INITIAL COMMENTS
|
This report is a result of an on-site incident investigation conducted on August 27, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site investigation, Clearbrook Treatment Centers, LLC d/b/a Huntington Creek Recovery 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 investigation:
|
Plan of Correction
|
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
Based on a physical plant inspection on August 27, 2026, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repairs at all times.
During the physical plant inspection, DDAP staff observed, in the adolescent building, that bedroom #2 had a large puddle of water that orginated at the wall and spread out into the center of the bedroom.
This finding was reviewed with facility staff during the incident investigation process.
|
Plan of Correction
The puddle was cleaned up, and the source of the puddle was remediated. Weekly walkthroughs by facility operations staff will identify any items in need of repair. In addition, all facility staff will submit a work order request to facility operations with any items in need of repair. Although this has been an existing process, staff were immediately reminded on 08/27/26 to address these matters as they arise. |
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.
|
Observations
Based on a review of patient records, facility policies and security videos, the facility failed to follow written procedures for the managment of treatment/rehabilitation services for clients.
The facily's "Clinical Observation and Rounding " policy notes that "adolescent clients are monitored every 30 minutes." Client #1, an adolescent, was admitted on June 29, 2026, and was discharged on August 20, 2026. A progress note dated August 18, 2026, notes an increase in the frequency of observed rounding for client #1 to every fifteen minutes due to mental health concerns.
It was observed by DDAP staff that on August 20, 2026, in the "HCRC Q-15 Patient Observation Log" that all rounds on August 20, 2026 between the hours of 8:00am-4:00pm were reported complete. DDAP staff reviewed the security video for August 20, 2026, and verified that the following rounds were not completed as noted in the observation log:
o14:23-14:45 No obserevation was complated.
o 1500 No observation was completed.
o15:15 No observation was completed.
o15:30 No observation was complated.
o15:36-16:00 no observation was completed.
These findings were reviewed with facility staff during the incident investigation process.
|
Plan of Correction
The facility has ceased to conduct Q15s. In the event that a client needs more supervision than the routine observations, the client will be placed on 1:1 until transported to the emergency room for further evaluation. In addition, in the case of a client expressing suicidal ideation or thoughts of self-harm, staff will utilize the C-SSRS as guidance for sending a client to the emergency room. The policy on observation and rounding was revised on 09/10/26 to reflect this. Staff will sign attestations on understanding and adhering to these changes by 09/18/26. The staff member identified as not completing rounds as expected was terminated.
The Director of Q&PI will conduct a random sample of observation checks monthly to compare the documentation with the video surveillance. Deficiencies will be reported to the CEO and facility leadership team who will then address the deficiencies with staff. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
|
Observations
Based on a review of outpatient client records, review of the facility's security video, and facility staff interviews, the facility failed to ensure 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 progress notes.
Client #1 was admitted on June 29, 2026, and was discharged from the facility on August 20, 2026. DDAP staff reviewed a progress note that indicated a treatment planning session occurred, with Client #1 present, on August 20, 2026, between the hours of 2:00-3:00pm. A review of the facility's security video revealed that Client #1 was in her bedroom and also the adolescent community room during those hours on August 20, 2026.
This finding was reviewed with facility staff during the incident investigation process.
|
Plan of Correction
After reviewing the cameras again on 09/04/26, the counselor was observed going into the client's room on 08/20/26 at 10:52am to conduct the counseling session. The counselor left the room at 11:22am. The counselor did not document the session as an individual session note but as a general note from 2pm to 3pm. Clinical leadership retrained the counselor on the proper documentation of a session and the difference between a session note and a general note to chart. Documentation will be monitored through 09/30/26 via spot checks on the counselor's notes, and additional training will occur as needed. |