INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 2, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cranberry Township 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(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 applicable personnel training records, the facility failed to have counselors complete at least 25 clock hours of annual training in one of two records. Staff #5 was hired as a counselor on December 29 2021 and was still in this position at the time of the inspection. Staff #5 had documented 19.5 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 monitor training completion/attendance each month in supervisor and document an ongoing log of compliance.
Clinical Supervisor will require each counselor to write a plan of action to complete training hours if the required training in not met by the end of quarter 3 to ensure compliance by end of calendar year
Program Director will monitor overall compliance and review with Clinical Supervisor monthly individual staff progress. Program Director will implement PIP if compliance is not met by end of quarter 3.
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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 a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in three of seven applicable records reviewed. Client #1 was admitted on April 15, 2015 and was still active at the time of the inspection. The facility had a Department-approved exception allowing this client ' s treatment plan updates to be completed every 120 days. A treatment plan update was completed on April 1, 2025 and the next update was due no later than August 1, 2025; however, the update was not completed until August 12, 2025. Client #2 was admitted on May 23, 2025 and was still active at the time of the inspection. The treatment plan was completed on June 18, 2025. A treatment plan update was due no later than August 18, 2025; however, the update was not completed until September 15, 2025. Client #7 was admitted on August 29, 2003 and was discharged on September 3, 2025. The facility had a Department-approved exception allowing this client ' s treatment plan updates to be completed every 120 days. A treatment plan update was completed on April 14, 2025 and the next update was due no later than August 14, 2025; however, this was not completed prior to discharge. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 9, 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.
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