INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Carbon Monroe Pike Drug and Alcohol Commission, Inc. 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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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of outpatient records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one out of seven records reviewed.
Client # 1 was admitted to outpatient level of care on August 13, 2025, and was discharged on October 22, 2025. There was a completed and signed release of information dated August 13, 2025, to an attorney that did not include the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff meeting done with all staff to review releases of information and ensuring appropriate purpose is checked on every release. Releases will then be reviewed during chart audits by clinical supervisor to ensure compliance. |
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 a review of client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project, in one of one applicable record reviewed.
Client # 3 was admitted to outpatient level of care on July 17, 2025, and was involuntarily discharged on September 30, 2025. The record did not contain documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Reviewed requirements for discharge letters with all clinical staff during case management meeting. Chart audits will be conducted by supervisor on discharged files to ensure compliance. |
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 administrative records and discussion with facility staff, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel.
There was documentation of the presence of ambulance personnel on July 29, 2025; however, facility did not fax a written unusual incident report to the Department until August 4, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
After the date of this incident, we have been able to activate the portal for submitting incident report. Review of incident report requirements and deadlines has occurred with the supervisory staff to ensure compliance to submission of incident reports within 72 hours. Treatment Program Manager will review all incident reports to ensure compliance. |