INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on January 28 & 29, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, York 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:
|
Plan of Correction
|
709.28 (c) 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.
|
Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two out of twelve records reviewed.Client #11 was admitted on September 16, 2025 and discharged on December 31, 2025. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. Client #12 was admitted on September 22, 2025 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
After reviewing the observations presented to the York CTC during DDAP's inspection on 1.28.2026 and 1.29.2026, the violation 709.28 © Licensure Confidentiality will be corrected as follows:
On 2/2/2026 corrective action was completed by the facility obtaining fully executed Funding Source ROIs for Patient #12. In addition, on 2/2/2026 same was uploaded into the patient's chart. Patient #12 had been discharged from the York CTC prior to the time of the inspection on 1/28/2026 and 1/29/2026, and no action could be taken.
A Funding Source ROI has been added as a required element of the Intake ROI Checklist, effective 02/02/2026. The EMR intake workflow was updated on 02/02/2026 to prevent the chart from moving forward until the Funding Source ROI is completed. All intake and billing staff were retrained on ROI requirements on 02/02/2026.
To ensure ongoing compliance the Clinical Supervisor will audit 100% of all new intakes weekly using the Quality Record Review (QRR) application to verify the Funding Source ROI and any missing items will be corrected within two business days. The Clinic Director will review trends monthly and provide corrective feedback as needed.
|
715.17(c)(3)(i-v) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(3) Inspection of storage areas. A narcotic treatment program shall inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State and local laws and regulations. A narcotic treatment program shall develop and implement written policies and procedures regarding who performs the inspections, how often, and in what manner the inspections are to be documented. The policies and procedures shall include the following:
(i) Disinfectants and drugs for external use shall be stored separately from oral and injectable drugs.
(ii) Drugs requiring special conditions for storage to insure stability shall be properly stored.
(iii) Outdated and contaminated drugs shall be removed and destroyed according to Federal and State regulations.
(iv) Administration of controlled substances shall be documented.
(v) Controlled substances and other abusable drugs shall be stored in accordance with Federal and State regulations.
|
Observations
Based on a physical plant inspection and a review of the facility ' s administrative documents, the facility failed to inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State, and local laws and regulations. The facility did not have documentation that the inspections were conducted. This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Plan of Correction:
After reviewing the observations presented to during DDAP's inspection on 1.28.26 and 1.29.26 of the York CTC 3405. On 3/02/2026 the violation 715.17(c)(3)(i-v) LICENSURE
Medication Control was corrected as follows:
A full corrective inspection of all drug storage areas and the dispensing station was completed on 03/02/2026 using the newly implemented Dispensary Quarterly Inspection Checklist. All issues identified were corrected on the same day.
The Dispensary Quarterly Inspection Checklist, revised 03/02/2026, now covers all elements required under 715.17(c)(3)(i?v). Policies and procedures were updated on 03/02/2026 to specify that the Nurse Supervisor conducts quarterly inspections, with documentation stored in the Medication Compliance Binder and digitally in the designated compliance repository.
To ensure ongoing compliance the Nurse Supervisor will complete and file the Dispensary Checklist quarterly during the first week of each quarter. The Clinic Director will review and sign each set of inspection documents. The Health & Safety Officer will conduct semiannual validations to ensure adherence to the procedure.
|
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
|
Observations
Based on a review of patient records, the facility failed to document notification to a patient's previous facility of the patient's admission including the date of initial dose in one in three applicable records reviewed. Patient #11 transferred to the facility on September 16, 2025 and was discharged on December 31, 2025. There is no documentation that the facility notified the transferring facility of the patient ' s admittance and date of first dose.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction: On 2/15/2026 after reviewing the observations presented to the York CTC during DDAP's inspection on 1.28.26 and 1.29.26. The violation 715.20 (4) Licensure Patient Transfers was corrected as follows:
Beginning 02/15/2026, the Transfer Notification Acknowledgment Form is now part of the standard transfer intake packet. The EMR was updated on 02/15/2026 to require this form?or documented good faith attempts?before the first dose can be administered to transfer patients. Counseling and nursing staff were retrained on transfer requirements on 02/15/2026.
To ensure ongoing compliance the Clinical Supervisor will review 100% of new transfer charts weekly to ensure documentation is present. The Clinic Director will conduct a monthly 10% sample audit of transfer charts, with trends reported during the monthly QA/PI meeting.
|
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:
|
Observations
Based on a review of client records, the facility failed to document that a comprehensive treatment plan was developed with the client within thirty days of admission, per the facility ' s policy and procedures manual in five out nine applicable records reviewed. Client #2 was admitted on September 10, 2025 and discharged on January 15, 2026. A comprehensive treatment plan was due no later than October 10, 2025; however, it was completed on November 5, 2025. Client #3 was admitted on December 12, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than September 4, 2025; however, it was completed on September 8, 2025. Client #5 was admitted on September 11, 2025 and discharged on November 17, 2025. A comprehensive treatment plan was due no later than October 11, 2025; however, it was completed on October 29, 2025. Client #11 was admitted on September 16, 2025 and discharged on December 31, 2025. A comprehensive treatment plan was due no later than October 16, 2025; however, it was completed on November 26, 2025. Client #12 was admitted on September 22, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than October 22, 2025; however, it was completed on October 30, 2025. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction:
After reviewing the observations presented to the York CTC during DDAP's inspection on 1.28.26 and 1.29.26. The violation 709.92 (a) Licensure Treatment and Rehabilitation Services was corrected on 2/13/2026 as follows:
Although Patient #2, Patient #3, Patient #5, Patient #11, and Patient #12 all had Treatment Plans. It was founded that the EMR system had a glitch which caused an oversight for Treatment Plan to be completed within the first the thirty (30) days of treatment. Our POC moving forward is that the glitch has since been rectified in our EMR system.
Treatment plans for Patients #2, #3, #5, #11, and #12 were reviewed and confirmed completed, with documentation updated in each file on 02/13/2026.
On 02/13/2026, the EMR was updated to include:
- Automated alerts at Days 21 and 27, and
- A day 30 hard stop preventing chart progression without a completed treatment plan.
The Intake & 30 Day Compliance Checklist was updated the same day. All clinical staff were retrained on timeline expectations and EMR alerts on 02/13/2026.
To ensure ongoing compliance the Clinical Supervisor will audit 100% of all new intakes and a percentage of interim records using the Quality Record Review (QRR) application. Any overdue plans will be corrected within seven business days. Additionally, the Clinical Supervisor and Clinic Director will generate reports from the EMR as well to review timeliness of treatment plans and ensure that the reports are generated accurately. The Clinic Director will review trends monthly and provide corrective feedback as needed.
|