INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 14, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Alternative Counseling Associates, 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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705.10 (b) (1) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(1) Maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on a physical plant inspection, the facility failed to maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
The facility provided documentation of a fire safety inspection report, dated July 1, 2025, which indicated all the hard-wired smoke detectors within the 438 side of the facility were inoperable. Facility staff reported they installed battery-operated smoke detectors until the hard-wired detectors could be replaced. During the physical plant inspection, it was observed that there were no operable hard-wired or battery-operated smoke detectors placed in the basement, first floor and third floor of the 438 building.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
705.10 in July 2025 our annual Fire inspection stated that our 438 fire system was inoperable and battery operated smoke detectors were missing
Battery operated smoke detectors were installed previously but were missing at the time of inspection. On 8/15/2025 a purchase of interconnected smoke detectors was made. They were installed on 9/17/2025 by ACA maintenance man. Ddap was notified on 8/15/2025
The APM and Maintenance man will inspect smoke detectors every week to ensure they are in working order. A form will be created to document that the checks are being done. |
705.10 (b) (2) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(2) On floors with resident bedrooms, maintain a smoke detector which shall be located within 15 feet of each bedroom door. On floors with no resident bedrooms, the smoke detection device shall be located in a common area or hallway. All detection devices shall be interconnected.
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Observations
Based on a physical plant inspection, the facility failed to ensure all detection devices, including smoke detectors, were interconnected.
At the time of the inspection, there were no operable interconnected smoke detectors located on each floor of the 438 side of the facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of inspection we did not have interconnected smoke detectors
on 8/15/2025 the APM purchased interconnected smoke detectors. they were delivered 8/16/2025 and installed by ACA maintenance man on 8/17/2025. Ddap was notified.
The APM ( administrative Program Manager ) and ACA maintenance man will check the smoke detectors on a weekly basis to ensure they are all in working order. A form will be created by the APM to document the checks |
705.10 (b) (3) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(3) Repair inoperable smoke detectors or fire alarms within 48 hours of the time the detector or alarm is found to be inoperative.
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Observations
Based on a physical plant inspection, the facility failed to repair inoperable smoke detectors or fire alarms within 48 hours of the time the detector or alarm is found to be inoperative.
The facility provided documentation of a fire safety inspection report, dated July 1, 2025, which indicated all the hard-wired smoke detectors within the 438 side of the facility were inoperable. As of August 14, 2025, the smoke detectors were still not corrected and not operating. Additionally, there were no operable smoke detectors placed in the basement, first floor and third floor of the 438 side of the facility, until repairs could be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of inspection our hardwired smoke detectors were inoperable as stated in the annual Fire inspection report.
The Executive Director was notified and he and the APM contacted the managing company on 7/9/2025 to get authorization to get the Fire system fixed. The APM called the Fire Systems company on 7/14/2025 to schedule an appt to see what we need to get our Fire System up and running. on 7/18/2025 the representative from the Fire Systems company returned my call. The representative came out on 7/19/2025 to see what is required to fix our system. on 7/31/2025 the representative from the Fire Systems company contacted me to schedule another visit to properly provide a proposal for the Fire Alarm system.The representative came out on 8/5/2025 to finish his proposal on a new Fire System. On 8/15/2025 the APM notified DDAP and sent a Letter from the Fire Systems company of the plan and upgrade . On Oct 1 2025 I received an email from our management company stating they have received an email from the finance dept of the Fire systems company with requirements of the down payment and as soon as they receive the go ahead with the permit from the Pottstown borough they will start immediately
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
At the time of the on-site inspection, conducted at approximately 10:15 AM, every fire extinguisher, located in both the 438 and 440 sides of the facility, were tagged documenting they all had last been inspected in July 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
at the time of inspection our fire extinguishers failed to be inspected.
It was unknown why, at the time of inspection , our Fire extinguishers were not inspected.
On 8/15/2025 The APM called the Fire Systems companyto inquire why our extinguishers werent inspected and to have a technician come out to inspect. The inspection date for the extinguishers on 438 and 440 was schedule for 8/29/2025. Ddap was notified that on 8/29/2025 all fire extinguishers have been inspected and approved.
The APM will call the Fire Systems company in June to ensure that they send the qualified technicians out to inspect our extinguishers at the time of our Annual Fire System inspection |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility's October 2024 through July 2025 fire drill logs, the facility failed to ensure a fire drill was conducted during sleeping hours at least every six months.
As of the date of the inspection, the last time a fire drill was conducted during sleeping hours was in December 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ACA failed to conduct an asleep fire drill within 6 months during the overnight hours
on 9/2/2025 an overnight fire drill was conducted. All went well
The APM will check the Fire Drill logs the beginning of every month to ensure we are in compliance with times of Fire drills |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
As of the date of the inspection, there was no financial audit completed for the project's fiscal year ending June 30, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.25. At the time of the inspection we failed to receive a copy from our management company.
On September 8 2025 I received an email from our CFO with an attachment from the CPA that they acquired stating the financial work that they will be performing for ACA and that they are working on the annual financial audit. On Sept 23 2025 I received the annual financial audit from The CPA.
Going forward an email will be sent to our CFO beginning 3 months prior( May, June, July ) for reminders that we need the required annual financial audit by August 1 2026 for our licensing inspection |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a medical history of the client, during the intake and admission process, in three of seven applicable client records reviewed.
Client # 1 was admitted on May 22, 2025 and was still active at the time of the inspection. There was no documentation of a medical history in the record at the time of the inspection.
Client # 2 was admitted on June 20, 2025 and was still active at the time of the inspection. There was no documentation of a medical history in the record at the time of the inspection.
Client # 4 was admitted on May 8, 2025 and was discharged on August 11, 2025. There was no documentation of a medical history in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.51. at the time of inspection active client # 1 admitted may 22 2025, active client # 2 admitted June 20, 2025 and active client # 4 failed to have a record of their medical history
It is unbeknownst why their medical history was not in their records as we require a complete medical history with their referral packet before their interview process and medical history will then be reviewed when they meet with their counselor and prior medical history will be incorporated into the new reviewed medical history with the client after being admitted to ACA . It will be signed and dated
The Executive Director and APM will review all referrals to ensure a medical history that is included in the referral packet is reviewed with the client and incorporated into ACA client medical history. The counselor will sign and date . This will be completed for the active clients # 1 and #2 on 9/10/2025 The Executive Director and APM will review client charts 5 days after a client is admitted to ACA to ensure a medical history has been reviewed with the client signed and dated |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. 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 a review of client records, the facility failed to document a drug and/or alcohol history of the client, during the intake and admission process, in three of seven applicable client records reviewed.
Client # 1 was admitted on May 22, 2025 and was still active at the time of the inspection. There was no documentation of a drug and/or alcohol history in the record at the time of the inspection.
Client # 2 was admitted on June 20, 2025 and was still active at the time of the inspection. There was no documentation of a drug and/or alcohol history in the record at the time of the inspection.
Client # 4 was admitted on May 8, 2025 and was discharged on August 11, 2025. There was no documentation of a drug and/or alcohol history in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.51 At the time of inspection active clients # 1 who was admitted on May 22 2025 and #2 admitted on June 20 2025 and discharged client # 4 failed to have drug and/or alcohol histories in their records.
It is unknown why the client histories were missing from their charts as we require drug and/or alcohol histories to be included in their referral packet sent to us from their rehab before an interview can be scheduled. Once admitted the counselor with review with the client, their drug and/or alcohol history and the prior drug and alcohol history will be incorporated in ACA client Drug and Alcohol history within 5 days.The counselor will sign and date that the client drug and alcohol history has been reviewed with the client.
By 9/10/2025 The executive director and APM will review all referral packets to ensure Drug and/or Alcohol histories are included in their referral packet before interviews are scheduled and new client records will also be reviewed in 5 days to ensure drug and /or alcohol histories are incorporated into ACA client drug and alcohol history. For active clients #1 and # 2 charts will be reviewed by the Executive Director and APM on 9/10/2025 and updated at that time. client charts will be reviewed weekly by the Executive Director and the APM |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation, during the intake and admission process, in three of seven client records reviewed.
Client # 1 was admitted on May 22, 2025 and was still active at the time of the inspection. There was no documentation of a psychosocial evaluation in the record at the time of the inspection.
Client # 2 was admitted on June 20, 2025 and was still active at the time of the inspection. There was no documentation of a psychosocial evaluation in the record at the time of the inspection.
Client # 4 was admitted on May 8, 2025 and was discharged on August 11, 2025. There was no documentation of a psychosocial evaluation in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.51 at the time of inspection active clients #1 admitted on May 22 2025 and # 2 admitted on June 20 2025 and discharged client # 4 failed to have Psychosocial evaluations in their records,
It is unknown why psychosocial evaluations were not in the client charts. psychosocial evaluation are required in referral packets before interviews are scheduled. the counselor will review with the client the prior facility Biopsychosocial evaluation within 5 days of admission to ACA and incorporate any information reviewed from the prior facility psychosocial evaluation into ACA psychosocial evaluation. This will be done by 9/10/2025.
The psychosocial evaluations review will be documented in active clients charts on 9/10/2025
The Executive Director and the APM will review all new admission records within 5 days of admission. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan, which is to be developed with the client, per the facility's policy in three of six client records reviewed.
The facility policy and procedure manual stated all individual treatment and rehabilitation plans will be completed within seven days after admission.
Client # 3 was admitted on June 25, 2025 and was still active at the time of the inspection. There was no individual treatment and rehabilitation plan documented in the record as of the date of the inspection.
Client # 4 was admitted on May 8, 2025 and was discharged on August 11, 2025. The individual treatment and rehabilitation plan was due to be completed no later than May 15, 2025; however, the plan was not completed until August 11, 2025.
Client # 7 was admitted on May 7, 2025 and was discharged on August 6, 2025. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.52 at the time of inspection the active client #3 admitted on June 25 2025 failed and discharged client # 7 on May 7 2025 failed to have treatment and rehabilitation plans in their records. Also C Discharged client # 4 May 8 2025 did not have a treatment and rehabilitation plan done within 7 days of being admitted. Counselors were informed of this at the weekly clinical meetings
The treatment plans for the active clients # 3 will be completed, signed and dated 9/1/2025
The Executive Director will ensure that all treatment and rehabilitation plans will be done within 7 days of the client being admitted and reviewed with the client every 30 days beginning 9/1/2025 |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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 to be provided on the individual treatment and rehabilitation plan in three of six client records reviewed.
Client # 2 was admitted on June 20, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on June 25, 2025, did not include documentation of the type and frequency of treatment and rehabilitation services the client was to receive.
Client # 4 was admitted on May 8, 2025 and was discharged on August 11, 2025. The individual treatment and rehabilitation plan, completed on August 11, 2025, did not include documentation of the type and frequency of treatment and rehabilitation services the client was to receive.
Client # 5 was admitted on April 23, 2025 and was discharged on May 8, 2025. The individual treatment and rehabilitation plan, completed on April 30, 2025, did not include documentation of the type and frequency of treatment and rehabilitation services the client was to receive.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.52 at the time of inspection active client #2 admitted on June 20 2025 and treatment plan was completed on June 25 2025 failed to have any documentation of the type of treatment and and frequency of treatment and rehabilitation services client was receiving. Discharged client # 4 DC August 11 2025 and discharge client # 5 on May 8 2025 failed to have any documentation of type and frequency of treatment and rehabilitation services the clients were receiving
This was discussed at the weekly clinical meetings and counselors were informed that their treatment plans must be more thorough to reflect the treatment and rehabilitation services they are receiving while at ACA. Done by 9/15/2025.
the treatment plans for active client # 2 will be corrected to reflect the type and frequency of treatment services provided. This will be done 9/15/2025
The Executive Director will review client initial treatment and rehabilitation plans within 7 days of client admissions and review them every 30 days |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in two of two applicable client records reviewed.
Client # 1 was admitted on May 22, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 22, 2025 and the first update was due no later than June 22, 2025; however, there was no update completed as of the date of the inspection.
Client # 2 was admitted on June 20, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 25, 2025 and the first update was due no later than July 25, 2025; however, there was no update completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.52 At the time of admission active clients # 1 admitted on May 22 2025 and client # 2 admitted on June 20 2025 failed to have updated treatment and rehabilitation plans updated within the time frame required
Counselors were informed and being enforced on 9/1/2025 at the weekly clinical meeting that all clients that are here over 30 days must have an updated treatment rehabilitation plan one and signed every 30 days. If clients are here less than 30 days they must have an updated treatment rehabilitation plan done and signed every 15 days
The Executive Director will review and sign off on treatment plans for active clients every 30 days and review and sign off on treatment rehabilitation plans every 15 days for clients here less than 30 days . The treatment plans for client # 1 and client #2 will be updated 9/15/2025 |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in one of one applicable client records reviewed.
Client # 1 was admitted on May 22, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on May 22, 2025, indicated the client was to receive one individual therapy session per week. The record of services and progress notes indicated the client did not receive any individual sessions from July 16, 2025 through the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.52 at the time of inspection active Client # 1 admitted on May 22 2025 was deficient in his individual therapy sessions according to his treatment rehabilitation plan. He was required to have 1 individual treatment session per week. His chart did not reflect that as he did not have an in dividual treatment session from July 16 2025 through august 14 2025
on 9/1/2025 counselors were informed that clients will have 1 individual treatment session per week. The treatment progress note must be documented within 48 hours and submitted to the APM for verification
The executive Director will check with the APM to ensure that the individual treatment session progress note was documented |