INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 05, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Harbor Counseling 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using Department approved curriculum withing the regulatory timeframe.
Employee #7 was hired as a counselor on October 7, 2024 and was still in the position at the time of the inspection. The employee completed the required 6 hours of training of HIV/AIDS on October 8, 2024; however, there was no documentation that the employee completed the required 4 hours of training for TB/STD within the regulatory timeframe.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure we receive training using the DDAP approved curriculum, Harbor Counseling has always relied on DDAP's training website for the required TB/STD training for its staff. For the past several years, TB/STD training is difficult to find. Our staff members have been on numerous waiting lists for the virtual training and have been unable to register. The in-person trainings are generally 3-4 hours from our location and entail travel expenses that are not within our budget. These trainings are also difficult to register for as they fill up fast. We have reached out to our SCA requesting TB/STD training be brought to our area but have received no response. We have now been informed that we do not need to use the DDAP training, but only a training that follows the approved curriculum. We are in possession of a 19-page Licensing Alert from 1997 detailing the approved curriculum and have been instructed to find a doctor who is willing to use this curriculum to train our staff.
Our plan of correction is as follows:
1. Immediate Corrective Action: Employee #7 is scheduled to attend an in-person DDAP TB/STD training on 3/3/26 in Port Matilda, PA.
2. Systemic Change: Contact local physicians, give them a copy of the 1997 Licensing Alert and attempt to find someone who is willing to conduct TB/STD training for us. If we are unable to arrange this, reach out to larger providers state-wide to see if we could attend training at their facility. Contact our SCA Director again to request that DDAP TB/STD training be scheduled in our area. Continue exploring options until a solution is found.
3. Staff Education: Conduct in-service education session with all supervisory staff on the requirements of 704.11(c) emphasizing the importance of timely completion and documentation of TB/STD training.
4. Ongoing Compliance Monitoring: Conduct quarterly audits of personnel records to confirm that all staff and volunteers have completed the required trainings within the designated timeframes.
5. Responsible Party: Project Director, Clinical Director, Clinical Supervisor
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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 seven client records, the facility failed to obtain informed and voluntary consent from the client for the disclosure of information in one of the seven records reviewed.
Client #2 was admitted on May 21, 2025, and discharged December 05, 2025. There was documentation that information was disclosed to a primary and secondary funding source while the client was in treatment; however, the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information for the secondary funder. Facility did confirm that billing had occurred.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Immediate remediation: Obtain retroactive consent form from client #2 for the secondary funding source disclosure, if feasible. Review all client records for active clients to ensure that informed and voluntary consent forms for disclosure to all funding sources are present and properly completed.
2. Staff training: Conduct mandatory training for all staff involved in client admissions, recordkeeping, and disclosures. Training will emphasize the importance of obtaining and documenting informed and voluntary consent before any information is released to third parties, including all funding sources.
3. Process improvement: Revise procedures to require verification of completed consent forms for each client and each funding source prior to any disclosure ? particularly for when there are changes in a client's funding source after admission into treatment has occurred.
4. Ongoing monitoring: Establish monthly audits of client records to confirm that all required consent documentation is present and accurate.
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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 ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information within 90 days of admission, per facility policy, in five of seven applicable records reviewed.
Client #2 was admitted on May 21, 2025 and was discharged on December 05, 2025. A case consultation was due no later than August 21, 2025; however, one was not documented until September 08, 2025.
Client #3 was admitted on March 12, 2025 and was discharged on September 25, 2025. A case consultation was due no later than June 12, 2025; however, one was not documented until July 17, 2025.
Client #5 was admitted on March 31, 2025 and was active at the time of the inspection. A case consultation was due no later than June 31, 2025; however, one was not documented until July 09, 2025.
Client #6 was admitted on September 04, 2025 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
Client #7 was admitted on June 19, 2025 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Immediate Remediation: For all active clients (including Clients #5, #6, and #7), case consultations will be done and the notes will be completed and added to their records within 10 business days.
All discharged client files identified with missing or late case consultation notes (Clients #2 and #3) will be reviewed, and documentation added as appropriate.
2. Staff Training: All clinical staff will receive training on the requirements of 709.93, with emphasis on the 90-day timeframe for case consultations and proper documentation procedures. Training will be completed by 1/31/26 and documented in personnel files.
3. Policy and Procedure Review: The facility's policy on case consultation documentation will be reviewed and revised, if appropriate, to clarify responsibilities, timelines, and oversight processes. The policy will be distributed to all staff and acknowledgement of receipt will be documented.
4. Ongoing Monitoring: A monthly audit will be conducted for the next six months to ensure compliance with case consultation documentation requirements. Results of audits will be reviewed in management team meetings and corrective action will be taken as needed.
5. Responsible Personnel: Clinical Director, Clinical Supervisor
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