INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 10, 2025 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:
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2024 through December 31, 2024 training year in one of three applicable personnel records reviewed.
Employee # 4 was hired as a counselor on April 3, 2023. There were 10.5 training hours completed and documented in the personnel record for training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Completion of required annual training hours is presented upon hire to every employee at MRC as a non-negotiable part of their job responsibilities. Such is further outlined in each employee's annual training plan and is being discussed in group and individual supervision sessions with reliable consistency. Employee #4 has been addressed in the beginning of this year (record in supervision session note dated as of 01.07.25) regarding this discrepancy. Employee #4 was re-educated on the importance of obtaining required training hours and was made aware that failure to deliver upon this requirement in the year 2025 will result in a formal administrative action. Employee #4 has a record of written warnings and is being monitored for wraparound compliance. On the Corrective Action Date indicated above, Employee #4 was once again reminded to make every effort to complete his training hours for 2025 as quickly as possible. At this time Employee #4 has completed 60% of his training hours for the year. While it is still a responsibility of each individual clinician to complete their necessary training hours, the ultimate responsibility to assure for maintenance of this compliance resides with the Clinical Director. Assistance toward finding trainings is being offered to each clinician in a form of coaching through DDAP TMS as well as via offering time within individual supervision sessions for assistance with finding trainings. Additional assistance with time for completion of in-person trainings is being offered as well. In-services are being sought after and offered when available by the Director of Operations and the Clinical Director at MRC. Continuous reminders are being issued to the whole clinical team regarding necessity of completion of the required trainings. It is expected that no further discrepancy should occur with regards to any clinical employee training hours for the year 2025 and moving forward. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made to on consent to release information forms in three of fourteen client records reviewed.
Client # 6 was admitted to the partial hospitalization activity on July 2, 2024 and was discharged on July 22, 2024. The release of information form to a funding source was signed by the client on July 2, 2024; however, the form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.
Client # 9 was admitted to the outpatient activity on April 10, 2025 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on April 10, 2025; however, the form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.
Client # 12 was admitted to the outpatient activity on July 22, 2024 and was discharged on March 11, 2025. The release of information form to the funding source was signed by the client on July 2, 2024; however, the form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In the process of addressing the stated discrepancy it was discovered that in the case of clients #6 and #12 (same client admitted successively to PHP and Outpatient levels of care), the stated ROI to the funding source was generated, but the electronic medical record populated into the form the client's insurance ID in place of the Insurance Provider's Agency Name. Toward remediation of this discrepancy three measures have been set in place on the Corrective Action Date indicated above: (1) the EMR support team has been contacted and a ticket has been created toward assuring that no further error of such kind takes place, (2) a separate release of information to the insurance provider has been created to stand in supplement of the overarching Patient Financial Responsibility / Assignment Agreement / Release of Information form (a document in which stated discrepancy occurred) to serve a safety net in case any such error does once again occur, and (3) additional real-time audits of financial documentation and consents have been implemented to be conducted at each new client's admission.
In case of client #9 it was found that at the time of admission the client was not granted an SCA by his insurance provider rendering, therefore, the overarching Patient Financial Responsibility / Assignment Agreement / Release of Information form impossible to complete due to lack of necessary information. In remediation of such, and as stated above, a separate ROI to insurance provider has been created to be automatically populated in each new client's chart and signed as a way of procuring release supplemental to or in place of Patient Financial Responsibility / Assignment Agreement / Release of Information form when such is not possible to complete.
The overall responsibility for maintenance of this compliance resides with facility's Director of Operations as supported by the Clinical Director.
For client #9, the proper ROI containing the name of the funding source has been populated and signed by the client as of 7.23.25.
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709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of seven applicable client records reviewed.
Client # 2 was admitted to the partial hospitalization activity on June 30, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 3, 2025; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client # 3 was admitted to the partial hospitalization activity on July 2, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 2, 2025; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client # 5 was admitted to the partial hospitalization activity on November 26, 2024 and was discharged on December 30, 2025. The individual treatment and rehabilitation plan was completed on November 29, 2024; however, the plan did not include the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In case of discrepancy pertaining to clients #2, #3, and #5, receiving or having received treatment in partial hospitalization program; re-education has been provided to all clinical staff regarding the necessity of including both type and frequency of treatment/rehabilitative services in client treatment plans. It was found that in instances outlined within this discrepancy, either one or the other has been included, in place of having indicated both. It has been further found that the treatment plan for client #5 was authored by a clinician who is no longer employed with MRC. Stated re-education has been provided within a multidisciplinary treatment team meeting, group supervision and individual supervision sessions. Examples of appropriate ways of completing treatment plans to include both type and frequency of service have been provided to each member of clinical staff. Additional real-time auditing of treatment plans has been implemented to be conducted weekly for the first month and monthly from then out, unless continuous discrepancies are observed. It is expected that MRC will remain in compliance with proper formatting of treatment plans from the Corrective Action Date indicated above, and moving forward. Clinical Director will be ultimately responsible for assuring maintenance of this compliance.
Treatment plans for active clients (client #2 and client #3) wherein the discrepancy was found have been updated to include both type and frequency of offered services/treatment as of the Corrective Action Date above. |
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 client records, the facility failed to document the type and frequency of treatment and rehabilitation services the client is to receive on the individual treatment and rehabilitation plan in five of seven applicable client records reviewed.
Client # 9 was admitted to the outpatient activity on April 10, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 17, 2025; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client # 10 was admitted to the outpatient activity on March 28, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 3, 2025; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client # 11 was admitted to the outpatient activity on December 30, 2024 and was discharged on April 10, 2025. The individual treatment and rehabilitation plan was completed on January 21, 2025; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client # 13 was admitted to the outpatient activity on December 12, 2024 and was discharged on April 17, 2025. The individual treatment and rehabilitation plan was completed on December 19, 2024; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client # 14 was admitted to the outpatient activity on November 19, 2024 and was discharged on February 6, 2025. The individual treatment and rehabilitation plan was completed on November 26, 2024; however, the plan did not include the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In case of discrepancy pertaining to clients #9, #10, #11, #13, and #14, receiving or having received treatment in Outpatient Program, re-education has been provided to all clinical staff regarding necessity of including both type and frequency of treatment/ rehabilitative services in client treatment plans. It was found that in instances outlined within this discrepancy, either one, or the other has been included, in place of having indicated both. It has been further found that treatment plans for clients #11, #13, and #14 were authored by a clinician who is no longer employed with MRC. Stated re-education has been provided within a multidisciplinary treatment team meeting, group supervision and individual supervision sessions. Examples of appropriate ways of completing treatment plans to include both type and frequency of service have been provided to each member of clinical staff. Additional real-time auditing of treatment plans has been implemented to be conducted weekly for the first month and monthly from then out, unless continuous discrepancies are observed. It is expected that MRC will remain in compliance with proper formatting of treatment plans from the Corrective Action Date indicated above, and moving forward. Clinical Director will be ultimately responsible for assuring maintenance of this compliance.
Treatment plans for active clients (client #9 and client #10) wherein the discrepancy was found have been updated to include both type and frequency of offered services/treatment as of the Corrective Action Date above. |