INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 31, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of applicable personnel records, the facility failed to ensure that each counselor met the qualifications of the position at the time of hire in in one of three records reviewed.
Staff #5 was hired as a counselor on December 22, 2025 and was still in this position at the time of the inspection. Staff #5 did not meet the educational requirements to be a counselor.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Education and credentials of all current staff will be reviewed to ensure that degrees were obtained from accredited educational institutions, certifications are current and valid, and that each staff member meets the eligibility requirements for their position. This review will be completed by the Director in coordination with the Human Resources department by May 15, 2026.
Human Resources staff have been added to the hiring verification process. A standardized qualifications checklist based on 28 Pa. Code §704.7(b) will now be completed and signed for every counselor position prior to hire. Staff #5 has enrolled in the PACertboard Certified Advanced Alcohol & Drug Counselor (CAADC) program with anticipated completion in May 2026. Staff #5 will maintain weekly supervision logs and receive three months of direct supervision of all counseling activities, followed by continued indirect supervision until full CAADC certification is obtained. All future counselor hires will be verified against these requirements before orientation.
This staff member's entire caseload was taken over by the Clinical Supervisor immediately following the DDAP inspection on 4.1.26. This will continue until the counselor is replaced or fully transitions to an Assistant Counselor role with direct supervision and supporting documentation or qualifies as a FTE Counselor. |
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 two staff records.
Staff #6 was hired as a support staff member on October 23, 2023 and was still in this position at the time of the inspection. The HIV/AIDS training was to be completed no later than October 23, 2025; however, this was not completed until February 10, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #6 completed the required DDAP-approved HIV/AIDS and TB/STD training on February 10, 2026. The Clinical Director/Supervisor has been trained on both internal policy and DDAP requirements for onboarding and first-year training timelines. A new onboarding checklist will be used for all staff to ensure HIV/AIDS (6 hours) and TB/STD (4 hours) training is completed within the regulatory timeframes (1 year for counselors/assistants; 2 years for all other staff). Compliance will be monitored through the staff training log and reviewed quarterly.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the facility physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. During a physical plant inspection conducted on March 31, 2026, the Department observed broken tiles on a wall in the dining hall.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All maintenance needs identified during the March 31, 2026 inspection were reviewed and logged in the facility's maintenance tracking spreadsheet. The broken tiles in the dining hall wall were removed and replaced with drywall on April 21, 2026. The maintenance log will be reviewed monthly by the Facility Manager to ensure all grounds and building exterior remain clean, safe, sanitary, and in good repair. |
705.2 (3) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(3) Keep exterior exits, stairs and walkways lighted at night.
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Observations
Based on the facility physical plant inspection, the facility failed to keep exterior exits, stairs and walkways lighted at night. During a physical plant inspection conducted on March 31, 2026, the Department observed a broken exterior light outside one of the dining hall exits.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All maintenance needs identified during the March 31, 2026 inspection were reviewed and logged in the facility's maintenance tracking spreadsheet. The broken exterior light outside the dining hall exit was replaced on April 23, 2026. Exterior exits, stairs, and walkways will be inspected weekly and lighting will be maintained at all times. The maintenance log will be reviewed monthly by the Facility Manager. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the facility physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. During a physical plant inspection conducted on March 31, 2026, the Department observed a bathroom light fixture contained dead bugs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All maintenance needs identified during the March 31, 2026 inspection were reviewed and logged in the facility's maintenance tracking spreadsheet. The bathroom light fixture containing dead bugs was cleaned and restored on April 25, 2026. Cleaning of all light fixtures has been added to the monthly staff cleaning checklist. Bathroom functionality and sanitation will be verified during weekly environmental rounds. |
705.7 (b) (2) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(2) Clean and disinfect food preparation areas and appliances following each prepared meal.
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Observations
Based on the facility physical plant inspection, the facility failed to clean and disinfect food preparation areas and appliances following each prepared meal. During a physical plant inspection conducted on March 31, 2026, the Department observed grease on the appliances, walls, and vent hood.
The Department observed rags on the floor by the fryer and oven.
The Department observed dust and dirt in a hole in the floor of the kitchen. Dishes and spices were stored on shelving above this hole.
The Department observed rust on a shelf in a refrigerator in the kitchen.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All cleaning and maintenance needs identified during the March 31, 2026 inspection were reviewed and logged in the facility's maintenance tracking spreadsheet. The kitchen was fully deep-cleaned by April 9, 2026. Kitchen cleaning and disinfection following each meal has been added to the weekly cleaning rotation and daily staff checklist. The Facility Manager will conduct weekly kitchen inspections to ensure ongoing compliance. The hole was shaved down and will be filled with filler by 5/08/26. The shelves will be sanded and painted by 5/08/26. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on the facility physical plant inspection, the facility failed to clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area. During a physical plant inspection conducted on March 31, 2026, the Department observed excess coffee grounds left on the pantry counter surrounding the facility ' s coffee grinder.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All cleaning and maintenance needs identified during the March 31, 2026 inspection were reviewed and logged in the facility's maintenance tracking spreadsheet. The kitchen was fully deep-cleaned by April 9, 2026. All eating, drinking, and cooking utensils and food preparation areas will be cleaned after each use and stored in clean, enclosed areas. The Facility Manager will conduct weekly kitchen inspections to ensure ongoing compliance. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on the facility physical plant inspection, the facility failed to keep cold food at or below 40 hot food at or above 140 and frozen food at or below O During a physical plant inspection conducted on March 31, 2026, the Department observed one of the refrigerator ' s temperatures at 45 Additionally, the Department observed a freestanding, chilled salad bar that the temperature was unable to be monitored.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Further inspection determined that the refrigerator door seal was failing. New seals have been ordered with an expected arrival date of May 1, 2026. Once installed, refrigerator temperatures will be re-checked and verified to maintain cold food at or below 40°F. All refrigerators and the salad bar will be monitored daily with temperature logs maintained by kitchen staff. The Facility Manager will review logs weekly and address any issues immediately. Full correction and verification will be completed by May 15, 2026. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on the facility physical plant inspection, the facility failed to limit smoking to designated smoking areas. During a physical plant inspection conducted on March 31, 2026, the Department observed a coffee can used for cigarette disposal outside a dining hall emergency exit. After a discussion with facility staff, it was determined that this is not a designated smoking area.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The coffee can used for cigarette disposal outside the dining hall emergency exit has been removed. Smoking is now strictly limited to the designated smoking area only. A Smoking area is being added to provide options for smoking areas by 5.8.26 and it will be appropriately signed to show smoking is allowed. Staff and residents have been re-educated on the facility smoking policy on.4.21.26. A "No Smoking" sign has been posted at the former location. The Facility Manager will monitor the exterior daily to ensure compliance with designated smoking areas only. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on the facility physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed. During a physical plant inspection conducted on March 31, 2026, the Department observed empty cardboard boxes and trash blocking an external, covered walkway exiting the dining hall. Additionally, another exit from the dining hall was observed to be manually locked with a sliding lock while staff were inside the building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All maintenance needs identified during the March 31, 2026 inspection were reviewed and logged in the facility's maintenance tracking spreadsheet. Cardboard boxes and trash blocking the external covered walkway have been removed and assigned a permanent storage location away from all exits. The manually locked sliding bolt on the dining hall exit door was removed and a panic bar was installed on April 24, 2026. All exits will be inspected daily to ensure they remain unobstructed and unlocked. The Facility Manager will conduct weekly exit checks. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill log for the months of January 2025 through March 2026 and an interview with facility staff, the facility failed to provide documentation of fire drills being conducted in the separate kitchen and dining hall building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility fire drill rotation and log have been updated to include the separate kitchen and dining hall building. Fire drills in the kitchen/dining hall will be conducted at least quarterly. The first kitchen/dining hall fire drill was completed on April 24, 2026. All future drills will be documented and unannounced per regulation. The Facility Manager is responsible for maintaining the updated drill schedule |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on applicable client record reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in one of two records.
Client #11 was admitted to outpatient on July 15, 2025 and discharged on July 21, 2025. There was no documentation in the client record notifying the client, in writing, of termination from the project.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 27, 2025 annual licensing inspection.
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Plan of Correction
The facility's termination policy has been reviewed and submitted to the policy committee for updating to clarify mailing notifications of termination (when client is not present to sign). policy submitted 5.1.26 and will be reviewed in the quarterly policy meeting.
The Clinical Supervisor and all clinical staff will be retrained on administrative discharge processes and incident reporting policies. Retraining will be conducted through a mandatory staff training session and specifically included the requirement to notify the client in writing of any decision to involuntarily terminate treatment and to send administrative discharge notifications via mail when the client is not able to receive them in person. All mailed communications will be noted in the progress note section of the clients EHR. The Clinical Director will review administrative discharge records when they occur to ensure compliance. |
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 applicable client records, the facility failed to report the department within three business days an unusual incident involving an event at the facility requiring the presence of police, fire, or ambulance personnel in one of one records.
Client #11 was admitted to outpatient on July 15, 2025 and discharged on July 21, 2025. Interview with facility staff and a case note in the client record indicated that the police were called to the facility on the client ' s discharge date; however, this was not reported to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility's existing incident reporting policy has been reviewed and found to be up to date. All staff will be trained on the existing policy for incident reports that covers what qualifies as a reportable incident, including the presence of emergency services (fire, police, ambulance). Staff will be trained on the 24-hour timeframe for submitting the incident report and the internal process to follow for submitting incident reports. All staff will be included in this training on 5.8.26. The Clinical Director is responsible for submitting reports and will maintain a copy of all reportable incidents. These efforts are to ensure future incidents will be reported in a timely manner. |