This report is a result of an on-site licensure renewal inspection. The physical plant inspection was conducted on February 11, 2026, and the client record review was conducted February 18, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the annual inspection, Pennsylvania Counseling Services, 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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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of four applicable records reviewed.Client #3 was admitted on August 27, 2025 and was still active at the time of the inspection. A treatment plan was completed on September 30, 2025, and the next update was due no later than November 29, 2025; however, it was not completed until December 3, 2025. The next update was due no later than February 1, 2026; however, there was no documentation that one was completed. Client #5 was admitted on July 21, 2025 and discharged on December 22, 2025. A treatment plan was completed on October 7, 2025, and the next update was due no later than December 6, 2025; however, there was no documentation that one was completed. Client #7 was admitted on July 11, 2025 and discharged on October 15, 2025. A treatment plan was completed on August 6, 2025, and the next update was due no later than October 5, 2025; however, it was not completed until October 15, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will ensure that all staff receive re-education regarding the requirement that treatment plan updates must be completed within regulatory timeframes (every 60 days). Local office administration will maintain a tracking system to monitor and ensure treatment plan updates are submitted within the required 60-day period. The Quality Improvement Department will conduct random chart reviews to verify that staff are adhering to regulatory requirements and that the internal tracking system is effectively maintaining compliance. |