INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on March 17 & 18, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Wilkes-Barre Treatment LLC dba Clearbrook 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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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 a review of ten personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #10 was hired on June 18, 2025 as a counselor assistant. Employee #10 has a high school diploma and 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. Employee #10's personnel record did not have documentation of direct observation occurring from June 18, 2025, through the time of the inspection or close supervision documented from September 18, 2025, to the time of the inspection.
Direct observation is defined by regulation as follows: " In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities " .
Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " .
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Corrective Action:
Upon review, it was confirmed that direct observation and close supervision were occurring; however, documentation of said observation and supervision was not completed in accordance with regulatory requirements. As part of the corrective action, retrospective documentation has been completed to accurately reflect the observation and supervision that took place during the identified period. A new form has been developed to capture the type and frequency of direct observation and close supervision, ensuring that all required documentation is completed contemporaneously and maintained in the personnel record going forward.
Ongoing Monitoring:
The Clinical Director will conduct monthly reviews of supervision documentation for all counselor assistants currently within their required direct observation or close supervision period to verify that documentation is completed. Any gaps identified will be corrected promptly. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs for the partial hospitalization building from January 2025 - December 2025, the facility failed to prepare alternative exit routes to be used during fire drills, as all drills utilized the same exit route.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
The Facilities Manager ensured that clients participating in outpatient and partial hospitalization programming utilized alternative exit routes during the monthly fire drill conducted on April 3, 2026. Alternative exit routes were documented appropriately on the fire drill log at the time of the drill.
Ongoing Monitoring:
To maintain continued compliance, the Facilities Manager will submit completed monthly fire drill logs to the Compliance and Quality Department following each drill. The Compliance and Quality Department will conduct routine spot checks of fire drill logs to verify that exit routes are being alternated on a monthly basis. In the event that a spot check reveals a deficiency, corrective measures will be implemented promptly. |
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 a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of twenty-three records reviewed.
Client #1 was admitted to the detox level of care on November 13, 2025 and stepped down to the residential level of care on November 19, 2025. Client #1 then stepped down to the partial hospitalization level of care on December 13, 2025 until January 23, 2026, at which time they stepped down to outpatient level of care and remained active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for a family member; however, there was documentation in the client record that the facility called the family member on November 13, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
Upon review of this deficiency during the survey, the Clinical Director discussed this consent with the surveyor, noting that the intake coordinator responsible for this consent lapse was terminated due to these issues. The patient was discharged prior, and a consent was not able to be obtained. On April 1, 2026, the Clinical Director conducted a refresher training with clinical and intake staff reinforcing the requirement that informed and voluntary consent must be properly documented in the client record prior to the disclosure of any information to a third party. On April 8, 2026, the Clinical Supervisor audited five charts to ensure that any family contact notes included documented consent for that individual. No discrepancies were found.
Ongoing Monitoring:
Monthly chart audits conducted by the Clinical Supervisor and Clinical Director will include a review to verify that all required consents are obtained and documented prior to any disclosure of information. Any discrepancies identified will be corrected in real time. |