INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 18, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Council of Southeast Pennsylvania, 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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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 ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in two of three applicable client records reviewed.
Client # 3 was admitted on August 29, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on August 29, 2025 and the first update was due no later than October 29, 2025; however, the update was completed on November 7, 2025.
Client # 5 was admitted on August 5, 2025 and was discharged on October 24, 2025. The individual treatment and rehabilitation plan was completed on August 6, 2025 and the first update was due no later than October 6, 2025; however, the update was not completed prior to discharge.
This is a repeat citation from the February 7, 2024 and February 25, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To prevent recurrence, the program is implementing a more detailed report in the EHR with reminders for treatment plan deadlines. The Facility Director/Clinical Supervisor will review upcoming due dates monthly and incorporate treatment plan timeliness into routine chart audits and supervision with clinicians. Ongoing monitoring will occur through monthly clinician self- audits to track trends and ensure compliance. The Facility Director/Clinical Supervisor will oversee the tracking system and audits. and the Program Director will ensure overall program compliance. All corrective actions will be fully implemented by 3/23/2026.
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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.
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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 ensuring treatment and rehabilitation plans are reviewed and updated at least every 60 days was submitted and approved by the Department for the February 7, 2024 and February 25, 2025 annual licensing inspections. Not reviewing and updating treatment and rehabilitation plans at least every 60 days was again found to be a deficiency in the February 18, 2026 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To prevent recurrence of citations in the future, the Facility Director/Clinical Supervisor will present all initial citations in group supervision for all clinical staff. Corrective Action items will also be a permanent review item of individual supervision. In the event that a clinician is not adhering to the corrective action plan, a 60 Day Performance Improvement Plan will be implemented to address the deficiency. Performance Improvement Plans are an initial step to provide staff with support to address specific issues. If the Performance Improvement Plan is not successful, further steps will be taken. These steps include, but are not limited to a position change or termination. |