INITIAL COMMENTS
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This report is a result of an on-site provisional license follow up inspection conducted on March 16, 2026 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 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 the September 2025 through February 2026 fire drill logs, the facility failed to maintain a written fire drill record, which is to include documentation of the exit route used.
At the time of the inspection, the December 2025 fire drill log did not include which exit route was used during the fire drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
P147 stated we failed to document exit routes on our routine fire drill logs.
This was an oversight on only one of all the fire drills we conducted. To ensure that this doesnt happen again the lead tech will check the fire drill log sheet after each fire drill.He will then give the form to the Administrative Program Manager who will then check to ensure all Fire drill documentation is complete. This will be completed by 3/31/2026 |
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.
The facility provided an audit engagement letter at the time of the inspection; however, there was no finished financial audit provided for the project's fiscal year ending June 30, 2024.
This is a repeat citation from the August 14, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
#0169 states that the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the projects Drug and alcohol abuse services
ACA has a management company that handles all our financials. We do not have access to those documents.The plan that is put in place to ensure that this deficiency does not happen again is that the Administrative Program manager sent an email and a phone call on 4/27/2026 and again on 5/13/2026 followed up by a phone. Our controller informed me that we will have July 1 2024-June 30 2025 audit by 06/30/2026. Going forward we will have the yearly audits by 08/30 of every year. This plan will all be ongoing to remind the Controller that we need the financial audit every year by 08/30 This procedure will start by 04/27/2026 |
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 the medical history of the client during the intake and admission process in three of seven client records reviewed.
The facility policy and procedure manual stated the medical history is to be completed within five days of admission.
Client # 2 was admitted on December 6, 2025 and was still active at the time of the inspection. There was a medical history documented by the facility in the client record; however, there was no indication of the date it was completed. Additionally, there was documentation of a medical history from the client's prior treatment provider, but there was no documentation indicating the history was reviewed by the facility for completeness and accuracy with a dated signature.
Client # 5 was admitted on January 19, 2026 and was still active at the time of the inspection. The medical history was due to be completed no later than January 24, 2026; however, the history was not completed until January 28, 2026.
Client # 7 was admitted on February 10, 2026 and was still active at the time of the inspection. There was a medical history documented by the facility in the client record; however, there was no indication of the date it was completed. Additionally, there was documentation of a medical history from the client's prior treatment provider, but there was no documentation indicating the history was reviewed by the facility for completeness and accuracy with a dated signature.
This is a repeat citation from the August 15, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
#1749 states that the facility failed to document the medical history of the client during the admission/intake process and /or medical history done in a timely manner.
To ensure that this doesnt happen again a plan was put in place. A form was created to document and incompleteness, deficiencies, time frame issues to be completed within 5 days regarding the medical history. Charts will be reviewed by the administrative program manager within one week of the new client admission. All findings will be documented on the form. The form will be given to the counselor for review and discussion with the administrative program manager and director. This will be done by 04/30/2026 |
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 the drug and/or alcohol history of the client during the intake and admission process in three of seven client records reviewed.
The facility policy and procedure manual stated the drug and/or alcohol history is to be completed within five days of admission.
Client # 2 was admitted on December 6, 2025 and was still active at the time of the inspection. There was a drug and/or alcohol history documented by the facility in the client record; however, there was no indication of the date it was completed. Additionally, there was documentation of a drug and/or alcohol history from the client's prior treatment provider, but there was no documentation indicating the history was reviewed by the facility for completeness and accuracy with a dated signature.
Client # 5 was admitted on January 19, 2026 and was still active at the time of the inspection. The drug and/or alcohol history was due to be completed no later than January 24, 2026; however, the history was not completed until January 28, 2026.
Client # 7 was admitted on February 10, 2026 and was still active at the time of the inspection. There was a drug and/or alcohol history documented by the facility in the client record; however, there was no indication of the date it was completed. Additionally, there was documentation of a drug and/or alcohol history from the client's prior treatment provider, but there was no documentation indicating the history was reviewed by the facility for completeness and accuracy with a dated signature.
This is a repeat citation from the August 15, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
#1751 states that there was a failure to document the drug and/or alcohol history of the clients during the intake and admission process
To ensure this doesnt happen again, a plan was put in place. A form was created to document any deficiencies, incomplete facility drug and alcohol histories on clients and time frames to be done. All charts on new client admissions will be reviewed by the administrative Program manager within one week of client admission. The form is then given to the counselor for discussion with the administrative program manager and the director. This will be done by 04/30/2026 |
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 four of seven client records reviewed.
The facility policy and procedure manual stated the psychosocial evaluation is to be completed within five days of admission.
Client # 2 was admitted on December 6, 2025 and was still active at the time of the inspection. There was no psychosocial assessment documented by the facility in the client record at the time of the inspection. Additionally, there was documentation of a psychosocial assessment from the client's prior treatment provider, but there was no documentation indicating the psychosocial assessment was reviewed by the facility for completeness and accuracy with a dated signature.
Client #3 was admitted on December 1, 2025 and was still active at the time of the inspection. There was no psychosocial assessment documented by the facility in the client record at the time of the inspection. Additionally, there was documentation of a psychosocial assessment from the client's prior treatment provider, but there was no documentation indicating the psychosocial assessment was reviewed by the facility for completeness and accuracy with a dated signature.
Client # 5 was admitted on January 19, 2026 and was still active at the time of the inspection. The psychosocial assessment was due to be completed no later than January 24, 2026; however, the assessment was not completed until January 28, 2026.
Client # 7 was admitted on February 10, 2026 and was still active at the time of the inspection. There was no psychosocial assessment documented by the facility in the client record at the time of the inspection. Additionally, there was documentation of a psychosocial assessment from the client's prior treatment provider, but there was no documentation indicating the psychosocial assessment was reviewed by the facility for completeness and accuracy with a dated signature.
This is a repeat citation from the August 15, 2025 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
#1759 states the facility failed to document/ complete on time a biopsychosocial in the clients records.
To ensure this doesnt happen again a plan was put in place and a form was created to document any , reviews, deficiencies, incompleteness, thoroughness and time frames of completion pertaining to the facility Biopsychosocial. Charts will be reviewed by the administrative program manager on all new clients within 1 week of their admission to ACA. The findings will be documented on the form and given to the counselor for review and discussion with the administrative program manager and the director. This will be done by 4/30/2026
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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 that all individual treatment and rehabilitation plans will be completed within seven days after admission.
Client # 4 was admitted on January 12, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than January 19, 2026; however, the plan was not completed until January 22, 2026.
Client # 5 was admitted on January 19, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than January 26, 2026; however, the plan was not completed until February 16, 2026.
Client # 6 was admitted on January 22, 2026 and was still active at the time of the inspection. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
Client # 7 was admitted on February 10, 2026 and was still active at the time of the inspection. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
This is a repeat citation from the August 15, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
#1763 states that the facility failed to document individual treatment plans within the 7 day time frame from admissions.
To ensure that this doesnt happen again a plan was put in place. A form was created to document all deficiencies, incompleteness and adherence to timeframes. The form will be completed by the administrative program manager. The form will then be given to the counselor the following day for review and discussion with the Director and Program Manager. This will be done by 04/30/2026. Client #6 Treatment plan was missing from his chart and was in another folder for filing but was completed on 1/22/2026. Client Client #7 Treatment plan was not placed back in his chart at time of inspection but was completed on 2/27/2026 |
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 five of five applicable client records reviewed.
Client # 1 was admitted on February 20, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on February 27, 2026, did not include documentation of what type and frequency of treatment and rehabilitation services the client was to receive.
Client # 2 was admitted on December 16, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on December 17, 2025, did not include documentation of what type and frequency of treatment and rehabilitation services the client was to receive.
Client # 3 was admitted on December 1, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on December 3, 2025, did not include documentation of what type and frequency of treatment and rehabilitation services the client was to receive.
Client # 4 was admitted on January 12, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on January 22, 2026, did not include documentation of what type and frequency of treatment and rehabilitation services the client was to receive.
Client # 5 was admitted on January 19, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on January 28, 2026, did not include documentation of what type and frequency of treatment and rehabilitation services the client was to receive.
This is a repeat citation from the August 15, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
#1767 failure to document the type and frequency of treatment rehabilitation services were provided.
To ensure that this doesnt happen again, a plan was put in place and a form was created. Chart reviews will be done every 2 weeks and incompleteness, type of treatment services offered deficiencies, thoroughness of the tx plans will be documented on the form. This form will be reviewed by the Administrative Program Manager and Director. The form will then be given to the counselor the following day for review and discussion with the Administrative Program manager and Director. This will be done by 04/30/2026 |
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 three of three applicable client records reviewed.
Client # 2 was admitted on December 16, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 17, 2025 and the first update was due no later than January 17, 2026; however, the update was not completed until March 6, 2026.
Client # 3 was admitted on December 1, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 3, 2025 and the first update was due no later than January 3, 2026; however, the update was not completed until March 6, 2026.
Client # 4 was admitted on January 12, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 22, 2026 and the first update was due no later than February 22, 2026; however, the update was not completed until March 6, 2026.
This is a repeat citation from the August 15, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
#1771 was a failure to update and review client treatment plans every 30 days.
To ensure this doesnt happen again, a plan was put in place and a form was created to document any incomplete tx plans or review and update tx plans every 30 days. All deficiencies, incompleteness, timeliness of tx plans will be documented on the form, given to the counselor for discussion to review with the Administrative Program Manager and Director. This will be done by 4/30/2026 |