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 November 12 & 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, Harrisburg 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to document that the facility director met both the education and experiential qualifications to include supervision of others, direct service and program planning for the position. Employee #2 was hired on October 13, 2025 as a facility director. Employee #2 does not have direct service experience that meets the qualification for the facility director position. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Failure to obtain an exception may necessitate the need to obtain a new director.
Upon rejection of the request, the regional director would assume oversight and operations, and current director would be moved to an "assistant director" role while they work to meet competencies required to transition into director role. This would include monthly training/supervision to review progress towards competencies. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of administrative information and personnel records, the project failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completing a mechanism to collect feedback on completed training. The policy and procedure manual did not include procedures on mechanisms to provide feedback for training, and the personnel records did not contain any feedback on trainings attended by the personnel. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinic Director will develop a staff development program which will include a formal process for collecting feedback on all completed trainings, specifying responsible parties (Clinic Director and Clinical Supervisor) and time frames for completion, with staff required to submit feedback within 10 business days and management reviewing it within 30 business days. A standardized Training Feedback Form will be implemented and maintained in each employee's personnel file. All staff will be notified of this updated process during the next staff meeting, and the Clinic Director will conduct quarterly audits of personnel files to ensure ongoing compliance. The notification and implementation of the feedback mechanism, will be completed by 12/19/2025. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from November 2024 through October 2025, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of unannounced fire drills occurring during the months of November and December 2024. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director will ensure full compliance with monthly unannounced fire drill requirements by implementing a formal Fire Drill Schedule and assigning the Nursing Supervisor to conduct and document one unannounced fire drill each month. These corrective actions will be fully implemented by November 30, 2025. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 records from January 2020 to October 2025, the facility failed to maintain a written fire drill record that included 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.The fire drill record dated January 17, 2025, failed to include the number of people at the facility at the time of the drill.The fire drill record dated February 18, 2025, failed to include the number of people at the facility at the time of the drill; if they followed their exception to utilize an alternate method to notify people of the drill rather than setting off the fire alarm or smoke detector; or the exit route used. The fire drill record dated April 25, 2025, failed to include if the facility followed their exception to utilize an alternate method to notify people of the drill rather than setting off the fire alarm or smoke detector.The fire drill record dated May 28, 202, failed to include the number of people at the facility at the time of the drill.The fire drill record dated June 17, 2025, failed to include the number of people at the facility at the time of the drill.The fire drill record dated September 30, 2025, failed to include if the facility followed their exception to utilize an alternate method to notify people of the drill rather than setting off the fire alarm or smoke detector and the exit route used.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director will review the fire drill form after each monthly drill to ensure that it fully meets §705.28 requirements by capturing the date, time, evacuation duration, exit route used, number of individuals present, any problems encountered, and whether the fire alarm, smoke detector, or approved alternate notification method was used. The Nurse Supervisor will be responsible for completing the form in full during each drill, and all staff will receive instruction on proper documentation at the next team meeting. The Clinic Director will conduct monthly reviews of all fire drill logs to ensure accuracy and completeness, and corrective measures will be applied immediately if any omissions are identified. All updates and compliance measures will be fully implemented by November 30, 2025. |
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 eleven records reviewed.Client #9 was admitted on September 14, 2021 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director will ensure compliance with §709.28(c) by immediately obtaining a completed informed and voluntary consent from Client #9 for the disclosure of information to the funding source. All active client records will be reviewed to verify that required consents are on file, and staff will be retrained on the process for obtaining and documenting informed consent prior to billing or sharing client information. The Clinical Supervisor will conduct monthly audits of new admissions to ensure consents are completed timely, and the Clinic Director will perform bi-monthly quality assurance checks to maintain ongoing compliance. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of eleven records reviewed. Client #10 was admitted on August 19, 2025 and discharged on November 5, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for two medical entities, a legal entity, an emergency contact and a substance abuse facility dated August 19, 2025 was offered to the client. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinic Director will ensure compliance with §709.28(c) by immediately obtaining a completed informed and voluntary consent from Client #10 for the disclosure of information to the funding source. All active client records will be reviewed to verify that required consents are on file, and staff will be retrained on the process for obtaining and documenting informed consent prior to billing or sharing client information. The Clinical Supervisor will conduct monthly audits of new admissions to ensure consents are completed timely, and the Clinic Director will perform bi-monthly quality assurance checks to maintain ongoing compliance. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of requested administrative information and personnel records, the facility failed to ensure that their data collection and recordkeeping system allowed for the efficient retrieval of the data to measure the project's performance in relationship to its stated goals and objectives. Information was requested from the facility to begin the licensing process and that information was not provided timely to evaluate the project ' s performance to its stated goals and objectives. The inspection process was extended to enable a full review of all regulatory requirements. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director will ensure compliance with §709.31(a) by developing an internal data collection and recordkeeping system that allows for the efficient retrieval of information needed to measure the project's performance against its stated goals and objectives. Staff will be educated on the use of the system to ensure timely and accurate reporting of requested information. The Clinical Supervisor will conduct quarterly audits during staff supervision to verify that data is complete, accessible, and retrievable as needed for administrative review and licensing purposes. The Clinic Director will perform quarterly quality assurance checks with the Clinical Supervisor to ensure ongoing compliance. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical plant inspection and a review of the facility ' s files the facility failed to inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State, and local laws and regulations. The facility did not have documentation that the inspections were conducted. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinic Director will ensure compliance with §709.32(c)(3)(i)-(v) by re-educating the Nursing Supervisor on the medication control policy to document quarterly inspections of all drug storage areas and the dispensing station, including verification of proper storage conditions, separation of disinfectants and external-use drugs, removal of outdated medications, and availability of drug-related regulations. The Nursing Supervisor will be assigned to conduct and document these inspections using a standardized checklist. Nursing staff will be trained on the updated policy and the importance of maintaining accurate inspection records. The Clinic Director will review completed inspection logs monthly to ensure ongoing compliance. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document what materials were sent to the receiving narcotic treatment program in one out of one applicable record. Patient #5 was admitted on July 10, 2024 and transferred to another treatment facility on January 10, 2025. There was no documentation in the patient ' s record of what documents were sent to the receiving facility. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director will provide reeducation during all staff meetings by 12/31/25 on the transfer policy and that all materials sent to a receiving narcotic treatment program will be scanned and documented appropriately in the patient's record. The Clinic Supervisor will review all future transfer records within 7 business days to ensure the required documentation is included. The Clinic Director will also conduct quarterly audits to ensure ongoing compliance. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to document an annual physical examination by the narcotic treatment physician within the regulatory timeframe in two out of five applicable records reviewed.Patient #2 was admitted on February 26, 2015 and discharged on November 3, 2025. An annual physical was due no later than February 26, 2025; however, it was completed on March 10, 2025. Patient #11 was admitted on March 9, 2021 and was still active at the time of the inspection. An annual physical was due no later than March 9, 2025; however, it was completed on March 18, 2025. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director will ensure compliance with §715.23(b)(5) by implementing a system to monitor annual physical examination due dates for all patients and ensure timely completion by the narcotic treatment physician. Staff will be retrained on the importance of scheduling and documenting annual physicals within the required timeframe, and the Clinical Supervisor will conduct monthly audits to verify compliance. The Clinic Director will perform bi-monthly quality assurance reviews to ensure ongoing adherence to regulatory requirements. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure that the annual evaluation of each patient's status was completed by the patient's counselor and was reviewed, dated and signed by the medical director in two out of five applicable records reviewed. Patient #2 was admitted on February 26, 2015 and discharged on November 3, 2025. An annual evaluation was due no later than February 26, 2025; however, it was completed on March 10, 2025. Patient #11 was admitted on March 9, 2021 and was still active at the time of the inspection. An annual evaluation was due no later than March 9, 2025; however, it was completed on March 11, 2025. This is a repeat citation from September 26, 2023 and October 16, 2024 licensing inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director will ensure compliance with §715.23(c)(1-7) by implementing a tracking system to monitor annual evaluation due dates for all patients and ensure timely completion by the counselor, with review, dating, and signature by the medical director. Staff will be retrained on the requirement to complete annual evaluations within the regulatory timeframe and on proper documentation procedures. The Clinical Supervisor will conduct monthly audits of patient records to verify timely completion, and the Clinic Director will perform bi-monthly quality assurance reviews to ensure ongoing adherence and prevent repeat citations. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document that a comprehensive treatment plan was developed with the client within thirty days of admission, per the facility ' s policy and procedures, in four out four applicable records reviewed. Client #1 was admitted on August 11, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than September 11, 2025; however, it was not completed until September 16, 2025.Client #4 was admitted on November 11, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 11, 2024; however, it was not completed until January 3, 2025.Client #6 was admitted on August 4, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than September 3, 2025; however, it was not completed until September 15, 2025.Client #7 was admitted on July 10, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than August 9, 2025; however, it was not completed until August 25, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director and Clinical Supervisor will ensure compliance with §709.92(a) by reinforcing the requirement that comprehensive treatment plans be completed within 30 days of admission and updating the tracking system to clearly flag upcoming due dates. The Clinical Supervisor will conduct weekly audits of new admissions to verify timely completion, and staff will receive immediate retraining on treatment plan timeframes and documentation standards. The Clinic Director will complete monthly quality assurance checks to ensure ongoing adherence to the required timelines. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to follow the regulatory requirement to update treatment and rehabilitation plans every 60 for clients in treatment more than twice a month and every 120 days for clients who are stable and receiving counseling less than twice a month in three out of ten records reviewed. Client #4 was admitted on November 11, 2024 and was still active at the time of the inspection. A treatment plan update was completed on January 6, 2025, and the next update was due no later than March 7, 2025; however, it was not completed until March 24, 2025. Client #9 was admitted on September 14, 2021 and was still active at the time of the inspection. A treatment plan update was completed on May 8, 2025, and the next update was due no later than September 5, 2025; however, it was not completed until October 13, 2025. Client #11 was admitted on March 9, 2021 and was still active at the time of the inspection. A treatment plan update was completed on May 3, 2025, and the next update was due no later than July 2, 2025; however, it was not completed until July 8, 2025. The next treatment plan update was due no later than September 6, 2025; however, it was not completed until September 10, 2025. This is a repeat citation from October 16, 2024 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director will ensure compliance with §709.92(a) by reeducating the requirement that treatment plans be updated every 60 or 120 days depending on the patient's level of care. The clinical staff will generate weekly reports to identify patients who are due for their treatment plan update and add an alert in the EMR system to identify the patients at their next check-in. It is with understanding that the treatment plan must still be completed within the designated time frame regardless if the patient is involved. The Clinical Supervisor will conduct biweekly audits to verify staff are completing within the 60 or 120 as assigned as well as having a copy of their recent weekly report.
The Clinic Director will complete monthly quality assurance checks to ensure ongoing adherence to the required timelines.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations every ninety days for the first year and annually thereafter, per facility policy, in three out of nine applicable records reviewed. Client #2 was admitted on February 26, 2015 and discharged on November 3, 2025. A case consultation was due no later than February 26, 2025; however, there was no documentation that one was completed. Client #6 was admitted on August 4, 2025 and was still active at the time of the inspection. A case consultation was due no later than November 4, 2025; however, there was no documentation that one was completed. Client #11 was admitted on March 9, 2021 and was still active at the time of the inspection. A case consultation was due no later than March 9, 2025; however, it was not completed until March 20, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director will ensure compliance with §709.93(a)(8) by reeducating the requirement that case consultations be completed every 90 days during the first treatment year and annually thereafter, per facility policy. The Clinical Supervisor will implement a tracking system to flag upcoming consultation deadlines and conduct weekly audits to ensure timely completion. Staff will receive retraining on documentation requirements, and the Clinic Director will complete monthly quality assurance reviews to ensure consistent adherence moving forward. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for completing and documenting annual evaluation was submitted and approved by the Department for the September 26, 2023, and October 16, 2024, annual licensing inspections. Completing and documenting annual evaluation was again found to be a deficiency in the November 12 & 13, 2025 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director and Medical team will meet weekly to review and ensure all aspects of the plan of correction are being followed and completed. CD will develop checklist of deficiencies that track random audits for POC.
Clinical Supervisor will review deficiencies with team at monthly staff meetings and provide re-education and address with individual staff members as needed.
CD and RD will meet monthly to review POC audits to determine if additional education, training or assistance is needed to ensure no reoccurrences.
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