INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 8, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Duncansville Comprehensive Treatment Center 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to prohibit heaters that are not permanetly mounted or installed.
During the onsite complaint investigation, a portable heater was observed in the facility director's office.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
All portable heaters have been removed. For next winter, we will have heaters installed in order to meet this standard.
The director is responsible for ensuring that no electric heaters are being used by the staff.
Each month there is an inspection of the fire alarm, outlets, and egresses, and added to that inspection will be electric heaters.
In addition, staff has been informed of the dangers of electric heaters, and informed that these are prohibited. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of unusual incidents and staff interview, the facility failed to report an event at the facility requiring the presence of police, fire or ambulance personnel to DDAP within 3 buisness days.
A note was observed during the onsite complaint investigation stating that an ambulance was called to the facility on December 19, 2025 for a client medical emergency. There was no documentation that this incident was reported to DDAP. There have been no unusual incidents at the facility reported since January 16, 2025.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Staff was congregated and re-educated on documentation, how to document, what to document, and when in doubt, ask someone.
In addition, the director and clinic supervisor reviewed examples from the past ten years that were documented, just to be familiar with the range of what needed proper documentation.
The director keeps and maintains a notebook of unusual incidents, and these are reviewed each month with the leadership team.
Each staff members has a monthly meeting with his or her supervisor, and that item is put on the agenda for discussion. If there are any unusual activities which are not already documented, they are documented at that time and the employee received a refresher on what unusual incidents and and how we must handle those.
The director will be the one submitting unusual incidents to DDAP. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis.
Client #1 was admitted on January 31, 2023 and is currently active in treatment. There is no documentation showing that client #1 has been provided with individual counseling since August 5, 2025. There is no documentation showing that client #1 has been provided with group therapy since June 27, 2025. Client #1's last treatment plan, completed on November 29, 2025 indicated that client #1 was to receive 2.5 hours of individual and group therapy per month.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
The director and clinic supervisor met with staff to discuss these counseling sessions, when they needed to happen, and provided a timeline for the counselors as a reference.
We also meet weekly with counselor, and look at their clients, noting anything that is needed to be done, so that nothing will be missed or late moving forward. |