INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 23, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Montco Recovery Center LLC 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:
|
Plan of Correction
|
704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
|
Observations
Based on a review of personnel records, the facility failed to ensure each employee's annual written individual training plan was based upon that employee's previous education, experience, current job functions, and performance in four of four personnel records reviewed.
In every personnel record reviewed, the individual training plan for the employee was identical to the other employees reviewed. The plans were not individualized based on the employee's previous education, experience, current job functions and job performance.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
In response to this found deficiency, a study of pertinent documentation was conducted wherein it was observed that individual training plans have defaulted to looking the same for each employee due to poor formatting on the document and lack of due emphasis placed on importance of staff suggesting annual adjustments to such. In response to this findings two measures have been taken (1) The Individual Training Plan document has been reformatted to force identification of new goals as well as evaluation of last year's progress toward goals identified within the previous document, and (2) staff has been re-educated on importance of treating individual training plans as guides for seeking out CEs to maintain expected qualification and meet annual requirements. Document revision has been completed as of 7/30/2026. Staff re-education has been initiated on 7/30/2026 in a treatment team meeting and will continue within weekly group and individual supervision sessions moving forward. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of personnel records, the facility failed to ensure the project director and facility director completed at least 12 clock hours of training annually, during the facility's January 1, 2025 through December 31, 2025 training year, in one of one applicable personnel record reviewed.
Employee # 1 was hired as project director and facility director on March 11, 2024. The personnel record documented 4 hours of required training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The found deficiency manifested as a result of an accident wherein existing certificates for last year's trainings for employee #1 were destroyed by a spilled beverage resultant in only 4 CE hours' worth of record being salvaged. The certificates of completion proved impossible to reproduce due to employee #1's inability to recollect what internet service they have been obtained through. In remediation of this discrepancy two measures were set in place. (1) Employee #1 has completed the full 12 hours of necessary training for this calendar year prior to this on-site visit, and (2) training certificates will from here on out be filed into HR charts more promptly to avoid exposure to accidents, and a digital backup to each certificate will be created and stored. Employee #1's training hours for 2026 have been completed and certificates digitally backed up as of June 3rd of 2026. Other abovementioned adjustments to procedures relevant to filing and storing staff training records are effective as of 7/30/2026. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on a consent to release information form in one of fourteen client records reviewed.
Client # 8 was admitted to the outpatient activity on May 4, 2026 and was active at the time of the inspection. The release of information form to the emergency contact was signed by the client on May 4, 2026, but the release form did not include the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Upon discovering the stated deficiency an examination of the pertaining document was conducted wherein it was found that within a scope of the emergency release only the information pertinent to the case of emergency can be disclosed. As such, the document has been reformatted to identify this as the default and only form of information to be disclosed and the option to select/deselect such was removed. The emergency ROI is therefore now written in a way where patient's signature alone confirms understanding of this being the case. Staff have been re-educated on the importance of going over the entire document with each client when any signature is being obtained. The adjustment to the document in the electronic medical record is effective 7/24/2026. Staff reeducation has been initiated on 7/23/2026 within the multidisciplinary treatment team meeting and will continue within weekly group and individual supervision sessions moving forward. Intermittent chart audits will continue with additional emphasis on monitoring this compliance. Re-education will therefore continue until such time as no further discrepancies of this kind are observed. Client #8 has an updated emergency ROI populated in their chart as of 7/30/2026 and will sign it by 8/3/2026 when they next present in treatment. Clinical Director will be ultimately responsible for maintenance of this compliance. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
|
Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 30 days in four of four applicable client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on June 17, 2026 and was active at the time of inspection. An individual treatment and rehabilitation plan was completed on June 18, 2026 and the first update was due to be completed no later than July 18, 2026; however, the update was not completed at the time of inspection.
Client # 4 was admitted to the partial hospitalization activity on May 14, 2026 and was discharged on June 26, 2026. An individual treatment and rehabilitation plan was completed on May 20, 2026 and the first update was due to be completed no later than June 20, 2026; however, the update was not completed prior to discharge.
Client # 6 was admitted to the partial hospitalization activity on May 21, 2026 and was discharged on July 1, 2026. An individual treatment and rehabilitation plan was completed on May 22, 2026 and the first update was due to be completed no later than June 22, 2026; however, the update was not completed prior to discharge.
Client # 7 was admitted to the partial hospitalization activity on June 2, 2026 and was discharged on July 21, 2026. An individual treatment and rehabilitation plan was completed on June 11, 2026 and the first update was due to be completed no later than July 11, 2026; however, the update was not completed until July 21, 2026.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
In review of this deficiency two reasons for lack of stated compliance were identified. (1) One identified clinician's submission of treatment plan update was late (as in case with Client #1) and (2) (as in case with clients # 4, 6, and 7) facility as a whole was unaware that treatment plan updates were necessary for completion when clients are disengaged and are in process of being intermittently spoken with remotely with attempt to re-engage. For Clients #4, 6, and 7 clinical notes identifying their disengagement were entered in real time and all attempts at re-engaging were further documented. Upon receiving reeducation outlined in this deficiency the following measures were set in place. (1) Additional chart audits have been scheduled with emphasis on monitoring this compliance to be carried out at least monthly by the Clinical Director. (2) Reeducation has been provided to all staff on 7/23/2026, and separate reeducation session was provided to the identified clinician responsible for deficiency with Client #1 on 7/24/2026. Client #1's treatment plan was updated as of 7/28/2026. Compliance toward such discrepancies will be monitored in real-time by the Clinical Director and reviewed in weekly group and individual supervision sessions. (3) Reeducation was provided to all staff regarding necessity to continue with treatment plan updates for clients that have disengaged, but still appear active on census for purposes of reengagement as of 7/23/26 within the multidisciplinary treatment team meeting. Continued reeducation will be provided within weekly group and individual supervision sessions moving forward. Staff were also advised to consider discharging disengaged clients prior to dates on which treatment plan updates are due unless bona fide clinical reason exists for continued efforts at encouraging re-engagement. Staff were informed that treatment plan goals can be deferred due to disengagement and TPUs can be signed without client present in these circumstances. Clinical Director will be ultimately responsible for assuring maintenance of this compliance. |
709.83(a)(11) LICENSURE Client records
709.83. 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:
(11) Follow-up information.
|
Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in one of one applicable client record reviewed.
The facility policy and procedure manual stated follow-up information will be completed within 6 months of discharge.
Client # 5 was admitted to the partial hospitalization activity on September 5, 2025 and was discharged on October 6, 2025. There was no documentation of follow-up information in the record at the time of the inspection.
This finding was reviewed with project staff during the licensing process.
|
Plan of Correction
In review of this deficiency, it was found that the follow-up notes were missed as a result of transitionary period between two administrative assistants under whose responsibility those notes do fall. It was further gathered that the follow-up calls to Client #5 were likely made, but no notation of such was entered. As the calls were (likely) made by staff who is no longer employed at MRC, no notation of such could presently be reproduced. In remediation of this discrepancy two measures were set in place. (1) New administrative assistant was hired as of 7/27/2026 and is being rapidly educated and trained on making the follow-up calls to newly discharged clients as well as making proper notation of such outreach. (2) It has been discussed in treatment team meetings as well as in individual and group supervision sessions during the week of 7/27/2026 that in instances when Administrative Assistant is not available, the responsibility for making those phone calls and producing respective record falls onto clinicians to whose caseload the discharged clients belong. It was further discussed that shall respective clinician not be available to make the stated phone calls and produce the stated record, this responsibility will reside with the Clinical Director as the first line of backup and the Director of Operations as the second line of backup. This procedure is in effect staring immediately and as of reeducation date of 7/27/2026. Clinical Director will be ultimately responsible for maintenance of this compliance. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of seven applicable client records reviewed.
Client # 11 was admitted to the outpatient activity on July 9, 2025 and was discharged on October 20, 2025. A treatment and rehabilitation plan update was completed on August 15, 2025 and the next update was due no later than October 15, 2025; however, the update was not completed until October 27, 2025.
Client # 12 was admitted to the outpatient activity on December 1, 2025 and was discharged on April 14, 2026. A treatment and rehabilitation plan update was completed on January 21, 2026 and the next update was due no later than March 21, 2026; however, the update was not completed until April 1, 2026.
Client # 14 was admitted to the outpatient activity on April 10, 2025 and was discharged on October 20, 2025. A treatment and rehabilitation plan update was completed on August 14, 2025 and the next update was due no later than October 14, 2025; however, the update was not completed until October 20, 2025.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
In review of this deficiency, three main reasons for such were identified. (1) In case of Client #11, the identified treatment plan update was signed by the client on time and by clinician on the later date, identified in the described deficiency. (2) In case of client #12, an overall late submission of a treatment plan update by a clinician who has been previously reeducated on similar deficiencies. (3) In case of Client #14, the treatment plan was authored and inappropriately maintained by a clinician who is no longer employed at MRC secondary to ongoing record deficiencies identified continuously at their time of employment. In remediation of this deficiency, several measures were set in place. Overall reeducation on importance of timely treatment plan submission was provided to staff during multidisciplinary treatment team meeting on 7/27/2026. Reeducation pertaining to deficiency as it applies to client #11 was provided to respective staff prior to this citation as it was discovered during former chart audits in real time. Additional reeducation/reminder has been provided to said staff during individual supervision session on 7/28/2026. Reeducation was provided to clinician responsible for deficiency in timely treatment plan update submission for Client #12 within individual supervision session on 7/28/2026. Stated clinical was informed that audits with emphasis on this compliance have been set in place and that a disciplinary action will follow shall continued lack of this compliance be observed. For Client #14, no further remediation is possible as staff responsible for this deficiency is no longer employed with MRC for reasons, among others, of inability to maintain similar paperwork compliances. It is expected that maintenance of this compliance be established and sustained as of the date of this POC (7/30/2026) and moving forward. The ultimate responsibility for assuring maintenance of this compliance will reside with the Clinical Director. |