INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on November 12 through 13, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Discovery House, Inc. dba Wilkes Barre Comprehensive 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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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential 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 November 13, 2025, the facility failed to ensure that facility heaters were permanently mounted or installed. A portable heater was observed in a physician ' s office.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On November 14, 2025, the portable heater was removed from the office and taken off-site to ensure it cannot be used again in the facility. Staff working in that office were notified the same day that the use of portable heaters is prohibited per DDAP regulations and internal policy. The entire staff was reeducation at the 11/19 staff meeting and 705.26 was reviewed with staff at that time. A site inspection will be completed by clinic director to ensure compliance with physical plant safety measures starting in December 2025. |
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 program failed to obtain an informed, voluntary, written consent before an agent may be administered in one of eight patient records reviewed.Patient #3 was admitted on July 2, 2025, and was discharged September 3, 2025. The informed, voluntary, written consent was documented on July 9, 2025; however, the agent was administered prior to that, on July 2, 2025.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Staff were re-educated on the intake process during the Monthly Staff meeting on November 19th. During this review an emphasis was placed on §715.12(1-5) specifically regarding the requirement that no narcotic agent may be administered prior to obtaining the informed voluntary written consent, without exception. Additional training and education will be completed by 12/8/2025 for all medical and nursing staff to review all new admissions, ensuring the Pt. Informed Voluntary Written Consent is signed prior to the Pt.s initial dose. As part of the Quality Record Review (QRR) process on site, the Clinical Supervisor or Clinic Director will review all new admissions within 24 hours to ensure Pt. informed voluntary written consent is in the record and compliance to same. The Clinical Supervisor and Clinic Director will continue with monthly QRR's of all admissions to ensure sustained compliance with §715.12.
Any instance of non-compliance will result in immediate corrective retraining and review of procedures.
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715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on the review of patient records, the program failed to transfer the patient file that included admission date, urinalysis reports or summary, exception requests and current status of the patient in one out of two applicable patient record reviewed.Patient #5 was admitted on February 21, 2025 and transferred to another program on June 20, 2025. There was no documentation that the program transferred the patient ' s files to the receiving program.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Staff received training on 11/19/25 to review 715.20(1) specifically focused on ensuring that all transferring patients sign the appropriate release to share pertinent documentation to the receiving facility to facilitate transfer. The released information will be documented in SMART under Disclosure within the Authorization section as well as noted within the body of the Pt. record with all released information scanned and uploaded into chart with date sent. The clinical supervisor will conduct monthly record audits inspecting for proper completion and transmittal of the Transfer paperwork in the Patient's chart for patients that have transferred their MAT services. Clinical supervisor will also collaborate with nursing staff to ensure all transfer criteria has been met and documented. |
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 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 given to the patient by the receiving narcotic treatment program in one of three applicable patient records reviewed.Patient #1 was admitted on December 9, 2024, and was active at the time of the inspection. There was no documentation that the program notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Staff received training on 11/19/25 to review 715.20(4) specifically focused on ensuring that all transferred patients include completing and transmitting the Transfer Acknowledgement Form. The clinical supervisor will conduct monthly record audits inspecting for proper completion and transmittal of the Transfer Acknowledgement Form in the Patient's chart for patients that have transferred in their MAT services. Clinical supervisor will also collaborate with nursing staff to ensure all transfer criteria has been met and documented. |