INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal, and methadone and buprenorphine monitoring inspection conducted on September 22 & 23, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Care LLC, dba State College Medical 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:
|
Plan of Correction
|
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
Based on a review of administrative documents, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.
The last documented sign-off from the project director was dated January 15, 2025, and the next one was due no later than January 15, 2026; however, the documentation provided was dated August 11, 2026, and signed by the compliance specialist. When the document was reviewed with the project director, their signature was also added on to the document.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director will review and ensure policies are updated and issue a signed attestation to that effect by January 15, 2027.
|
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.
|
Observations
Based on a review of patient records, the facility failed to ensure that the annual evaluation of each patient's status was completed by the patient's counselor and was reviewed, dated and signed by the medical director annually on the patient ' s admission date, per facility policy, in one out of six applicable records reviewed.
Patient #8 was admitted on June 5, 2023, and was still active at the time of the inspection. The annual evaluation was due no later than June 5, 2026; however, it was not completed until June 8, 2026.
This is a repeat citation from September 11, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Supervisor will print list of Annual Evals due the month prior and will be sure they are completed during that month. Will follow up with individual counselors during supervisions to be sure the annual evals were completed before due date. ED will monitor completion and signatures to be sure they are fully completed the month prior to the due date. |