INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 17, 2025 and September 18, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Care, LLC dba State College Medical 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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709.28 (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.
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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 specific information to be disclosed in one of eight client records reviewed.Client #3 was admitted on June 30, 2025 and was active at the time of the inspection. A release of information form for the funding source, signed by the client on June 30, 2025, did not specify the specific information to be disclosed.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When specifying what information is to be disclosed per patient consent on a Release of Information, the box specifying "other" will be checked, in addition to the specific information being noted on the line that follows this box. This was reviewed with staff on 10/8/2025 by Executive Director. Clinical Supervisor and Executive Director will check 10 charts per month, reviewing consents to ensure that information to be released is specified, including the check box. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records, the project failed to offer a copy of the release of information forms in one of eight client records reviewed.Client #8 was admitted on May 12, 2025 and was a current client at the time of the inspection. There was no documentation that the client was offered a copy of two release of information forms, one for the funding source and the other for a social services agency; both signed and dated by the client on May 12, 2025.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Executive Director reviewed with all staff on 10/8/25 that each patient is to be offered a copy of release forms and this will be denoted on the form by checking "accept" or "decline" on the form. Clinical Supervisor and Executive Director will check 10 charts per month, reviewing consents to ensure that information to be released is specified, including the check box. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
The facility failed to document an annual evaluation of each patient's status that was completed by the patient's counselor and was reviewed, dated and signed by the medical director in one of eight applicable patient records reviewed.Patient #6 was admitted on June 18, 2018 and was a current patient at the time of the inspection. An annual evaluation was due in June 2025, per the program's policy and procedure of completion within their anniversary month; however, there was no documentation in the patient record of an annual evaluation at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
EMR system has been updated to include Medical Director's signature and date. Executive Director and Clinical Supervisor will review each annual evaluation when completed to ensure that Medical Director has signed. |