INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on December 3, 2025 through December 5, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Caron Treatment Centers 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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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on December 5, 2025, the facility failed to ensure that hot water temperature may not exceed 120 degrees Fahrenheit.
When tested, the hot water in a cafeteria bathroom of the Howard Family Hall building was 127 degrees Fahrenheit. Additionally, the first-floor bathroom in the Chen-See building was 124 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Maintenance Technician adjusted the water temperatures in the Taigwad Family Hall building and the Chen See building on 12/5/2025 so that they were below 120 degrees Fahrenheit. The Director of Plant Operations will implement an ongoing work order for water temperatures to be checked monthly by the Maintenance Technician to ensure that water temperatures stay below 120 degrees Fahrenheit. The work order system will be implemented by 1/31/26. |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosures will be made to in one of twenty-one records reviewed.
Client #10 was admitted on June 12, 2025 and was discharged on July 11, 2025. A release of information form, signed by the client on July 10, 2025, did not specify the name of the person, agency or organization to whom disclosure is to be made.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Health Records Management Department is going to conduct a training for staff on 42 CFR Part 2 requirements during the month of January to ensure staff understand which fields are mandatory to complete on the informed and voluntary consent forms. The training will include instruction for staff to double check that all fields are completed prior to finalizing/signing the form. The Health Records Management Department will conduct weekly audits to ensure that all required fields on the involuntary consent forms are completed accurately. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of two applicable client record reviewed.
Client #14 was admitted on June 3, 2025 and was involuntarily discharged on June 24, 2025. There was no documentation in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment prior to the client ' s discharge.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Directors will re-educate staff during team supervision meetings regarding the process for providing written involuntary termination notification when a patient is involuntarily discharged. This re-education will be conducted by 2/4/2026. The Quality Analyst will conduct quarterly chart reviews to review compliance with the process and will report progress to leadership on a quarterly basis. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on the review of client records, the project failed to document two weekly individual counseling sessions in three of seven partial hospitalization clients reviewed.
Client #17 was admitted on November 7, 2025 and was active at the time of the inspection. The project only documented one individual counseling session for the week of November 16, 2025 through November 22, 2025.
Client #20 was admitted on August 20, 2025 and was discharged on September 17, 2025. The project only documented one individual counseling session for the week of September 7, 2025 through September 13, 2025.
Client #21 was admitted on August 11, 2025 and was discharged on September 8, 2025. The project only documented one individual counseling session for the weeks of August 17, 2025 through August 23, 2025, and August 31, 2025 through September 6, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Directors will re-educate staff during team supervision meetings regarding the requirement of individual counseling sessions needing to be conducted and documented at least twice weekly. This re-education will be conducted by 2/4/2026. The Clinical Director will conduct chart reviews on a monthly basis to ensure that individual counseling sessions are conducted and documented at least twice weekly. The Quality Analyst will conduct quarterly chart reviews to review compliance with the process and will report progress to leadership on a quarterly basis. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on the review of client records and the project ' s policies and procedures manual, the project failed to document a complete client record on an individual that included a follow-up contact note within ten days of discharge, per facility policy, in one of three applicable client records reviewed.
Client #4 was admitted on November 4, 2025 and was discharged on November 8, 2025. There was no follow-up contact documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Directors will re-educate staff during team supervision meetings regarding the process for conducting and documenting follow-up calls after a patient is discharged. This re-education will be conducted by 2/4/2026. The Quality Analyst will conduct quarterly chart reviews to review compliance with the process and will report progress to leadership on a quarterly basis. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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.
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Observations
Based on the review of client records and the project ' s policies and procedures manual, the project failed to document a complete client record on an individual that included a follow-up contact note within ten days of discharge, per facility policy, in two of four applicable client records reviewed.
Client #13 was admitted on April 30, 2025 and was discharged on May 17, 2025. There was no follow-up contact documented in the client record.
Client #14 was admitted on June 3, 2025 and was discharged on June 24, 2025. There was no follow-up contact documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Directors will re-educate staff during team supervision meetings regarding the process for conducting and documenting follow-up calls after a patient is discharged. This re-education will be conducted by 2/4/2026. The Quality Analyst will conduct quarterly chart reviews to review compliance with the process and will report progress to leadership on a quarterly basis. |