INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 20-21, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Castle 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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709.92(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 applicable client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client in three of four records.
The facility policy and procedures states the individual treatment plan will be developed with the client within thirty days of admission.
Client #3 was admitted on September 3, 2025 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed on October 2, 2025 did not include documentation of the plan being developed with the client.
Client #6 was admitted on January 24, 2025 and was discharged on May 8, 2025. The comprehensive treatment plan was due no later than February 24, 2025, but was not completed until February 27, 2025. Additionally, the comprehensive treatment and rehabilitation plan developed on February 27, 2025 did not include documentation of the plan being developed with the client.
Client #8 was admitted on January 16, 2025 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed on February 14, 2025 did not include documentation of the plan being developed with the client until February 17, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review services due weekly to ensure all treatment plans are completed by the due date and follow up with clinician to ensure it was created with patient and documentation supports this.
Clinical Supervisor will review timelines and policy regarding timelines each month in group clinical supervision
Clinical Supervisor will follow corrective action policy once she establishes a pattern of late documentation.
Program Director will monitor overall compliance and review in supervisor with Clinical Supervisor each month outcomes of each counselor's documentation and develop PIPS as needed |
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.
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Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in two of six applicable records.
Client #1 was admitted on February 10, 2017 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on October 16, 2024. The next treatment and rehabilitation plan update was due no later than December 16, 2024, but was not completed until December 20, 2024.
A treatment and rehabilitation plan update was completed on April 17, 2025. The next treatment and rehabilitation plan update was due no later than June 17, 2025, but was not completed until June 20, 2025.
Client #8 was admitted on January 16, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on March 14, 2025. The next treatment and rehabilitation plan update was due no later than May 14, 2025, but was not completed until May 16, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 24-25, 2024 annual licensing inspection.
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Plan of Correction
Clinical Supervisor will review services due weekly to ensure all treatment plans/updates are completed by the due date.
Clinical Supervisor will review timelines and policy regarding timelines each month in group clinical supervision
Clinical Supervisor will follow corrective action policy once she establishes a pattern of late documentation.
Program Director will monitor overall compliance and review in supervisor with Clinical Supervisor each month outcomes of each counselor's documentation and develop PIPS as needed |
709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
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Observations
Based on client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in two of six applicable records. The facility policy and procedure manual indicate a case consultation to occur at three months, six months, nine months, and twelve months from admission. Case consultations will occur annually thereafter.
Client #4 was admitted on December 2, 2024 and was still active at the time of the inspection. The three-month case consultation was due to occur no later than March 2, 2025, however this was not completed until March 18, 2025.
Client #6 was admitted on January 24, 2025 and was discharged on May 8, 2025. The three-month case consultation was due to occur no later than April 24, 2025, however this was not completed until April 30, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review services due weekly to ensure all case consults are completed by the due date.
Clinical Supervisor will review timelines and policy regarding timelines each month in group clinical supervision
Clinical Supervisor will follow corrective action policy once she establishes a pattern of late documentation.
Program Director will monitor overall compliance and review in supervisor with Clinical Supervisor each month outcomes of each counselor's documentation and develop PIPS as needed |