INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 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, Glenbeigh Center of Erie 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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704.11(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 personnel records, the facility failed to ensure staff received at least 6 hours of HIV/AIDS training within the first year of employment in one of one applicable records.
Staff #4 was hired as a counselor on November 4, 2024 and still employed at time of inspection. Communicable disease training was due no later than November 4, 2025 but not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will develop a check list of required DDAP trainings and will make sure all new hires complete the required trainings using the checklist as a reference. Progress on the required trainings shall be checked on quarterly with the new hire and the project director to ensure that the required trainings are completed. |
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.
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Observations
Based on a review of personnel training records, the facility failed to ensure all counselors complete at least 25 clock hours of annual training in one of two applicable records.
Staff #4 was hired as a counselor on November 4, 2024 and still employed at time of inspection. Staff #4 completed 11 hours of training from July 1, 2025 to June 30, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employees shall submit their yearly plan for annual trainings in July of each calendar year to the Project Director. The Project Director shall check on the progress of the completion of these trainings quarterly to ensure they are on pace to be completed in the calendar year. |
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 within 60 days in three of six client records.
Client #1 admitted February 25, 2026 and discharged June 22, 2026. A treatment plan was completed on March 20, 2026 and an update was due by May 19, 2026 but not completed until June 22, 2026.
Client #2 admitted May 22, 2026 and discharged August 24, 2026. A treatment plan was completed on May 22, 2026 and an update was due by July 21, 2026 but not completed until July 31, 2026.
Client #5 admitted May 13, 2026 and still a current client. A treatment plan was completed on May 13, 2026 and an update was due by July 12, 2026 but not completed until July 14, 2026.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the September 9, 2025 licensing renewal inspection.
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Plan of Correction
A new medical record will be instituted at our facility which enables the medical record to flag treatment and rehabilitation plans that are due to expire days before a new plan is due. This medical record will send a flag to both the primary counselor and the Project Director. The Project Director will follow up to ensure treatment plans are completed on time. |
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.
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Observations
Based on a review of client records, the facility failed to complete case consultations in three of four applicable records.
Per agency policy and procedures, case consultations are to be completed quarterly.
There were no case consultations documented in the following client records.
Client #1 admitted February 25, 2026 and discharged June 22, 2026.
Client #4 admitted April 16, 2026 and discharged August 5, 2026.
Client #5 admitted May 13, 2026 and still a current client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A new medical record will be instituted at our facility which enables the medical record to flag the medical record when case consultations are due. This will happen two weeks after a client is admitted to treatment. This medical record will send a flag to both the primary counselor and the Project Director. The Project Director will follow up to ensure case consults are documented and are completed on time. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in three of four applicable records.
According to agency policy and procedure, aftercare plans should be created at the beginning of treatment and finalized within 7 days of discharge for all discharges.
There were no aftercare plans in the following client records.
Client #1 admitted February 25, 2026 and discharged June 22, 2026.
Client #2 admitted May 22, 2026 and discharged August 24, 2026.
Client #3 admitted February 12, 2026 and discharged May 15, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A new medical record will be instituted at our facility which enables the medical record to flag client discharges and the paperwork needed to complete discharge. The aftercare plan will be documented in the client discharge summary. This medical record will send a flag to both the primary counselor and the Project Director. The Project Director will follow up to ensure discharge summaries are completed on time. |