INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 29- 30, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Family Service & Children's Aid Society 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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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to include documentation of medical histories at intake in four of seven records reviewed.
Client #1 was admitted February 24, 2025 and discharged June 16, 2025.
Client #3 was admitted February 3, 2025 and discharged May 28, 2025.
Client #5 was admitted March 25, 2025 and still a current client.
Client #7 was admitted May 2, 2025 and still a current client.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 16, 2023 and September 26, 2024 licensing inspection.
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Plan of Correction
The program director and clinical supervisor reviewed this deficiency on 10/10/25 and spoke to staff during the following week about why medical histories are not completed. Based on feedback from the staff program director and clinical supervisor agreed that medical data will be centralized into a service that will be added to the intake form group rather than separated into the three sections of the client's profile as this was cumbersome for staff to attend to.
Staff will also be instructed to insert 'NA' in any field that is not applicable instead of leaving it blank to demonstrate a review of medical history.
The change request was submitted to the agency form builder on 10/20/25 and is expected to be implemented by 1/01/2026.
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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, the facility failed to complete initial treatment plans according to agency policy and procedure in three of seven records.
According to agency policy and procedures, the preliminary treatment plan is completed at intake, initial treatment plan is completed within 30 days, and all additional updates are done every 60 days thereafter.
Client #3 was admitted February 3, 2025 and discharged May 28, 2025. The client ' s initial treatment plan was due March 5, 2025 but not completed until March 24, 2025.
Client #4 was admitted February 19, 2025 and discharged May 30, 2025. The client ' s initial treatment plan was due March 21, 2025 but not completed until March 25, 2025.
Client #7 was admitted May 2, 2025 and still a current client. The client ' s initial treatment plan was due June 1, 2025 but not completed until June 6, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director reviewed this deficiency with the clinical supervisor and the CEO on 10/10/25. At this time, it was decided to change program policy from 'initial treatment plan is completed within 30 days,' to 'initial treatment plan will be completed by the fifth session.' This policy change will be effective as of 11/1/2025. This will account for potential missed appointments or changes in scheduled sessions.
All treatment plans will be tracked and monitored by the clinical supervisor to ensure they are done by the fifth session.
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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 the documentation of medical histories at intake was submitted and approved by the Department for the October 17, 2023 and September 26, 2024 annual licensing inspections. Medical histories were again found to be a deficiency in the September 30, 2025 licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Program director and clinical supervisor discussed this deficiency on 10/10/25. To ensure that all corrections are followed the clinical supervisor will maintain a compliance list beginning November 1, 2025, to review with staff. The clinical supervisor will review this list on a weekly basis and provide time for counselor to complete identified tasks if extra time is needed before documents are out of compliance.
The program director will receive updates on a weekly basis from the clinical supervisor regarding compliance and will utilize progressive disciplinary steps according to policies and procedures in cases where compliance is not met as the new plan of correction protocol will become policy.
Ongoing compliance will be incentivized through monthly recognition during program staff meetings.
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