INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 30 - October 1, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pittsburgh 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the personnel training records, the facility failed to have the facility director complete at least 12 clock hours of annual training in one of one record. Staff #2 was promoted to facility director on February 12, 2016 and was still in this position at the time of the inspection. Staff #2 had documented 11 hours of training for the January 1, 2024 through December 31, 2024 training year.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will ensure that all clinical staff completed the required training hours and will review weekly in individual supervision.
Clinical Supervisor and Clinic Director will also review in staff meetings the yearly requirements and have staff complete at least 1 training quarterly.
Clinic Director will complete 1 training per quarter to complete the 12 hours of required training for the year. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the personnel training records, the facility failed to have counselors complete at least 25 clock hours of annual training in one of one record. Staff #8 was hired as a counselor on September 1, 2022 and was still in this position at the time of the inspection. Staff #8 had documented 24.25 hours of training for the January 1, 2024 through December 31, 2024 training year.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will ensure that all clinical staff completed the required training hours and will review weekly in individual supervision.
Clinical Supervisor and Clinic Director will also review in staff meeting in November 11/4/25 and ongoing meetings the yearly requirements and have staff complete at least 1 training quarterly. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on applicable patient records reviewed, the facility failed to ensure that each patient file included the results of the initial physical examination in one of three records.Patient #4 was admitted on April 17, 2025 and was discharged on July 14, 2025. There was no documentation of who completed the initial physical examination on March 28, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director and Regional Director will announce to Pittsburgh ACJ med unit staff weekly meetings starting on 10/30/25 the finding and ensure that all paperwork from the initial physical exam is scanned in the chart before shredding it.
Clinic Director will randomly pull 2 intakes monthly 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 three of three records. The facility ' s policy and procedures state the individual treatment plan will be developed with the client within thirty days of admission.Client #2 was admitted on May 15, 2025 and was discharged on September 11, 2025.The comprehensive treatment and rehabilitation plan was to be developed no later than June 15, 2025; however this was not completed until July 9, 2025.Client #4 was admitted on April 17, 2025 and was discharged on July 14, 2025. The comprehensive treatment and rehabilitation plan was to be developed no later than May 17, 2025; however this was not completed until June 4, 2025.Client #7 was admitted on May 8, 2025 and was still active at the time of the inspection.The comprehensive treatment and rehabilitation plan developed on June 8, 2025 did not include documentation of the plan being developed with the client until June 20, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will review treatment plans with all patients and complete before the due date. Clinic Director and Clinical Supervisor will announce in team meeting on 11/4/25. Clinical Supervisor will review treatment plans monthly and if a correction is needed it will be documented in the general note section of the treatment plan- authored on this date and opened for correction and the date. |
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 in two of five applicable records. The facility policy and procedure indicates a case consultation to occur within three, six, nine, and twelve months of admission. A case consultation will occur annually after the first year of treatment. Client #2 was admitted on May 15, 2025 and was discharged on September 11, 2025.The three-month case consultation was due to occur no later than August 12, 2025, however this was not completed until August 20, 2025.Client #7 was admitted on May 8, 2025 and was still active at the time of the inspection.The three-month case consultation was due to occur no later than August 8, 2025, however this was not completed until August 29, 2025.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will complete case consults by the due date and Director and Supervisor will announce in Clinical Meeting on 10/30/25. Clinical Supervisor will check these randomly during monthly chart audits. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure in three of four records. The policy and procedure indicates a discharge summary be completed within seven days of discharge.Client #2 was admitted on May 15, 2025 and was discharged on September 11, 2025. The discharge summary was due to be completed no later than September 18, 2025; however, this was not completed at the time of the inspection.Client #3 was admitted on May 1, 2023 and was discharged on May 1, 2025. The discharge summary was due to be completed no later than May 8, 2025; however, this was not completed until June 13, 2025.Client #4 was admitted on April 17, 2025 and was discharged on July 14, 2025. The discharge summary was due to be completed no later than July 21, 2025; however, this was not completed until July 31, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will go into the Counselor's calendar for manual discharges to clock off their time to complete the discharge summary and follow up. For the AWOL discharges counselors will review their AWOL list daily and once a pt is showing 25 days AWOL with no contact they will block off time in their calendar to complete the discharge summary. This will be announced in Clinical Meeting on 10/30/25 and review in weekly supervision as needed. This will be reviewed monthly during d/c audits. |