INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on August 26-27, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the off-site complaint investigation, Caron Treatment Centers, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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.
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Observations
Based on a physical plant inspection and staff interviews, the facility failed to 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.
During the physical plant inspection, DDAP staff observed what appeared to be mold on a ceiling HVAC vent in building 3000, room 30122.
This finding was discussed with facility staff during the investigation.
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Plan of Correction
The facilities department cleaned the HVAC vent in building 3000, room 30122 and the issue was completely resolved by 9/9/2025. The facilities department will clean the HVAC vents on a monthly basis. Weekly inspections are being conducted by the Environmental Services Team as well.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client #2 was admitted on August 1, 2025, and was active at the time of the inspection. A treatment plan dated August 15, 2025, noted that the client would receive one individual therapy session per week. In the client record there were no individual sessions documented between August 15-August 26, 2025.
This finding was discussed with facility staff during the investigation.
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Plan of Correction
The Executive Director and Clinical Supervisor re-educated the therapist of client #2 regarding the requirement that counseling services need to be provided and documented in accordance with the patient's individual treatment plan on 8/27/2025. Additionally, all clinicians were re-educated on this requirement during a clinical team meeting on 9/10/2025. The Clinical Supervisors will conduct chart reviews on a monthly basis to ensure that counseling services are provided and documented in accordance with the treatment plan. |