INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Al-Assist Behavioral Healthcare Center 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
At the time of the inspection, which was conducted on July 8, 2026 at approximately 10:30 AM, there was an individual counseling session being held in a therapist's office located on the first floor and the session could be clearly heard in the registration area.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to ensure compliance of 705.23 so that counseling sessions are not heard outside of the counseling office.
On July 9, 2026, counseling staff were instructed to utilize their noise cancelation machines during every individual or group therapy session and to place the noise cancelation machines on the outside of the therapy room to mask incoming noise, muffle voices from within the office, and protect privacy against listeners. On July 29, 2026, site director purchased additional noise cancelation machines to ensure privacy throughout treatment activity areas and to readily have available additional sound cancelling machine for use when engaging Clients that speak at an unusually high-pitched tone during counseling sessions.
Monitoring:
Noise level monitoring has been added to the security officers' daily walk-throughs to ensure the protection of confidentiality throughout the course of the day. Security will ensure each office in use has the sound machines on and placed on the outside of the office void of obstructing entrance and exit to the office. If sound is still unmuffled, Security officer will place an additional sound machine nearby the office and notify the clinical supervisor of the need to inform the counselor.
Site director and clinical supervisors will monitor the security officer's daily walk-throughs and notifications, to make needed modifications.
On-going monitoring to ensure compliance of regulation 705.23 |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information in two of seven client records reviewed.
Client #1 was admitted on February 3, 2026 and was still active at the time of the inspection. There was evidence of disclosures to the funding source since the start of the treatment episode; however, there was no valid consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client #3 was admitted on March 24, 2026 and was still active at the time of the inspection. There was evidence of disclosures to the funding source since the start of the treatment episode; however, there was no valid consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In order to address citation 709.28(c) the primary counselor will notify Client #1 and Client #3 during their next scheduled individual counseling or group therapy session, whichever comes first, of the need complete consent forms for their funding source to cover drug and alcohol treatment services. The consent shall include: (1) Name of the person, agency or organization to whom disclosure is made. (2) Specific information disclosed. (3) Purpose of disclosure.
(4) Dated signature of client to ensure that the next claim submitted to the funding source is released in accordance with 709.28 (c).
Counselor will ensure that the updated consent form(s) align with the current treatment episode and is fully executed with (1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client,
prior to the start of their scheduled session.
Clinical supervisor will review the EHR within 30-minutes of the next scheduled session for Client #1 and #3 to ensure the consent form(s) were updated and meets standard 709.28 (c) prior to the end of the scheduled session.
Additionally, it was discovered during the completion of a root cause analysis of this infraction, that additional targeted training is needed during orientation for new hires. As a result, mock exercises have been added to the orientation training targeting Consents to release information at time of intake and program transfer (episode change). Testing for Consent to release has also been added to new hire orientation which includes but is not limited to appropriate information for the following areas:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian
On August 15, 2026, a training/meeting will be conducted with all registration assistant staff to review the correct process of completing consent to release information based on regulations. This training will include the mock exercises and testing of the existing registration assistants across all locations. This training will also include the need to complete new consent forms whenever a program transfer occurs.
On August 28,2026, an all-staff meeting will take place which will include counselors, registration assistants, and clinical supervisors, to review Standard 709.28 (c) and the proper procedures for completion of consent to release information, along with the need to complete new consent forms whenever a program transfer occurs.
Monitoring On-Going
Monitoring: Clinical supervisors and coordinators will do daily review of intakes to ensure that the proper substance abuse authorizations are completed for all D&A clients prior to adding the new client to clinical tracker for compliance monitoring.
Clinical supervisors and coordinators will ensure that Clients transferred from the Mental Health program to the D&A program have new consent forms completed that fully comply with Standard 709.28 (c) prior to signing off on the transfer and placing the transferred client on the clinical tracker for compliance monitoring.
Quality Assurance Department (QA) will conduct on-going monitoring throughout each quarter to ensure the correct consents are being used based on D&A program admission and Standards. QA will provide quarterly reports based on the findings with recommendations for continued improvement. |
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 a review of client records, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable client record reviewed.
Client #4 was admitted on August 21, 2025 and was involuntarily terminated on February 25, 2026. There was no documentation indicating the client received written notice of the involuntary termination from the project in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
n order to address citation 709.33(a) Notification of termination.
On Monday August 17, 2026, client #4 will be mailed a letter of discharge stating reason for termination and provide information for client to resume services if they choose.
On 8/28/2026 the project will conduct an all-staff meeting discussing the existing discharge letter and the importance of distributing the letter in conjunction with termination is completed.
Additionally, all-staff will be reminded of the need to capture email addresses and to enroll Clients in the Portal to ensure quick and quality correspondence that is integrated in the EHR system in hopes of reengagement oppose to program discharge.
Monitoring: On-Going
Clinical supervisor and director will meet weekly with discharge and admissions department to review discharges to ensure proper notification of the intent to discharge has been executed.
The Discharge and Admissions Department will not finalize a discharge until proof of notification has been secured.
The Discharge and Admissions Department will provide quarterly reports on discharges and status of compliance at time of discharge based on regulation to the BH Leadership Team and CBHO. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide the client with an opportunity to request reconsideration of a decision terminating treatment in one of one applicable client record reviewed.
Client #4 was admitted on August 21, 2025 and was involuntarily terminated on February 25, 2026. There was no documentation, in the record, indicating the client had been given the opportunity to request reconsideration of the involuntary termination from the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
In order to address citation 709.33(a) Notification of termination.
On Monday August 17, 2026, client #4 will be sent a letter of discharge notification stating reason for termination of treatment and instructions to request reconsideration of the decision to terminate treatment if Client #4 choose to reengage treatment.
Effective August 17, 2026, missed appointment written correspondence will include language to notify Clients in advance of the intent to terminate treatment for repeated failure to engage in treatment over a specified time-period. The correspondence will also include termination of treatment preventive measures and instructions on how to request reconsideration of the decision to terminate treatment.
On 8/28/2026 the project will conduct an all-staff meeting discussing the existing discharge letter and the revised missed appointment letter. Staff will also be reminded to notify Clients via written correspondence immediately of the intent to discharge and to ensure all required elements of 709.33 (b) are included in the correspondence.
Additionally, staff will be reminded of the need to capture email addresses and to enroll Clients in the Portal to ensure efficient and quality correspondence that is integrated in the EHR system.
Monitoring: On-Going
Clinical supervisor and director will meet weekly with discharge and admissions department to review discharges to ensure proper notification of the intent to discharge has been executed.
The Discharge and Admissions Department will not finalize a discharge until proof of notification has been secured.
The Discharge and Admission Department will provide quarterly reports on discharges and status of compliance at time of discharge based on regulation to the BH Leadership Team and CBHO.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a valid consent to treatment, during the intake and admission process, in three of seven client records reviewed.
Client #1 was admitted on February 3, 2026 and was still active at the time of the inspection. There was documentation of a consent for mental health treatment in the record; however, there was no documentation of a substance use disorder consent to treatment at the time of the inspection.
Client #3 was admitted on March 24, 2026 and was still active at the time of the inspection. There was documentation of a consent for mental health treatment in the record; however, there was no documentation of a substance use disorder consent to treatment at the time of the inspection.
Client #6 was admitted on February 11, 2026 and discharged on April 20, 2026. There was documentation of a consent for mental health treatment in the record; however, there was no documentation of a substance use disorder consent to treatment at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to address citation 709.91(b), the primary counselor will notify Client #1 and Client #3 during their next scheduled individual counseling or group therapy session, whichever comes first, of the need to complete the consent for drug and alcohol treatment in accordance with 709.91 (b).
Counselor will ensure that the consent to treatment align with the current treatment episode and is fully executed prior to the start of their scheduled session.
Clinical supervisor will review the EHR within 30-minutes of the next scheduled session for Client #1 and #3 to ensure a consent for drug and alcohol treatment has been obtained and meets standard 709.91 (b) prior to the end of the scheduled session.
Additionally, it was discovered during the completion of a root cause analysis of this infraction, that additional targeted training is needed during orientation for new hires. As a result, mock exercises have been added to the orientation training targeting the required DDAP Consents to obtain at time of intake and program transfer (episode change). Testing for Consents have also been added.
On August 15, 2026, a training/meeting will be conducted with all registration assistant staff to review the correct process of completing consents based on regulations. This training will include the mock exercises and testing of the existing registration assistants across all locations. This training will also include the need to complete new consent forms whenever a program transfer occurs.
On August 28,2026, an all-staff meeting will take place which will include counselors, registration assistants, and clinical supervisors, to review Standard 709.91 (b) and the proper procedures for completion of consents along with the need to complete new consent forms whenever a program transfer occurs.
Monitoring On-Going
Monitoring: Clinical supervisors and coordinators will do daily review of intakes to ensure that the proper substance abuse authorizations are completed for all D&A clients prior to adding the new client to clinical tracker for compliance monitoring.
Clinical supervisors and coordinators will ensure that Clients transferred from the Mental Health program to the D&A program have new consent forms completed that fully comply with Standard 709.91 (b) prior to signing off on the transfer and placing the transferred client on the clinical tracker for compliance monitoring.
Quality Assurance Department (QA) will conduct on-going monitoring throughout each quarter to ensure the correct consents are being used based on D&A program admission and Standards. QA will provide quarterly reports based on the findings with recommendations for continued improvement.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 counseling services were being provided according to the individual treatment and rehabilitation plan in five of seven client records reviewed.
Client #1 was admitted on February 3, 2026 and was still active at the time of the inspection. The individual treatment plan completed on March 2, 2026 and the treatment plan updates completed on May 4, 2026 and June 29, 2026 indicated the client was to receive one group counseling session per week and one individual counseling session bi-weekly. There was no documentation, in the record, showing the client had received an individual counseling session during the week of May 24, 2026.
Client #2 was admitted on March 17, 2026 and was still active at the time of the inspection. The individual treatment plan completed on March 17, 2026 and the treatment plan updates completed on April 9, 2026 and June 11, 2026 indicated the client was to receive one individual counseling session per week. There was no documentation, in the record, showing the client had received an individual counseling session during the week of May 31, 2026.
Client #5 was admitted on April 13, 2026 and was discharged on July 8, 2026. The individual treatment plan completed on April 13, 2026 and the treatment plan update completed on May 20, 2026 indicated the client was to receive one counseling session per week. There was no documentation, in the record, showing the client received any counseling sessions during the week of May 31, 2026, as well as during the weeks of June 14, 2026 through June 28, 2026.
Client #6 was admitted on February 11, 2026 and was discharged on April 20, 2026. The individual treatment plan completed on February 11, 2026 and the treatment plan update completed on March 25, 2026 indicated the client was to receive one group counseling session per week and one individual counseling session bi-weekly. There was no documentation, in the record, showing the client had received any group counseling sessions during the entirety of the client ' s treatment episode.
Client #7 was admitted on September 19, 2025 and was discharged on May 29, 2026. The individual treatment plan completed on September 19, 2025 and the treatment plan updates completed on October 16, 2025, December 18, 2025, February 26, 2026, and April 30, 2026 indicated the client was to receive one group counseling session per week and two individual counseling sessions per month. There was no documentation, in the record, showing the client had received any group counseling sessions during the months of December 2025, January 2026, and April 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
709.92(c) LICENSURE
Treatment and rehabilitation services:
709.92. Treatment and rehabilitation services. (c) The project shall ensure that counseling services are provided according to the individual treatment and rehabilitation plan.
To ensure compliance with §709.92(c), the Program has implemented procedures to ensure counseling services are delivered in accordance with each member's individual treatment and rehabilitation plan while supporting member engagement, individualized care, and value-based treatment principles.
Effective July 27, 2026, treatment and rehabilitation plans will utilize a flexible, member-centered approach that allows treatment services to be based on the member's clinical needs, treatment goals, preferences, and ability to participate in treatment. Counselors and members will collaborate to establish an appropriate treatment schedule that promotes recovery and meaningful engagement in services.
The treatment and rehabilitation plan will generally encourage members to participate in a minimum of three treatment services per month, which may include any combination of: Individual counseling sessions; and/or Group therapy sessions.
Members may participate in up to eight treatment services per month when clinically indicated and mutually agreed upon by the member and counselor. Additional services scheduled will be documented in the plan section of the progress note with clinical justification as needed. The impact of additional services received will be discussed in the updated treatment and rehabilitation plan.
In addition to counseling services, members may access other supportive services as clinically appropriate, including: Peer Support Services, Community Health Worker Services, Psychiatric Evaluation, and Medication Management Services.
Members who fail to attend a scheduled treatment session will receive follow-up and reengagement efforts consistent with agency policy. Engagement interventions may include appointment reminders, telephone outreach, motivational interventions, and other clinically appropriate activities intended to support continued participation in treatment.
If a member is unable to participate in the minimum anticipated treatment frequency despite engagement efforts, the treatment and rehabilitation plan will be reviewed and revised to reflect the member's current level of participation, clinical needs, treatment goals, and readiness for treatment. Modifications to service frequency will be documented in the clinical record and incorporated into the updated treatment and rehabilitation plan.
Monitoring and Oversight
Clinical Supervisors will ensure that the frequency of individual counseling and group therapy sessions identified in each treatment and rehabilitation plan is entered into the DA Tracker. The DA Tracker will be reviewed weekly to monitor compliance with scheduled treatment frequency and identify members who may require additional outreach, treatment plan review, or engagement interventions.
Clinical Supervisors will document monitoring activities and provide ongoing oversight to ensure counseling services are delivered in accordance with the individualized treatment and rehabilitation plan and remain compliant with §709.92(c).
Quality Assurance
As part of the program's continuous quality improvement process, treatment scheduling and service utilization data will be reviewed regularly to ensure counseling services are being provided in accordance with member treatment plans. Findings will be used to identify opportunities for improvement in treatment engagement, service delivery, and compliance with §709.92(c). |
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 maintain a complete client record on an individual, which is to include the documentation of case consultation notes, in three of five applicable records reviewed.
Per the facility's policy and procedure manual, case consultation notes are to be completed every 90 days.
Client #1 was admitted on February 3, 2026 and was still active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client #2 was admitted on March 17, 2026 and was still active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client #4 was admitted on August 21, 2025 and was discharged on February 25, 2026. There were no case consultation notes documented in the record at the time of the inspection.
This is a repeat citation from the August 13, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address the deficiency associated with standard 709.93 (a)(8) the facility will comply with the completion of case consultation notes every 90 days for the first year and annually thereafter.
The following measures will be put in place, so that case consultation standards are met: The Clinical Supervisor in conjunction with the Quality Assurance team will utilize the tracking system for all active cases. The tracker will not display any patient identifying information except for the client record number. The tracker will be reviewed by the Clinical Supervisor, the Counselor III and the Drug & Alcohol Committee on a weekly basis for the first 90 days and monthly thereafter.
The Clinician will bring current active charts into compliance with standard 709.93 (a)(8) within the next 30 days, and complete case consultation notes every 90 days for the first year to be presented in clinical meetings two times a month. Clinician will check daily audits of case consultations provided by the Quality Assurance Department, and complete case consultations in compliance with standard 709.93 (a)(8).
Clinical Supervisors will monitor the quality assurance report beginning August 17,2026. Clinical Supervisors will also complete daily audits of at least five charts from each clinician and review charts for compliance during biweekly supervision.
Site director will be responsible to provide on-going monitoring of the Clinical Supervisors to ensure review of client records to meet facility policy and compliance with standard 709.93 (a)(8).
An in-service meeting will be held on August 28, 2026, with the Clinical staff, to review timelines regarding the development, approval, monitoring, and evaluation of client services, which will include but not be limited to consents, treatment planning, case consultation, level changes, and discharge.
Monitoring: Site directors and clinical supervisors will utilize the drug and alcohol tracker to help inform and support counselors for completion of case consultation. |