INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 14, 2025, October 15, 2025, and October 20, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Watsontown 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records and the projects policies and procedure manual, the project failed to document a written initial individual training plan for each employee within thirty days of their hire date and yearly in the month of January, that is appropriate to that employee's skill level with input from both the employee and the supervisor in one out of six records reviewed.Employee #3 was hired as a clinical supervisor on September 5, 2023 and was currently in that position at the time of the inspection. An individual training plan was documented in the personnel record on January 9, 2024, with the next training plan due no later than January 31, 2025; however, the individual training plan was not documented in the personnel record until October 9, 2025.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
he Clinic Director will ensure, in compliance to the project policies and procedures as well as §704.11(b)(1) that all Individual training plans are completed at the time of hire and at each Annual Performance Evaluation.
The Clinic Director will review with each manager that such is completed for all new hires within the first week of employment and for all existing personnel immediately following the close of the Performance Review period on/around January 12, 2026.
This will remain a focused discussion and review during various Mgmt. Team Meetings to assess staff progress towards plan as well as preparation for future drafts. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on the review of the fire drill log from December 2024 through September 2025, the facility failed to maintain written fire drill records that indicated whether the fire alarm or smoke detector was operative.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In response to deficiency 705.28, this facility will implement additional protocol for maintaining a written fire drill record that meticulously documents essential details, including the date, time, and duration of the evacuation. Each record will specify the evacuation route utilized, the number of individuals present in the facility during the drill, and any issues encountered, as well as the operational status of fire alarms and smoke detectors. Currently, we do indicate the workings of our detectors through a checkbox but moving forward our maintenance staff will ensure to indicate that they are working. Moving forward, we are committed to ensuring that greater attention is paid to the functionality of all fire safety devices, thereby enhancing the overall safety and preparedness of our facility. This will be reviewed every 30 days with staff by the clinical director. |
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 applicable client record reviewed.Client #8 was on June 11, 2024 and was involuntarily discharged on January 27, 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.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinic Director will review during group supervision with the counseling team, the Projects policy and procedure, as well as §709.33(a) regulation surrounding consistent and proper written notification for any patient who is determined to non-compliant and may be recommended for an involuntary transition from care during Multi-Disciplinary Team (MDT) review meetings.
The group supervision session review will occur by December 17, 2025. Such will also be presented and discussed during each MDT meeting when appropriate.
The Clinic Director and Clinical Supervisor will review compliance during weekly Quality Record Reviews and reinforce such during individual supervision sessions.
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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on the review of the unusual incident log, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the death or serious injury of a client due to trauma, suicide, medication error or unusual circumstances.Project staff were notified of three separate client deaths on February 13, 2025, February 14, 2025 and June 30, 2025. Written unusual incident reports were not filed with the Department.Project staff were notified of a client ' s death on September 1, 2025; however, a written unusual incident report was not filed with the Department until September 10, 2025. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinic Director will ensure compliance to the reporting parameters surrounding §709.34(c)(2). With the transition of administrative leadership on site, §709.34 was one of the specific training reviews completed by the Regional Director during the on-boarding process. A training with the Clinic Director and Clinical Supervisor was completed on September 10, 2025 when notification issues were identified. Continued reviews were also provided to all counseling staff members during weekly group supervision. Such regulatory discussions will remain part of Monthly staff meetings held by the Clinic Director. The clinical director and clinical supervisor will ensure written unusual incident report is prepared and filed with the department within three business days of the event. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the unusual incident log, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.On August 29, 2025, law enforcement responded to the facility. A written unusual incident report was not filed with the Department.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinic Director will ensure compliance to the reporting parameters surrounding §709.34(c)(2). With the transition of administrative leadership on site, §709.34 was one of the specific training reviews completed by the Regional Director during the on-boarding process. A training with the Clinic Director and Clinical Supervisor was completed on September 10, 2025 when notification issues were identified. Continued reviews were also provided to all counseling staff members during weekly group supervision. Such regulatory discussions will remain part of Monthly staff meetings held by the Clinic Director. The clinical director and clinical supervisor will ensure written unusual incident report is prepared and filed with the department within three business days of the event. |
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 the review of sixteen weeks of narcotic treatment physician time sheets, the program failed to provide the required number of hours onsite for the physician based on the census for two weeks reviewed. A narcotic treatment physician must provide one-third of the required hours, with a certified registered nurse practitioner or physician's assistant providing the remaining two-thirds of the required hours. During the week of July 6, 2025 through July 12, 2025, the patient census was 240. The narcotic treatment physician was required to provide one-third of the 24.0 hours, which equals 8 hours. The narcotic treatment physician only provided 5.5 hours. During the week of August 31, 2025 through September 6, 2025, the patient census was 244. The narcotic treatment physician was required to provide one-third of the 24.4 hours, which equals 8.1 hours. The narcotic treatment physician only provided 4.5 hours. These findings were reviewed with program staff during the licensing process.
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Plan of Correction
In response to the deficiency outlined under 715.6(d), the Clinic Director and Charge Nurse will complete weekly reviews for the preceding week, to ensure appropriate levels of Physician time is scheduled. In the event of an unforeseen occurrence that impacts such an exception will be filed by the Clinic Director acknowledging the shortage due to the unforeseen event |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the program failed to obtain an informed, voluntary, written consent before an agent may be administered in two of nine patient records reviewed.Patient #2 was admitted on January 30, 2025, and was active at the time of the inspection. The informed, voluntary, written consent documented in the record on February 13, 2025; however, the agent was administered prior to that, on January 30, 2025.Patient #5 was admitted on April 1, 2025, and was active at the time of the inspection. The informed, voluntary, written consent documented in the record on April 2, 2025; however, the agent was administered prior to that, on April 1, 2025.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
In response to deficiency 715.12, the Clinic Director will provide a review and trainings on Intake/Admission protocols to include the need to obtain a signed voluntary Pt. consent to treatment, prior to the administration of any medications. Additional training and education will be provided by December 16, 2025 for all medical and nursing staff to review all new admissions presenting, ensuring the Pt. Informed Voluntary Written Consent is signed prior to Pt's initial dose. As part of the Quality Record Review (QRR) process on site, the Clinical Supervisor and Clinic Director will review all new admission with 24 hours to ensure compliance. The Clinic Supervisor and Clinic Director will continue with monthly QRR's on all new admission to ensure sustained compliance to §715.12. |
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 the review of outpatient client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in three of nine applicable records reviewed.Client #2 was admitted on January 30, 2025, and was active at the time of the inspection. An updated comprehensive treatment and rehabilitation plan was documented in the record on July 15, 2025, with the updated treatment and rehabilitation plans due no later than September 15, 2025; however, there were no updated treatment and rehabilitation plans documented in the client record until September 30, 2025.Client #3 was admitted on May 28, 2025, and was discharged on November 25, 2024. An updated comprehensive treatment and rehabilitation plan was documented in the record on July 13, 2025, with the updated treatment and rehabilitation plans due no later than September 13, 2025; however, there were no updated treatment and rehabilitation plans documented in the client record until September 29, 2025.Client #9 was admitted on July 5, 2016, and was active at the time of the inspection. An updated comprehensive treatment and rehabilitation plan was documented in the record on January 6, 2025, with the updated treatment and rehabilitation plans due no later than March 6, 2025; however, there were no updated treatment and rehabilitation plans documented in the client record until April 17, 2025. Additionally, the next treatment and rehabilitation plan update was due no later than June 17, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until June 23, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In response to deficiency 709.92, a review of timely, collaborative treatment planning was provided on November 6, 2025 by the Regional Director and Clinic Director for all counseling personnel. The training included a discussion on time-management and scheduling to include a review of the Pt. Services Due report within the EHR/SMART system in order to provide ample notification to Pt.'s for scheduling individual sessions for Treatment plan reviews and update completions as needed. The Clinic Supervisor and/or Clinic Director will monitor compliance during individual supervision and weekly checklist reviews; as well as during group supervision reviews. Accordingly such will remain part of the Quality Record Review (QRR) process on site to ensure sustained compliance to same. |