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 December 3 & 4, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Dunmore 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable record reviewed.Client #10 was admitted on June 30, 2021 and was terminated on October 17, 2025. There is no documentation that the facility provided notification, in writing, to the client of the decision to terminate the client ' s treatment. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CD will review the policy and DDAP regulation and provide training to CS and leadership staff members regarding written letter of notification to patient in the event of an involuntary termination. This will occur in Leadership meeting on 1/7/26 and will be documented in Leadership meeting minutes. All involuntary termination requests are reviewed during weekly MDT meetings and CS will be assigned duty of completing the written notification and uploading to patient record as well as documenting communication of such in general contact note within patient record. CD will review chart for completion of such documentation as part of Quality record review discharge chart review at the end of each month. CD will review with CS during monthly individual supervision. |
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 facility failed to document that it notified the patient's transferring narcotic treatment program of the patient's admission including the date of initial dose in one out of one applicable record. Patient #3 transferred to the facility on April 18, 2025 and was still active at the time of the inspection. There is no documentation that the facility sent notification of the patient ' s date of admission or initial dose to the transferring narcotic treatment program. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CD will update intake checklist to include notification of transfer to patient previous home clinic at intake. Nursing staff member who completes intake will sign off that notification of transfer was completed and faxed to referring clinic. Documentation will be uploaded into patient record with fax receipt. Clinic Director/Clinical Supervisor and/or Nurse Supervisor will each intake chart as part of quality record review process to ensure that notification of transfer was completed and sent to referring clinic. This process will be reviewed during all staff meeting scheduled for 1/15/2026. CD will review all submitted intake Quality record reviews on a weekly basis to ensure that compliance to this regulation is met.
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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 treatment and rehabilitation plan was developed with the client within thirty days of admission, per the facility ' s policy and procedures, in two out five applicable records reviewed. Client #3 was admitted on April 18, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan was due no later than May 18, 2025; however, it not was completed until May 22, 2025.Client #12 was admitted on October 9, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan was due no later than November 8, 2025; however, it was not completed until November 13, 2025. This is a repeat citation from the October 30, 2024 licensing inspection. 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 review this policy and regulation during group and individual weekly supervision sessions beginning immediately. A review with all clinical team members will be conducted by CD and CS during all staff meeting scheduled for 1/15/25. Clinical supervisor will continue with compliance reviews during regular supervision schedules and timely to Pt. admission for utilizing upcoming services due report and will review with assigned primary counselor all treatment plans due. Hard counselor holds will be applied to ensure patient meets with primary counselor to develop and sign rehabilitation treatment plan timely, documenting such in patient record. During monthly quality record reviews clinical supervisor and Clinic Director will review initial treatment plans for timeliness to ensure initial treatment plans are completed within 30 days of admission. Clinical Supervisor will review all new admissions to ensure individual comprehensive treatment planning sessions are scheduled timely. Compliance will be reviewed during regular weekly individual supervision and group supervision |
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 facility failed to ensure that the clients received counseling services according to their individual treatment and rehabilitation plan in seven out of twelve applicable records reviewed.Client #2 was admitted on July 29, 2025 and was still active at the time of the inspection. The treatment plan dated August 20, 2025, indicated two and half hours of individual or group counseling a month. The client only received one hour of counseling for the months of July and October 2025. Client #4 was admitted on May 27, 2025 and was still active at the time of the inspection. The treatment plan dated July 7, 2025, indicated four hours of individual or group counseling a month. There was no documentation that the client received counseling in August 2025. Client #6 was admitted on March 29, 2023 and was still active at the time of the inspection. The treatment plans dated February 27, May 13, July 17, and September 18, 2025, indicated two and half hours of individual or group counseling a month. There was no documentation that the client received counseling in the months of April or August 2025, and only one hour of counseling in the months of June, September and October 2025. Client #7 was admitted on March 28, 2014 and discharged on October 27, 2025. The treatment plan dated March 3, 2025, indicated one hour of individual or group counseling a month. There was no documentation that the client received counseling in the month of April 2025. The treatment plan dated May 20, 2025, indicated half an hour of individual or group counseling a month. There is no documentation that the client received counseling in the month of June 2025. Client #8 was admitted on July 14, 2021 and discharged on September 26, 2025. The treatment plan dated January 2, 2025, indicated one hour of individual or group counseling a month. There was no documentation that the client received counseling in the month of February 2025. Client #10 was admitted on June 30, 2021 and discharged on October 17, 2025. The treatment plan dated April 25, 2025, indicated one hour of individual or group counseling a month. The treatment plan dated June 25, 2025, indicated half an hour individual or group counseling a month. There was no documentation that the client received counseling sessions in the months of May and July 2025. Client #11 was admitted on August 17, 2018 and was discharged on November 5, 2025. The treatment plans dated February 10, April 30, June 25 and August 5, 2025, indicated one hour of individual or group counseling a month. There was no documentation that the client received counseling in March, June and July 2025. The client received half an hour of counseling in August 2025. This is a repeat citation from October 30, 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 review this policy and regulation with each clinical team member during all staff meeting scheduled for 1/15/26. The Clinical Supervisor and Counseling staff will monitor compliance of all patients counseling requirements utilizing the direct services due report in SMART. Counseling staff members will place hard counselor holds on patient to ensure patient schedules a session that is convenient to meet with their counselor. These sessions will be scheduled in accordance to patient's individual treatment plan recommended hours. Additional reviews for compliance will be conducted during weekly supervision and end of day checklist reviews, as well as part of the internal quality record reviews, ensuring completion of clinical sessions and compliance to required treatment hours according to treatment plan.
In the event that a patient does not show for a scheduled individual or group session the counselor will enter a "no show counseling" note into the EMR. Continued engagement efforts and outreach via phone call, ring central text message and hard counseling holds will occur with patients who are non-compliant with treatment hours as indicated and agreed upon within the patient treatment plan. These efforts will be documented within the patient's record. Continued non-compliance to treatment hours will be reviewed at MDT meetings and avenues for patient engagement will be explored. A general contact note will be added at the end of each month providing an explanation as to Pt.'s barrier to maintain counseling compliance as per the treatment plan, should a patient remain non-compliant. Compliance to regulation will be reviewed and documented during regular weekly individual supervision and group supervision.
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