INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 26, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation Clearbrook Treatment Centers, LLC d/b/a Huntington Creek Recovery Center, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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, observation logs and the Client Observation and Rounding policy, the facility failed to follow its policy in two of three records reviewed.Per the Client Observation and Rounding policy, residential clients are to be monitored every two hours. This is to be used for all clients, noting activity, behavior and location.Client # 1 was admitted on April 23, 2026, and discharged on April 28, 2026. An undated observation form had no observations documented durimg the following times; 10:30 am, 1:15 pm, 6:00 pm, 7:15 pm, and 8:30 pm. A second undated observation form had no observations documented at 8:30 pm. A third undated observation form was missing Client # 1 ' s name. A fourth undated observation form had no observations documented. A fifth undated observation form had no observations documented during the following times; 6:00 pm, 7:15 pm, and 8:30 pm. Lastly, a sixth undated observation form had no observations documented during the following times; 9:00 am blank, 1:15 pm, 6:00 pm, 7:15 pm and 8:30 pm.Client # 2 was admitted on April 28, 2026, and discharged on April 29, 2026. An undated observation form was missing Client # 2 ' s name. A second observation form had no observations documented.
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Plan of Correction
On 06/09/26, program staff were instructed to complete observation checks as indicated in the policy.
The Director of Q&PI is revising the form for client observation checks to include all required elements as identified by the leadership team. The new form will be implemented by 06/15/26.
Rounding forms will be given to the Patient Support Manager who will review them for accuracy and completion. The Patient Support Manager will provide immediate instruction to the team if improvement is needed. The Patient Support Manager will upload the rounding forms weekly to an internal shared folder and will also email these to the CEO and Director of Q&PI weekly for additional review. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of client records, the Incident Reporting policy, and administrative documentation, the facility failed to follow its procedures to respond to a claim of sexual assault by staff or a client.Per the Incident Reporting policy, any staff member who witnesses, discovers, or has direct knowledge of an incident must complete an incident report before the end of the shift/workday. The supervisor will notify the Risk Manager of a serious incident as well as take the lead in investigating non-serious incidents. The incident report will be routed to the facility risk manager within 24 hours of the incident. There was a claim of a sexual assault occurring on April 29, 2026. An incident report and investigation were not completed until June 1, 2026.
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Plan of Correction
Effective immediately (06/09/26), leadership will ensure that incident reports are completed according to policy. Incident reports for serious incidents will be sent to the Risk Management Assistant within 24 hours for review and for an investigation to commence. The Risk Management Assistant will conduct all reporting to DDAP in accordance with regulations.
Department management will oversee that their staff provide immediate notification to the Risk Management Assistant of any serious incidents and of submission of the incident report to the Risk Management Assistant within 24 hours. The Director of Q&PI reviews incidents with the Risk Management Assistant monthly. The Risk Management Assistant provides additional training to direct care staff whenever incident reporting by them requires improvement. |
709.15(b) LICENSURE Subchapter B.Licensing Procedures.Right to en
709.15. Right to enter and inspect.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
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Observations
Based on a direct, onsite request for information by DDAP staff, the facility failed to provide full and free access to the records of the facility and its clients, as per regulatory requirements. DDAP staff requested the facility ' s internal incident reports on May 26, 2026, and were denied access to these documents This finding was reviewed with facility staff after the onsite complaint investigation.
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Plan of Correction
On 06/09/26, the CEO provided instruction to facility leadership on providing access to records to DDAP that included informational guidance from the Acadia SVP of Quality & Risk. Also, the CEO instructed leadership to contact him for additional guidance and instruction during a DDAP visit. |