INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on August 12, 2026 through August 13, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lebanon 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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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, it was determined that the facility failed to ensure that a counselor assistant with a high school diploma or GED equivalent only counsel clients under direct observation of a trained counselor or clinical supervisor for the first three months of employment in one of one applicable record reviewed.
Employee #6 was employed as a counselor assistant on July 20, 2026, and was current in that position at the time of the inspection. There was no documentation indicating that this employee was counseling clients under direct observation at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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, documentation has been completed to accurately reflect the observation and supervision that took place during the identified period. Supervision and observation of clinical session forms are utilized to capture the type and frequency of direct observation and close supervision, ensuring that all required documentation is completed and maintained in the personnel record going forward.
Clinic 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.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the fire drill log from August 2025 through July 2026, the facility failed to prepare alternate exit routes to be used during fire drills.
The same exit was documented during each drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CD will review with Health and Safety Team by 9/28/26. Health and Safety team will review completed drills quarterly in Health and Safety program meetings according to policy to ensure different exit routes are utilized during all drills. Health and Safety team will create corrective action plans as needed to ensure that plans progress and result in completion to avoid future deficiencies. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in five of eight records reviewed.
Client # 2 was admitted on June 20, 2021, and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan update documented in the client record on July 18, 2025, indicated that the client was to receive one individual counseling session per month; however, there were no individual counseling sessions documented in the record for the months of September 2025, November 2025 or April 2026.
Client #4 was admitted on December 14, 2016, and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan update documented in the client record on September 16, 2025, indicated that the client was to receive one individual counseling session per month; however, there were no individual counseling sessions documented in the record for the month of May 2026.
Client #5 was admitted on December 8, 2022, and was discharged on June 19, 2026. A comprehensive treatment and rehabilitation plan update documented in the client record on December 1, 2025, indicated that the client was to receive one individual counseling session per month; however, there were no individual counseling sessions documented in the record for the month of February 2026.
Client #7 was admitted on July 23, 2024, and was discharged on November 30, 2025. A comprehensive treatment and rehabilitation plan update, documented in the client record on June 23, 2025, and October 9, 2025, indicated that the client was to receive one individual counseling session per month; however, there were no individual counseling sessions documented in the record for the month of October 2025.
Client #8 was admitted on April 17, 2025, and was discharged on December 2, 2025. A comprehensive treatment and rehabilitation plan update documented in the client record on August 8, 2025, indicated that the client was to receive three hours of group counseling sessions per month; however, there were no group counseling sessions documented in the record for the months of August 2025, September 2025, October 2025 or November 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
CD reviewed no show procedures with staff in Clinical Supervision on 08/18/2026. CD reviews caseloads/paperwork weekly to ensure patients are being offered recommended services, and their charts are notated appropriately. |