INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 27, 2025 through October 28, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clearbrook Treatment Centers, LLC dba Huntington Creek Recovery 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on the review of personnel records and supervision logs, the project failed to ensure that a counselor assistant with a high school diploma only counsel clients under direct observation of a trained counselor or clinical supervisor for the first three months of employment and only under close supervision for the remaining nine months of the counselor assistant ' s first year of employment.Employee #8 was employed as a counselor assistant on April 1, 2025 and was a current employee at the time of the inspection. Due to employee #8 only having a high school diploma, employee #8 was only to only counsel clients under direct observation of a trained counselor or clinical supervisor for the first three months of employment and only under close supervision for remaining nine months of the counselor assistant ' s first year of employment; however, there was no documentation that the employee received direct observation from April 14, 2025 through July 1, 2025, nor was there documentation that the employed received close supervision thereafter, which entailed one hour of case review and one hour of direct observation per week.The findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinical Director has taken over the supervision of all counselors.The Clinical Director has scheduled the times for the CA supervisions that meets the requirements for a CA with a high school diploma. This particular CA has had direct observation for a total on one month, based on the supervision notes. This CA will continue to have direct observation for two more months. The Clinical Director, Clinical Manager, and/or qualified counselor will provide the direct observation of the CA when with clients. Once the period of direct observation is completed, the Clinical Director or Clinical Manager will provide the close supervision for a period of nine months that will include one hour of case review and one hour of direct observation per week. For any new CAs with a high school diploma or equivalent, the Clinical Director Clinical Manager, and/or qualified counselor will provide the direct observation of the CA for a period of three months and then close supervision for a period on nine months. For new CAs with an Associate's degree or higher, the Clinical Director or Clinical Manager will provide close supervision for the period of time as designated by DDAP regulations. The Clinical Director will complete the CA supervision form for each supervision completely and appropriately. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records and the project ' s policies and procedures, the project failed to document a written individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor within thirty days of hire and yearly in January thereafter, in eight out of eighteen records reviewed. Employee #2 was hired on April 22, 2024, and was to have an annual individual training plan documented by the end of January 2025; however, the annual individual training plan was not documented in the personnel record until October 20, 2025.Employee #3 was hired on August 18, 2025, and was to have an initial individual training plan documented by September 18, 2025; however, the initial individual training plan was not documented in the personnel record until October 20, 2025.Employee #4 was hired on May 12, 2025, and was to have an initial individual training plan documented by June 12, 2025; however, the initial individual training plan was not documented in the personnel record until October 20, 2025.Employee #5 was hired on July 16, 2025, and was to have an initial individual training plan documented by August 16, 2025; however, the initial individual training plan was not documented in the personnel record until October 20, 2025.Employee #6 was hired on February 17, 2025, and was to have an initial individual training plan documented by March 17, 2025; however, the initial individual training plan was not documented in the personnel record until October 20, 2025.Employee #7 was hired on May 10, 2022, and was to have an annual individual training plan documented by the end of January 2025; however, the annual individual training plan was not documented in the personnel record until October 18, 2025.Employee #8 was hired on April 1, 2025, and was to have an initial individual training plan documented by May 1, 2025; however, the initial individual training plan was not documented in the personnel record until October 18, 2025.Employee #9 was hired on September 1, 2022, and was to have an annual individual training plan documented by the end of January 2025; however, the annual individual training plan was not documented in the personnel record until October 18, 2025.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The initial individual training plans will be completed within 30 days of hire by their supervisor. Annaul training plans will be completed in Q4 of each year during the employee's annual performance evaluation.
The Quality Director will monitor for compliance on a quarterly basis for the initial individual training plans and in January of each year for the annual training plans.
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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, the facility failed to ensure that nine of eighteen employees received a minimum of six hours of HIV/AIDS and four hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.Employee # 10 was hired as the behavioral health assistant supervisor on July 12, 2022 and was still in that position. Employee #10 was due to have the communicable disease trainings no later than July 12, 2024. There was no documentation that the employee received six hours of HIV/AID training and four hours of TB/STD training at the time of the inspection.Employee # 11 was hired as the program monitor on August 17, 2023 and was still in that position. Employee #11 was due to have the communicable disease trainings no later than August 17, 2025. There was no documentation that the employee received four hours of TB/STD training at the time of the inspection.Employee # 12 was hired as the behavioral health assistant on May 3, 2023 and was still in that position. Employee #12 was due to have the communicable disease trainings no later than May 3, 2025. There was no documentation that the employee received six hours of HIV/AID training and four hours of TB/STD training at the time of the inspection.Employee # 13 was hired as the behavioral health assistant on August 5, 2021 and was still in that position. Employee #13 was due to have the communicable disease trainings no later than August 5, 2023. There was no documentation that the employee received six hours of HIV/AID training and four hours of TB/STD training at the time of the inspection.Employee # 14 was hired as the behavioral health assistant on March 15, 2022 and was still in that position. Employee #14 was due to have the communicable disease trainings no later than March 15, 2024. There was no documentation that the employee received six hours of HIV/AID training and four hours of TB/STD training at the time of the inspection.Employee # 15 was hired as the behavioral health assistant on April 7, 2022 and was still in that position. Employee #15 was due to have the communicable disease trainings no later than April 7, 2024. There was no documentation that the employee received six hours of HIV/AID training and four hours of TB/STD training at the time of the inspection.Employee # 16 was hired as the program monitor on February 24, 2023 and was still in that position. Employee #16 was due to have the communicable disease trainings no later than February 24, 2025. There was no documentation that the employee received four hours of TB/STD training at the time of the inspection.Employee # 17 was hired as the behavioral health assistant on June 1, 2022 and was still in that position. Employee #17 was due to have the communicable disease trainings no later than June 1, 2024. There was no documentation that the employee received six hours of HIV/AID training and four hours of TB/STD training at the time of the inspection.Employee # 18 was hired as the program monitor on January 31, 2023 and was still in that position. Employee #16 was due to have the communicable disease trainings no later than January 31, 2025. There was no documentation that the employee received four hours of TB/STD training at the time of the inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Existing employees who have not yet completed these trainings will complete them by 01/31/2026 either through DDAP or onsite by the Nursing Director or designated nursing staff. New employees will be notified of these trainings upon orientation by their supervisor and via an email from the Quality Director. New employees will complete these trainings either through DDAP or onsite by the Nursing Director or designated nursing staff within one or two years, depending on the DDAP requirements for the job position. The employee's supervisor and the Quality Director will monitor for compliance and follow-up as needed.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection on October 28, 2025, the facility failed to ventilate toilet and washrooms by exhaust fan or window.The exhaust fan in the joint bathroom for Hope House resident rooms two and four was not functioning and there was no window in that bathroom to provide ventilation.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Facility Operations will install a new bathroom fan by 11/12/25. The Facility Operations Director or designee will monitor to ensure that exhaust fans in the bathrooms without windows are operating properly. In addition, the staff member responsible for completing the weekly facility rounds will submit a work order for any exhaust fans found to be not fully operating.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on October 28, 2025, the facility failed to ensure that facility heaters were permanently mounted or installed. A portable heater was observed in a counseling office in the adolescent unit.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Operations Director immediately removed the portable heater. The Facility Operations Director tested the heating system in the counselor's office where the portable heater was found. The heating system is fully functional. All staff were reminded that portable heaters are not permitted. The Facility Operations Director or designee will monitor to ensure that portable heaters are not present in any rooms. In addition, the staff member responsible for completing the weekly facility rounds will either remove or instruct staff to immediately remove any portable heaters found.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 November 2024 through September 2025, the facility failed to maintain written fire drill records that indicated the exit routes used and whether the fire alarm or smoke detector was operative.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Quality Director will revise the drill form by 12/31/25 to include prompts for the exit routes used and whether the fire alarm or smoke detector was operative. The fire drill form is completed by the BHA onsite at the time of the drill or event. The Risk Management Assistant reviews all drill forms after a drill/event occurs and the form submitted within a week to ensure that the drill/event was conducted and documented properly. Any problem areas are addressed in an instructional meeting for direct care staff held by the Risk Management Assistant. In addition, effective immediately, the Facility Operations Director or designee will monitor fire alarms and smoke detectors are operative and will repair/replace these as necessary. The staff responsible for weekly facility rounds will ensure that exit routes remain clear, along with any other staff member that observes any obstruction. In addition, the staff responsible for weekly facility rounds and/or the Risk Management Assistant will immediately inform the Facility Operations Director of any inoperative fire alarms or smoke detectors.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for notifying emergency contacts within twelve hours if a client leaves against staff advice in two of four applicable records reviewed.Client #5 was admitted to the inpatient non-hospital residential level of care on December 13, 2024 and was discharged Against Staff Advice (ASA) on January 31, 2025. The facility failed to follow their policy related to ASA discharges of calling the emergency contact within twelve hours.Client #13 was admitted to the inpatient non-hospital detox level of care on August 4, 2025 and was discharged Against Staff Advice (ASA) on August 8, 2025. The facility failed to follow their policy related to ASA discharges of calling the emergency contact within twelve hours.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinical Director and/or the Clinical Manager will conduct a supervision with the counselors on notification to EMCs within 12 hours of an AMA or ACA discharge. The Clinical Director and/or the Clinical Manager will review the the charts of the AMA/ACA discharged clients to ensure documentation regarding EMC notification is present in the chart.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on the review of client records and the project ' s policies and procedures manual, the project failed to document a complete client record on an individual that included a follow-up contact note within one week of discharge, per facility policy, in three of four applicable records reviewed.Client #12 was admitted on January 26, 2025 and was discharged on January 30, 2025. There was no follow-up contact documented in the client record.Client #13 was admitted on August 4, 2025 and was discharged on August 8, 2025. There was no follow-up contact documented in the client record.Client #14 was admitted on March 29, 2025 and was discharged on April 4, 2025. There was no follow-up contact documented in the client record.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The staff member responsible for the aftercare follow-up call is no longer with the facility. The new employee responsible for this task (if Acadia's Pennsylvania Access Center has not already made the call) will be fully trained by the Clinical Director or designee by 12/15/2025, will make the call, and will ensure that documentation is present in the client record. The Clinical Director and/or the Admissions Supervisor will monitor monthly, at a minimum, for compliance.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on the review of client records and the project ' s policies and procedures manual, the project failed to document a complete client record on an individual that included a follow-up contact note within one week of discharge, per facility policy, in four of four applicable client records reviewed.Client #4 was admitted on November 7, 2024 and was discharged on November 27, 2024. There was no follow-up contact documented in the client record.Client #5 was admitted on December 13, 2024 and was discharged on January 31, 2025. There was no follow-up contact documented in the client record.Client #6 was admitted on June 12, 2025 and was discharged on June 26, 2025. There was no follow-up contact documented in the client record.Client #7 was admitted on January 2, 2025 and was discharged on February 11, 2025. There was no follow-up contact documented in the client record.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The staff member responsible for the aftercare follow-up call is no longer with the facility. The new employee responsible for this task (if Acadia's Pennsylvania Access Center has not already made the call) will be fully trained by the Clinical Director or designee by 12/15/2025, will make the call, and will ensure that documentation is present in the client record. The Clinical Director and/or the Admissions Supervisor will monitor monthly, at a minimum, for compliance.
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