INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 8-9, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Farrell 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of applicable staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in one of two staff records.
Staff #6 was hired on as a support staff on July 5, 2023 and was still in this position at the time of the inspection. HIV/AIDS and TB/STD trainings were to be completed by July 5, 2025. There was no documentation the HIV/AIDS training was completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director provided the employee who did not complete HIV training with the necessary information to register for this training through the Train PA website. Clinic Director will ensure that all future new hires receive this information to complete the required HIV training. Clinic Director will monitor completion of these trainings by putting reminders on her work calendar based on dates of hire for each employee to ensure they are completed within the specified time frames. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of medical staff coverage, the facility failed to provide narcotic treatment physician services at least one hour per week onsite for every ten patients for nine of eighteen weeks.
Physician service hours were reviewed from May 4, 2025 through September 6, 2025.
During the week of May 25, 2025 through May 30, 2025, the facility census was 488 patients. The facility was required to provide 48.8 hours of onsite physician services, however they provided only provided 47.5 hours.
During the week of June 1, 2025 through June 7, 2025, the facility census was 491 patients. The facility was required to provide 49.1 hours of onsite physician services, however they provided only provided 47.75 hours.
During the week of June 8, 2025 through June 14, 2025, the facility census was 484 patients. The facility was required to provide 48.4 hours of onsite physician services, however they provided only provided 48.25 hours.
During the week of June 29, 2025 through July 5, 2025, the facility census was 481 patients. The facility was required to provide 48.1 hours of onsite physician services, however they provided only provided 42 hours.
During the week of July 6, 2025 through July 12, 2025, the facility census was 482 patients. The facility was required to provide 48.2 hours of onsite physician services, however they provided only provided 34 hours.
During the week of July 27, 2025 through August 2, 2025, the facility census was 478 patients. The facility was required to provide 47.8 hours of onsite physician services, however they provided only provided 39.5 hours.
During the week of August 10, 2025 through August 16, 2025, the facility census was 472 patients. The facility was required to provide 47.2 hours of onsite physician services, however they provided only provided 42 hours.
During the week of August 17, 2025 through August 23, 2025, the facility census was 473 patients. The facility was required to provide 47.3 hours of onsite physician services, however they provided only provided 41.75 hours.
During the week of August 31, 2025 through September 6, 2025, the facility census was 472 patients. The facility was required to provide 47.2 hours of onsite physician services, however they provided only provided 33.5 hours.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinic Director reviewed this citation with Regional Director. A position will be posted to hire a mid-level practitioner to assist with coverage of required weekly medical hours. In the meantime, PA-C and the two physicians are working together to adjust schedules so that hours are covered until the new position is filled. Clinic Director will review on a weekly basis to ensure we are in compliance. |
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 two of two records.
The facility policy and procedures state the individual treatment plan will be developed with the client within thirty days of admission.
Client #5 was admitted on April 14, 2025 and was still active at the time of the inspection.
The comprehensive treatment and rehabilitation plan developed on May 8, 2025 did not include documentation of the plan being developed with the client until May 13, 2025.
Client #6 was admitted on August 28, 2025 and was still active at the time of the inspection.
The comprehensive treatment and rehabilitation plan developed on September 12, 2025 did not include documentation of the plan being developed with the client until September 30, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director and Clinical Supervisor met with the counselor who sees all new patients to review this citation. This counselor will ensure that all comprehensive treatment plans demonstrate that the plan was developed with input from the patient, through documentation of a counseling note, as well as patient signature on the tx plan on its due date. Clinical Supervisor will review these treatment plans weekly to ensure compliance. |