INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on December 9 & 10, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health - HALLC dba Chambersburg 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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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all fire extinguishers in the facility were inspected and approved annually by the local fire department or fire extinguisher company.
The fire extinguisher located in the dosing medication room expired September 2025.
This finding was reviewed with the facility during the licensing inspection.
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Plan of Correction
Dispensary Fire extinguisher was serviced 12/12/2025. Healthy and safety officer will review all fire extinguishers monthly to ensure compliance and document in heathy and safety binder. |
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 a review of fire drill records from April to October 2025, the facility failed to maintain a written fire drill record that included 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.
The fire drill record dated July 22, 2025, failed to document if the fire alarm or smoke detector was activated during the drill.
The fire drill logs dated August 27 and September 17, 2025, failed to document what exit route was used during the fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills will be conducted monthly and will include date, time, documentation as to the route of egress used and ensuring smoke detectors are checked and documented. Health and safety officer will review health and safety binder monthly to ensure proper documentation of all monthly fire drills and sign off on completed report. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of twelve client records reviewed.
Client #8 was admitted on May 5, 2025 and transferred out on August 14, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a substance use facility dated July 28, 2025, was offered to the client.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Training conducted 12/15/25 with administrative and clinical staff regarding intake check list and consents for transfer patients. Clinical supervisor will monitor compliance via chart audits utilizing quality record review application weekly on all intakes. |
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.
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Observations
Based on a physical plant inspection and a review of the facility's files, 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.
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Plan of Correction
A dispensary check list will be created by 1/30/2026. This checklist will be completed by the Nurse supervisor quarterly to ensure all drug storage areas in dispensary are inspected. The check list will 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. Check list will reviewed by health and safety officer to ensure compliance. Director will monitor monthly compliance with this check list and sign off complete. It will be stored with monthly check lists in Health and Safety binder. |
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.
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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 two of seven applicable records.
Patient #4 transferred to the facility on September 29, 2025 and was still active at the time of the inspection. There is no documentation that the facility notified the transferring facility of the patient ' s admittance and date of first dose.
Patient #9 transferred to the facility on September 29, 2025 and discharged on October 1, 2025. There is no documentation that the facility notified the transferring facility of the patient ' s admittance and date of first dose.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical meeting conducted on 12/15/25 discussed transfer paperwork required for all charts, including transfer acknowledgment forms. To ensure ongoing compliance, the Clinical Supervisor will review all transfer charts weekly as well as review intake check lists after each intake. Finally, quality record reviews will be completed on all admission charts and documented in the Quality Record Review application monthly |