INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 7, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Counseling Solutions of the Lehigh Valley, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure all staff received at least 6 hours of HIV/AIDS training and at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics training within the regulatory time frame in two of two applicable personnel records reviewed.
Employee #6 was hired as a counselor on August 26, 2023. The HIV/AIDS and TB/STD trainings were due no later August 26, 2024; however, the HIV/AIDS training was not completed until July 29, 2025 and the TB/STD training was not completed as of the date of the inspection.
Employee #8 was hired as a counselor on June 4, 2024. The HIV/AIDS and TB/STD trainings were due no later June 4, 2025; however, both trainings were not completed as of the date of the inspection.
This is a repeat citation from the August 1, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Our facility has hired an Administrative Coordinator and within their role, they are responsible for staff requirements quality assurance. This role will be responsible for assisting in scheduling trainings and follow up with training completion and evaluations in march, June, September, and December of every year.
Training compliance will be reviewed by the Administrative Coordinator quarterly with each staff member. Review was completed on Sep 6, 2025. Next scheduled review is Dec 6, 2025.
The team member responsible to ensure this POC is upheld is the Program Director. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training during the January 2024 through December 2024 training year in one of three applicable personnel records reviewed.
Employee # 6 was hired as a counselor on August 26, 2023. The personnel record documented 19.5 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Our facility has hired an Administrative Coordinator and within their role, they are responsible for staff requirements quality assurance.
Training compliance will be reviewed by the Administrative Coordinator quarterly with each staff member to ensure that all required hours are completed within the calendar year.
The team member responsible to ensure this POC is upheld is the Program Director. |
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.
|
Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 1 was admitted on February 21, 2025 and was active at the time of inspection. There was evidence of disclosures to the funding source; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
A list of required releases has been created and distributed to the staff. Every release will be verified by the witnessing team member during admission to prevent recurrence, and confirmation of a release to the funding source will be confirmed.
Our QA Support will complete a QA review for every active client to confirm that all required releases are correct in their charts, if any release needs to be updated, this will be completed by the primary counselor at the clients next individual session. This will be completed by 9/30/2025.
The team member responsible to ensure this POC is upheld is the Clinical Supervisor. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on a review of client records, the facility failed to ensure a copy of a consent to release information form was offered to the client in one of seven client records reviewed.
Client #6 was admitted on January 22, 2025 and was discharged on April 25, 2025. A release of information form to a social service agency was signed by the client on January 22, 2025; however, there was no documentation, in the record, indicating a copy of the consent form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Every release will be verified by the witnessing team member during admission to prevent recurrence, and confirmation that the client selects if the accept or refuse a copy will be confirmed.
Our QA Support will complete a QA review for every active client to confirm that all required releases are correct in their charts, if any release needs to be updated, this will be completed by the primary counselor at the clients next individual session. This will be completed by 9/30/2025.
The team member responsible to ensure this POC is upheld is the Clinical Supervisor. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in two of five applicable client records reviewed.
Client #3 was admitted on March 18, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on March 18, 2025 and the first update was due no later than May 18, 2025; however, the update was not completed at the time of inspection.
Client #5 was admitted on March 13, 2025 and was discharged on July 29, 2025. The individual treatment and rehabilitation plan was completed on March 13, 2025 and the first update was due no later than May 13, 2025; however, the update was not completed prior to discharge.
This is a repeat citation from the September 9, 2022, August 16-17, 2023, and August 1, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
To comply with plans of correction that were approved by the Department during the previous inspection. Treatment plans of all active clients will be reviewed by each counselor during the clients' upcoming individual session. All plans will be up to date by Sept 30, 2025.
A staff training was held on 9/6/2025 on documentation and treatment planning.
A monthly review of the treatment plans will continue to be completed to ensure that they are on time. The team member responsible for ensuring this POC is implemented is the Clinical Supervisor. |
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.
|
Observations
Based on a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include the documentation of case consultation notes, in two of five applicable client records reviewed.
Client #5 was admitted on March 13, 2025 and was discharged on July 29, 2025. There was no documentation of case consultation notes in the record at the time of the inspection.
Client #6 was admitted on January 22, 2025 and was discharged on April 25, 2025. There was no documentation of case consultation notes in the record at the time of the inspection.
This is a repeat citation from the August 1, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As a repeated citation. To comply with plans of correction that were approved by the Department during the previous inspection. This will be completed by 9/30/2025.
A staff training was held on 9/6/2025 on documentation and treatment planning, which included case consultation. Individual supervision is available weekly for every counselor where case consultations can be completed for their caseloads.
A monthly review of the Plans of Correction will continue to be completed. The team member responsible for ensuring this POC is implemented is the Program Director. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to review and update treatment and rehabilitation plans at least every sixty days was submitted and approved by the Department for the September 9, 2022, August 16-17, 2023, and August 1, 2024 annual licensing inspections. Failing to review and update treatment and rehabilitation plans at least every sixty days was again found to be a deficiency in the August 7, 2025 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
To comply with plans of correction that were approved by the Department during the previous inspection. This will be completed by 9/30/2025.
A staff training was held on 9/6/2025 on documentation and treatment planning.
A monthly review of the Plans of Correction will continue to be completed by the Clinical Supervisor. The team member responsible for ensuring this POC is implemented is the Program Director. |