retraining
Person responsible
Program Director
5. Completion date
April 27, 2026
All client treatment plans were reviewed and corrected on April 27, 2026, to ensure full compliance with regulatory requirements.
- Missing treatment plans were identified and completed to address previous deficiencies.
- Incomplete treatment plans were updated to include measurable goals, objectives, and clinical interventions.
- All treatment plans were individualized to reflect the current client needs.
- All treatment plans were signed and dated by appropriate clinical staff and clients (when required).
All corrected treatment plans are maintained in the client record and available for review.
The facility has implemented the following corrective actions:
- A standardized Treatment Plan Template has been implemented to ensure inclusion of:
o Measurable goals
o Objectives
o Clinical interventions
o Required signatures and dates
- A Treatment Plan Checklist is now required for every client's chart prior to finalization.
- All clinical staff have been retrained on the requirements for treatment plans under 709.92(a)(3), including documentation standards and timelines.
- A monthly internal chart audit process has been implemented to review treatment plans for compliance.
- All treatment plans will be reviewed and approved by the Clinical Supervisor before finalization.
- A treatment planning policy has been updated and implemented to reflect regulatory requirements
The Clinical Supervisor is responsible for ensuring compliance with the treatment plan.
The Facility Director is responsible for overall oversight and enforcement.
Ongoing monitoring is immediate and continuous.
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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 review and update treatment and rehabilitation plans at least every 60 days in one out of one applicable records reviewed.
Client #1 was admitted to the outpatient program on October 1, 2025 and was discharged February 3, 2026. A comprehensive treatment plan was completed on October 1, 2025, and updated on November 1, 2025. The next treatment plan update was due by January 1, 2026; however, no further updates were documented in the client record prior to the client ' s discharge from the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Corrective Action Taken:
A.L. Mental Health Counseling has implemented a system to ensure all treatment plans are reviewed and updated at least every 60 days in accordance with regulatory requirements.
All active client records have been reviewed, and treatment plan updates have been completed where necessary
2. Systemic Changes:
A treatment plan review tracking system has been implemented, including:
Calendar reminders
Client tracking log
Staff are required to:
Review due dates at each session
Treatment plan review dates are now clearly documented
3. Person Responsible:
Program Director
4. Monitoring Plan:
Weekly review of upcoming due dates
Monthly chart audits
Supervisor oversight to ensure compliance
5. Completion Date:
Immediately implemented as of: May 5, 2026
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