INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 22, 2025 through October 23, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pottstown Comprehensive Treatment 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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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of seven client records reviewed.
Client #2 was admitted on July 7, 2025 and was active at the time of the inspection. The facility failed to document a release of information for the funding source until September 24, 2025, and it was verified that billing had occurred.
Client #6 was admitted on April 3, 2015 and was active at the time of the inspection. The client ' s insurance company changed on October 23, 2022; however, the facility failed to document a release of information for the new funding source, and it was verified that billing had been occurring.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Pottstown CTC Clinical Supervisor and Administrative staff will ensure that all release of information forms are obtained for all patients. All releases of information will be reviewed for accuracy and that these releases of information are completed in its entirety on a monthly basis. This regulatory guideline was reviewed wth Acadia Billing Dept. to ensure proper notification to CTC staff is made for changes in funding source. This information was also presented during the October 29, 2025 staff meeting to ensure compliance to this regulation.
The CTC Director will monitor compliance in this area. The ROI for Pt #2 was signed 9/24/2025. Pt. #6 ROI for the new funding source was signed on 11/17/25. |
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 the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one applicable client record reviewed.
Client #4 was admitted on April 14, 2025 and was involuntarily discharged on August 1, 2025. There was no documentation in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Pottstown CTC Clinical Management Team will ensure patient records will have documented evidence of patient's written notification of a decision to involuntarily terminate patient's treatment. CTC Clinic Director reviewed this requirement during staff meeting on October 29, 2025. CTC Clinic Director will monitor for compliance to this regulation. |