INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 27, 2026 through May 28, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Aldie Counseling 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 the review of the fire drill log from July 2025 through April 2026, the facility failed to maintain written fire drill records that indicated whether the fire alarm or smoke detector was operative during each unannounced monthly drill in ten out of ten drills reviewed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Chief Executive Officer has reviewed the matter with the Clinical Director and Office Manager. The Officer Manager has made a change to the written form to indicate if the alarm or smoke detector are operational. The new form will be used in all future drills. The Office Manager will ensure compliance with a review of form after each monthly drill is completed. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on the review of patient records, the program failed to maintain onsite a photograph of each patient that included the patient ' s name and birth date in one applicable record reviewed.
Patient #3 was admitted on October 24, 2025, and was discharged March 6, 2026. A photograph of this patient was not documented in the patient record.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The CEO has reviewed the matter with the Chief Nursing Officer, who has initiated the process of ensuring that each patient has a photograph taken within the last 12 months. The process is underway to review each record, and where missing, arrange to have a new photograph taken. The Chief Nursing Officer will ensure, either through direct action or delegation, that the new photograph is taken and uploaded in the patient record. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on the review of patient records, the program failed to transfer patient files which included admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests and current status of the patient in two applicable patient records reviewed.
Patient #3 was admitted on October 24, 2025, and was transferred to another program on March 6, 2026. The transfer packet sent to the receiving program did not contain a psychosocial evaluation.
Client #7 was admitted on November 30, 2023, and was transferred to another program on May 13, 2026. The transfer packet sent to the receiving program did not contain a psychosocial evaluation.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The CEO has reviewed the deficiency with the Clinical Director and Assistant Clinical Director. The Clinical Director will review each transfer packet to ensure that a psychosocial evaluation is included. If an evaluation is not available the packet will not be sent until the document is complete. Compliance will be monitored during regular chart audits conducted by the Assistant Clinical Director. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the program failed to document an annual evaluation of each patient's status that was completed by the patient's counselor and was reviewed, dated and signed by the medical director in one of three applicable patient records reviewed.
Patient #7 was admitted on November 30, 2023, and was discharged on May 13, 2026. The annual evaluation documented in the patient record for November 2025 was not signed by the medical director until the date of the licensing inspection, May 27, 2026.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The CEO has reviewed the deficiency with the Clinical Director and the Medical Director. The Clinical Director with periodic delegation to the Assistant Clinical Director will arrange for the Medical Director to sign the annual evaluation within three (3) business days. The Clinical Director has addressed the matter with staff in group supervision and will continue to reinforce adherence during individual supervision. Compliance will be reviewed as part of regular chart audits. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The project failed to ensure that the intake procedures included the documentation of a psychosocial evaluation in two of six applicable client records reviewed.
Client #2 was admitted on October 30, 2025, and was discharged December 18, 2025. A psychosocial evaluation was not documented in the client record during the intake process.
Client #3 was admitted on October 24, 2025, and was discharged March 6, 2026. A psychosocial evaluation was not documented in the client record during the intake process.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CEO has reviewed the deficiency with the Clinical Director and Assistant Clinical Director. The psychosocial evaluation was not included in some of the records where the client transferred from a higher level of care. To correct the deficiency Aldie will perform its own psychosocial evaluation on all individuals being transferred. The Clinical Director will notify the Assessment Manager when a new client is being transferred. The Assessment Manager will contact the individual to schedule the psychosocial evaluation and upload the information as part of the clinical record. Compliance will be monitored as part of regular chart audits. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure that the intake procedures included the documentation of a preliminary treatment plan during the initial client assessment, per facility policy, in four of five applicable client records reviewed.
Client #1 was admitted on December 24, 2025, and was active at the time of the inspection. Per the projects policies and procedures, the preliminary treatment plan was to be developed on December 24, 2025; however, it was not documented in the client record until January 15, 2026.
Client #3 was admitted on October 24, 2025, and was discharged March 6, 2026. Per the projects policies and procedures, the preliminary treatment plan was to be developed on October 24, 2025; however, it was not documented in the client record until November 7, 2024.
Client #6 was admitted on March 25, 2026, and was active at the time of the inspection. Per the projects policies and procedures, the preliminary treatment plan was to be developed on March 25, 2026; however, it was not documented in the client record until April 30, 2026.
Client #8 was admitted on March 18, 2026, and was active at the time of the inspection. Per the projects policies and procedures, the preliminary treatment plan was to be developed on March 18, 2026; however, it was not documented in the client record until April 9, 2026.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CEO has reviewed the deficiency with the clinical director and assistant clinical director. The preliminary treatment plans were not included when individuals transferred from a higher level of care. The Assessment Manager will now complete the preliminary treatment plan as take of the initial intake and assessment process. The document will become part of the clinical record, and future compliance will be monitored as part of regular chart audits. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 and the facility's policy and procedure manual, the facility failed to develop an individual treatment and rehabilitation plan within 30 days of admission, per facility policy, in four of seven applicable client records reviewed.
Client #1 was admitted on December 24, 2025, and was active at the time of the inspection. Per the projects policies and procedures, a comprehensive individual treatment and rehabilitation plan was to be developed with the client no later than January 24, 2026; however, it was not documented in the client record until March 10, 2026.
Client #3 was admitted on October 24, 2025, and was discharged March 6, 2026. Per the projects policies and procedures, a comprehensive individual treatment and rehabilitation plan was to be developed with the client no later than November 24, 2025; however, it was not documented in the client record until January 13, 2026.
Client #6 was admitted on March 25, 2026, and was active at the time of the inspection. Per the projects policies and procedures, a comprehensive individual treatment and rehabilitation plan was to be developed with the client no later than April 25, 2026; however, it was not documented in the client record until May 15, 2026.
Client #8 was admitted on March 18, 2026, and was active at the time of the inspection. Per the projects policies and procedures, a comprehensive individual treatment and rehabilitation plan was to be developed with the client no later than April 18, 2026; however, it was not documented in the client record until May 27, 2026.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CEO has reviewed the deficiency with the Clinical Director and Assistant Clinical Director, who in turn have addressed the matter in group supervision. The importance of compliance was stressed. The Assistant Clinical Director will track all new admissions via a spreadsheet. The assigned therapist will report back to the Assistant Clinical when the treatment plan is complete. If not complete within 21 days a reminder will be sent to the therapist. Compliance will be monitored as part of regular chart audits. |
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 project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in two out of five applicable records reviewed.
Client #4 was admitted on August 7, 2018, and was discharged on November 6, 2025. Comprehensive treatment and rehabilitation plan updates, documented in the client record on May 20, 2025, and September 17, 2025, indicated that the client was to receive one hour of group counseling sessions per week; however, there were no group counseling sessions documented in the record for the months of September 2025 and October 2025.
Client #7 was admitted on November 30, 2023, and was discharged on May 13, 2026. Comprehensive treatment and rehabilitation plan updates, documented in the client record on July 13, 2025, September 13, 2025, November 13, 2025, and March 10, 2026, indicated that the client was to receive one hour of individual counseling sessions and one hour of group counseling sessions per week; however, there were no individual counseling sessions documented in the record for the weeks of October 26, 2025 through November 1, 2025. November 2, 2025 through November 8, 2025, November 23, 2025 through November 29, 2025, November 30, 2025 through December 6, 2025, January 11, 2026 through January 17, 2026, and February 1, 2026 through February 6, 2026. Additionally, there were no group counseling sessions documented in the record for the month of September.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CEO has reviewed the deficiency with the clinical director and assistant clinical director, who in turn have address the matter in group supervision. The clinical staff have been directed to adjust treatment plan updates to reflect the actual services being provided. If the clinical need for counseling has decreased it must be reflected in the updates. If clients are having difficulty keeping appointments the CRS staff will be involved to encourage engagement and assist with the mitigation of barriers. Progress will be reviewed during individual supervision and compliance monitored during chart audits. |