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 February 26, 2025 through February 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, Wilkes-Barre Treatment LLC dba Clearbrook Treatment Centers 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection on February 28, 2025, the facility failed to ensure privacy so that counseling sessions cannot be seen outside the counseling room. Small group room # 1 in the Clinical Services Building could be seen outside of the room through multiple windows with no window coverings.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 3, 2025, the Director of Operations and the Facilities Manager ordered window tint for the group room window. The installation was completed on Group Room 1 on March 7, 2025, to maintain compliance with confidentiality standards.
The Facilities Director has added a quarterly inspection to the routine equipment preventative maintenance checklist. During these routine rounds, they will assess the privacy of group and therapy rooms, including checks on window tint, blinds, and sound machines. The Executive Director will ensure this corrective action is completed and documented each quarter. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on February 28, 2025, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom as neither were in any client bathrooms in the detoxification or inpatient non-hospital bedrooms. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 4, 2025, the Director of Operations and the Facilities Manager ordered paper towel dispensers for the client bathrooms in Detox and Residential rooms. The installation was completed on March 18, 2025. The Facilities Director has added a quarterly paper towel dispenser check to the routine equipment preventative maintenance checklist for all detox and residential room bathrooms. The Executive Director will ensure this corrective action is completed and documented each quarter. |
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 a review of fire drill logs from March 2024 through January 2025, the facility failed to ensure that any of the fire drill logs included the exit route used for the Gatehouse building. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 5, 2025, the Facilities Director created a fire drill log tailored to the OP/PHP level of care building, ensuring it meets all applicable fire drill requirements. Moving forward, exit routes used during fire drills will be properly documented. The Compliance & Quality Specialist will conduct a quarterly review of the fire drill logs to maintain ongoing compliance. |
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 fourteen applicable client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable records reviewed.Client # 29 was admitted to the inpatient non-hospital level of care on January 5, 2025 and was discharged Against Staff Advice (ASA) on January 19, 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 the project staff during the licensing process.
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Plan of Correction
After a discussion with the Clinical Director, and a review of Client #29's chart, it was determined that the emergency contact was notified. The note was documented as a "Contact Note-Family" on 1/17/25 rather than on the discharge date of 1/19/25. The client had a planned AMA, and their emergency contact was notified on 1/17/25, confirming their agreement with the AMA plan for the 19th.
The facility will continue to adhere to the policy and procedure for documenting the notification of a client's emergency contact when they leave against medical advice.
The AMA incident reports include the question, "Was the emergency contact notified?" The compliance specialist reviews incident reports daily and checks that item for compliance. The Compliance Specialist will print all AMA incident reports and log them in a binder to ensure the documentation is readily available upon request. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of twenty-eight client records, the facility failed to ensure that consent to release information forms included the purpose of disclosure in nine applicable records reviewed.Client # 1 was admitted to the non-hospital detoxification level of care on December 23, 2024 and was transferred to the non-hospital level of care on December 29, 2024. Consent to release information forms to a doctor and pharmacy that were signed by the client on December 23, 2024, were missing the purpose of disclosure.Client # 2 was admitted to the non-hospital detoxification level of care on November 11, 2024 and was transferred to the non-hospital level of care on November 18, 2024. A consent to release information form to a pharmacy that was signed by the client on November 11, 2024, was missing the purpose of disclosure.Client # 4 was admitted to the non-hospital detoxification level of care on November 19, 2024 and was transferred to the non-hospital level of care on November 26, 2024. Consent to release information forms to a doctor and pharmacy that were signed by the client on November 19, 2024, were missing the purpose of disclosure.Client # 6 was admitted to the non-hospital detoxification level of care on October 26, 2024 and was transferred to the non-hospital level of care on October 31, 2024. A consent to release information form to a pharmacy that was signed by the client on October 26, 2024, was missing the purpose of disclosure.Client # 7 was admitted to the non-hospital detoxification level of care on February 21, 2025 and was active at the time of the inspection. A consent to release information form to a pharmacy that was signed by the client on February 21, 2025, was missing the purpose of disclosure.Client # 13 was transferred to the non-hospital level of care on November 10, 2024 and was transferred to the partial hospitalization level of care on November 29, 2024. Consent to release information forms to a doctor and pharmacy that were signed by the client on November 5, 2024, while in a higher level of care at the facility, were missing the purpose of disclosure.Client # 20 was admitted to the partial hospitalization level of care on January 8, 2025 and was active at the time of the inspection. A consent to release information form to a pharmacy that was signed by the client on January 8, 2025, was missing the purpose of disclosure.Client # 21 was admitted to the partial hospitalization level of care on November 18, 2024 and was active at the time of the inspection. A consent to release information form to a pharmacy that was signed by the client on November 18, 2024, was missing the purpose of disclosure.Client # 27 was admitted to the outpatient level of care on January 14, 2025 and was active at the time of the inspection. A consent to release information form to a pharmacy that was signed by the client on January 14, 2025, was missing the purpose of disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The consent form for releasing information has been updated to automatically include the purpose. To reinforce thorough review practices, the Director of Operations organized a refresher training for intake coordinators, and behavioral health technicians ensuring they accurately complete consents with clients at admission, including clearly specifying the purpose of the release of information.
The Intake supervisor met with active clients #20, #21, and #27 and reviewed a new consent-to-release form for the Pharmacy and Doctor to ensure that the purpose of the consent was checked off, the new consent was signed by the clients on 3/27/2025. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to ensure that verification of the individual's identity was obtained during the intake process in one of five applicable records reviewed.Patient # 4 was admitted to the non-hospital detoxification level of care on November 19, 2024 and transferred to a lower level of care on November 26, 2024. The record did not contain documentation that the individual's identity was verified during intake. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A refresher training was conducted for intake staff, behavioral health technicians, and nursing personnel to reinforce the importance of reviewing and documenting the proper identification of clients in a Medication-Assisted Treatment (MAT) program. A list of acceptable forms of identification was also provided.
The Director of Nursing will audit three MAT client charts quarterly to verify that proper identification is documented in the client's chart. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of five patient records, the facility failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug in one record reviewed. Patient # 6 was admitted to the non-hospital detoxification level of care on October 26, 2024 and transferred to the non-hospital level of care on October 31, 2024. There was no documentation of determination of physiological dependency made by a physician during the intake process, and prior to the administration of medication. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 10, 2025, the Executive Director, Director of Nursing, Physican Assistant and Medical Provider met to address non-compliance with face-to-face assessments for clients in maintenance treatment. The discussion emphasized the importance of these assessments in determining whether a client is currently physiologically dependent on a narcotic drug and has been for at least one year prior to admission. While the Medical Provider and Physician Assistant do meet with clients, proper documentation in the client's chart is required. Moving forward, the Medical Provider or Physician Assistant will document face-to-face determination in a Medical Provider note. To ensure ongoing compliance, the Director of Nursing will conduct quarterly audits of three MAT client charts. The Compliance & Quality department created a chart audit checklist specifically for spot-checking this documentation. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of five patient records, the facility failed to ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in one applicable record reviewed. Patient # 4 was admitted to the non-hospital detoxification level of care on November 19, 2024 and transferred to a lower level of care on November 26, 2024. The record did not contain documentation that the individual was informed of the possible risks.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 3, 2025, the Director of Nursing led a refresher training for the nursing staff, highlighting the importance of informing female clients about the potential risks of continued illicit drug use, as well as the risks associated with medication use or withdrawal during pregnancy. This information is included in the informed consent, which will be monitored monthly by the Director of Nursing. To ensure compliance, the Director of Nursing will review three MAT client charts quarterly to confirm that informed consent is properly documented and meets required standards. The Compliance & Quality department created a chart audit checklist specifically for spot-checking this documentation. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent before an agent was administered in three of five applicable records reviewed.Patient # 2 was admitted to the non-hospital detoxification level of care on November 11, 2024 and transferred to the non-hospital level of care on November 18, 2024. The patient was initially administered an agent on November 12, 2024; however, the facility did not obtain an informed, voluntary, written consent from the client.Patient # 4 was admitted to the non-hospital detoxification level of care on November 19, 2024 and transferred to a lower level of care on November 26, 2024. The patient was initially administered an agent on November 20, 2024; however, the facility did not obtain an informed, voluntary, written consent from the client.Patient # 6 was admitted to the non-hospital detoxification level of care on October 26, 2024 and transferred to the non-hospital level of care on October 31, 2024. The patient was initially administered an agent on October 26, 2024; however, the facility did not obtain an informed, voluntary, written consent from the client until October 27, 2024.This is a repeat citation from the February 22, 2024 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 3, 2025, the Director of Nursing conducted a refresher training for the nursing staff, emphasizing the importance of reviewing informed consent with each client and explaining its significance. To ensure compliance, the Director of Nursing will audit three MAT client charts quarterly to verify that informed consent is properly documented and meets required standards. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the narcotic treatment program failed to complete an initial urinalysis in one of five patient records reviewed.Patient # 2 was admitted to the non-hospital detoxification level of care on November 11, 2024 and transferred to the non-hospital level of care on November 18, 2024. There was no documented drug screen urinalysis completed; however, the initial dose was given to the patient on November 12, 2024.This is a repeat citation from the February 22, 2024 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 3, 2025, the Director of Nursing led a refresher training session for the nursing staff to review regulations regarding urinalysis testing, proper documentation procedures, and its significance. As part of the quarterly audits of three MAT client charts, the Director of Nursing will also incorporate an additional review to ensure all urinalysis testing is properly documented. The Compliance & Quality department created a chart audit checklist specifically for spot-checking this documentation. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to ensure that the narcotic treatment physician determined the initial dose and schedule. It was documented in the patient record that the facility's physician assistant (PA) rather than the narcotic treatment physician, determined the initial dose in two of three applicable patient records reviewed. Patient # 2 was admitted to the non-hospital detoxification level of care on November 11, 2024 and transferred to the non-hospital level of care on November 18, 2024. The initial medication order was written by the PA on November 12, 2024.Patient # 4 was admitted to the non-hospital detoxification level of care on November 19, 2024 and transferred to a lower level of care on November 26, 2024. The initial medication order was written by the PA on November 20, 2024.Additionally, during an observation of medication administration on February 27, 2025, nursing staff were observed preparing other patients ' medications, instead of observing the patient when ingesting the agent. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 10, 2025, the Director of Nursing, Physician Assistant, and Medical Provider met to discuss and ensure the implementation of the regulation requiring the Medical Provider to determine and authorize the initial dose of Methadone, with proper documentation in the client's record. Moving forward, the Medical Provider will directly communicate the initial dose and schedule, ensuring that the order is written and signed by them rather than the Physician Assistant.The Director of Nursing will audit three MAT charts quarterly to ensure ongoing compliance of all required NTP documentation.
The Director of Nursing has implemented a new medication administration process for Medication-Assisted Treatment (MAT) clients. Dosing hours have been adjusted to 6:00 AM ? 7:00 AM, limiting administration exclusively to MAT clients. Under this new process, one nurse will be responsible for administering the medication, while a second nurse will focus solely on closely observing the client during ingestion. This change is expected to enhance patient safety and ensure compliance with regulatory requirements. The Compliance Specialist will conduct a quarterly tracer of medication dosing to ensure that the client is being properly observed while ingesting the medication.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the receiving narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose in one of two applicable records reviewed. Patient # 6 was admitted to the non-hospital detoxification level of care on October 26, 2024 and transferred to the non-hospital level of care on October 31, 2024. This is a repeat citation from the February 22, 2024 annual licensing renewal inspection. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 3, 2025, a refresher training was conducted for the nursing and medical staff to reinforce the importance of documenting correspondence with a client's previous clinic, including their admission date and confirmation of receiving their first dose. The originally implemented process was reviewed, emphasizing the need to document this information in a PRN note when obtaining dosing history from the previous clinic during a nurse's call. The Director of Nursing will conduct quarterly chart audits on three MAT-specific clients to ensure proper documentation is maintained. The Compliance & Quality department created a chart audit checklist specifically for spot-checking this documentation. |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, in one of two applicable records reviewed. Client # 26 was transferred to the outpatient activity on May 14, 2024 and was discharged on August 6, 2024. The client record did not contain documentation of a completed aftercare plan.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 4, 2025, the Clinical Director held a refresher training with the Clinical Team and Case Managers, focusing on the contents of client records, including the critical role of an aftercare plan at all levels of care. To ensure compliance with documentation standards, the Clinical Director conducts monthly audits of client charts, she will incorporate the review of three charts each month specifically for the inclusion of an aftercare plan. |