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 March 25 & 26, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health-HA, LLC dba Lewistown 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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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 client 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 #7 was admitted on January 8, 2025 and discharged on November 10, 2025. There was no documentation that the facility obtained an informed and voluntary consent for a substance use facility; however, there was documentation in the client record that the facility had sent the provider information from the client record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. All staff will be educated again on
policy and procedure of releases by May 1, 2026
2. Staff will be educated on PHI and
confidentiality policy
3.CD will provide educated in next 30 days
4. Chart audits will be preformed on
random charts to ensure proper releases
are on file
5. Staff will not release information without
first ensuring there is a release on file
6. Staff will be trained on proper communication
to use when no release is in place. |
715.17(c)(3)(i-v) 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:
(3) Inspection of storage areas. A narcotic treatment program shall 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. A narcotic treatment program shall develop and implement written policies and procedures regarding who performs the inspections, how often, and in what manner the inspections are to be documented. The policies and procedures shall include the following:
(i) Disinfectants and drugs for external use shall be stored separately from oral and injectable drugs.
(ii) Drugs requiring special conditions for storage to insure stability shall be properly stored.
(iii) Outdated and contaminated drugs shall be removed and destroyed according to Federal and State regulations.
(iv) Administration of controlled substances shall be documented.
(v) Controlled substances and other abusable drugs shall be stored in accordance with Federal and State regulations.
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Observations
Based on a physical plant inspection and a review of the facility ' s administrative documentation, 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
1. CD and CN will review regulation
2. CD and CN will create a check list
to ensure quarterly checks- by May 1, 2026
3. CN will ensure quarterly checks are done
4. Quarterly checks will be kept in a binder in
dispensary for future review
5. CD and CN have made corporate office aware of this deficiency to get it implemented in the end of month check list, until this occurs CD and charge nurse will use facility created check list |
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 a review of patient records, the facility failed to document an annual physical examination within the regulatory timeframe in two out of two applicable records.
Patient #4 was admitted on February 26, 2025 and was still active at the time of the inspection. The annual physical examination was due no later than February 26, 2026; however, it was not completed until March 2, 2026.
Patient #5 was admitted on January 16, 2025 and was still active at the time of the inspection. The annual physical examination was due no later than January 16, 2026; however, it was not completed until January 19, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. CD and CN will provide and train
staff and medical staff on annuals being
done timely by May 1 2026
2. CN will place holds on accts to have them
scheduled within timeframe
3. Patients will be scheduled prior to due date
4. Patients charts will be updated if no showing
appts. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client and included written documentation of type and frequency of treatment and rehabilitation services in three out of eleven client records reviewed.
Client #1 was admitted on October 14, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 5, 2025, that did not include the type or frequency of treatment and rehabilitation services.
Client #2 was admitted on June 16, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 8, 2025, that did not include the type or frequency of treatment and rehabilitation services.
Client #3 was admitted on October 13, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 12, 2025, that did not include the type or frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Clinical staff will be educated on
proper documentation of frequency and type
of services to be provided by May 1, 2026
2. CD or CS will review all tx plans to ensure this is
correctly listed
3. Clincal staff will ensure documentation of missed
/ no show appointments and group sessions
documented to provide evidence of engagement
attempts to frequence and type. |
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 document treatment plan updates within the regulatory timeframe in six out of eleven records reviewed.
Client #4 was admitted on February 26, 2025 and was still active at the time of the inspection. A treatment plan was completed on April 22, 2025, and the next update was due no later than June 21, 2025; however, it was not completed until June 23, 2025. A treatment update was completed on October 7, 2025, and the next update was due no later than December 6, 2025; however, it was not completed until December 23, 2025. The next update was due no later than February 21, 2026; however, it was not completed until February 26, 2026.
Client #5 was admitted on January 16, 2025 and was still active at the time of the inspection. A treatment plan was completed on July 9, 2025, and the next update was due no later than September 7, 2025; however, it was not completed until September 12, 2025. A treatment plan was completed on November 7, 2025, and the next update was due no later than January 6, 2026; however, it was not completed until January 16, 2026.
Client #6 was admitted on September 15, 2025 and discharged on March 9, 2026. A treatment plan was completed on November 5, 2025, and the next update was due no later than January 4, 2026; however, it was not completed until January 12, 2026
Client #7 was admitted on January 8, 2025 and discharged on November 10, 2025. A treatment plan was completed on July 10, 2025, and the next update was due no later than September 8, 2025; however, it was not completed until September 25, 2025.
Client #10 was admitted on November 20, 2025 and was still active at the time of the inspection. A treatment plan was completed on January 14, 2026, and the next update was due no later than March 15, 2026; however, it was not completed until March 20, 2026.
Client #11 was admitted on April 1, 2025 and was still active at the time of the inspection. A treatment plan was completed on December 17, 2025, and the next update was due no later than February 9, 2026; however, it was not completed until February 22, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. CD will train clincial staff on
expectations and regulations for
treatment plan updates by May 1, 2026
2. CD will educate team on expectations
of tx plan being reviewed at every individual
session and that this is accurately noted
3. Clinical staff will ensure deadlines are
met by reviewing services due and
comparing to last date tx plan was updated
4. CD will audit progress notes daily for 60
days and 10 notes per a day after to ensure
tx plans are reviewed at each session
5. CD will audit tx plan due dates weekly
using services due reports |