INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on December 17, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Watsontown Comprehensive Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of patient records, administrative documentation, and the Patient Rights, the facility failed to follow its Patient Rights.
The Patient Rights indicates patients are to be protected from abuse by staff at all times including sexual abuse or harassment, sexual or financial exploitation, racism or racial/ethnic harassment, psychological abuse, and physical abuse or punishment. The patient has the right to have any reported infringement of rights investigated and receive a resolution to those concerns.
Client # 1 was admitted March 15, 2017, and was still an active patient at the time of the investigation. Client # 1 requested a counselor change on February 24, 2025, due to alleged sexual abuse and harassment. These allegations were not investigated.
Client # 2 was admitted November 7, 2019, and was still an active patient at the time of the investigation. Client # 2 submitted a grievance form on February 25, 2025, due to alleged sexual abuse and harassment. These allegations were not investigated.
Client # 3 was admitted November 2, 2021, and was still an active patient at the time of the investigation. Client # 3 verbally reported on February 27, 2025, being sexually harassed This allegation was not investigated.
Client # 4 was admitted July 14, 2016, and was still active at the time of the investigation. Client # 4 submitted a complaint form on February 26, 2025, due to alleged sexual abuse and harassment. These allegations were not investigated.
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Plan of Correction
In accordance with number 709.30, within the last 30 days, this agency has established updated written policies and procedures concerning grievance and complaint management, ensuring that both documents are distinct and accessible to all clients during their orientation for new clients, and within individual session with assigned counselors for all established clients. This approach will guarantee that clients are well-informed about the processes available to them and reinforce the agency's commitment to safeguarding clients from any form of staff misconduct, including sexual harassment, financial exploitation, racism, psychological abuse, and physical abuse. Should a client choose to report any such incidents described above, the client will have the opportunity complete a grievance or complaint form, or both if necessary and to review the resolution of their complaints or grievances within 72 hours. The resolution response will be authored by the Clinic Director, and signed by both the clinical supervisor and Director. A copy of the resolution will also be documented along with the complaint within a binder marked by date of occurrence, noted in their patient chart, and forwarded to regional leadership as well to ensure transparency and accountability.
Furthermore, several meetings occurred within the months of December 2025 and January 2026 with indicated victims. All identified victims were personally approached by the clinic director and presented with options for external therapeutic intervention; however, all clients indicated opted not to pursue external services at this time.
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715.23(b)(25) LICENSURE Patient records
(b) Each patient file shall include the following information:
(25) Documentation of patient grievances.
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Observations
Based on a review of patient records and the Patient Complaints/Grievances policy, the facility failed to follow its patient grievance procedure to include documentation of patient grievances in the patient record.
The Patient Complaints/Grievances policy indicates the patient will be provided with the Acknowledgement of Notification of Complaint Resolution which will provide written notification of the actions taken to address the complaint. A record of all complaints will be kept on file. The policy also says the Clinic Director will attempt to resolve the grievance within three (3) business days and will complete the Grievance Resolution form. This form will document efforts to resolve the grievance.
Client # 2 was admitted November 7, 2019, and was still active at the time of the investigation. Client # 2 submitted a grievance form on February 25, 2025. A Grievance Resolution form was missing from the patient record.
Client # 4 was admitted July 14, 2016, and was still active at the time of the investigation. Client # 4 submitted a complaint form on February 26, 2025. An Acknowledgement of Notification of Complaint Resolution form was missing from the patient record.
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Plan of Correction
In response to item 715.23 and within the last 30 days regarding patient records, our organization has updated our system for addressing grievances and complaints that prioritizes transparency and timely resolution. Both the grievance and complaint forms are prominently displayed in our front lobby, ensuring that patients are aware of their rights to any and all concerns. These forms are also thoroughly presented and explained during the orientation phase of treatment, or reviewed within individual session with their primary counselor. To enhance our grievance handling process, we have introduced a designated section within our policy for documenting the resolution of each complaint or grievance. All resolutions will be authored by the clinic director and signed by both the clinical supervisor and site director. All completed forms are organized in a binder, labeled by year and date, and securely stored in the clinical director's office. Additionally, a copy of these complaints will be submitted to regional leadership upon receipt to further promote accountability and oversight. We are committed to providing timely resolutions; therefore, a response will be presented to the client within 72 hours, with all actions documented in their medical chart. Furthermore, to ensure ongoing support and improvement, a 30-day follow-up is mandated following our weekly Multidisciplinary Team (MDT) meetings, allowing us to evaluate the effectiveness of the resolutions and address any further concerns or questions. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of patient records, administrative documentation, along with staff interviews, the facility failed to file a written unusual incident report with the Department within 48 hours following complaints of patient abuse.
Administrative documentation and patient records indicate allegations of patient abuse were made about an employee from February 24, 2025, through February 26, 2025. The facility did not notify the Department of the complaints.
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Plan of Correction
In response to item number 715.28, this facility is committed to upholding the highest standards of patient care and safety by implementing protocol for reporting unusual incidents and complaints of patient abuse. This protocol related to unusual incident reporting will include but is not limited to, physical, verbal, sexual, and emotional abuse, as well as incidents resulting in death or serious injury due to trauma, suicide, medication errors, and other unusual circumstances. Furthermore, we recognize the potential for unusual incident reports to reflect from disasters such as fires, storms, floods, or other occurrences, or anything which could provoke negative reactions from the community. To address these issues promptly and effectively, we implemented a system that mandates all employees report any unusual incidents immediately. Each report will be directed to the clinical supervisor and subsequently reviewed by the clinical director and medical director for evaluation. Following this review, the report will be signed by both the clinic director and medical director to confirm its authenticity. The report will then be given to our administrative staff member will ensure that all reports are uploaded to the unusual incident report system within 48 hours of completion. If the administrative staff member is unavailable to ensure the report is uploaded, the clinical director will complete this task within the 48-hour time frame.
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709.17(a)(4) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
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Observations
Based on a review of patient records, employee records, administrative documentation, and staff interviews, the facility showed gross incompetence, negligence or misconduct in the operation of the facility.
In February 2025, multiple allegations and instances of sexual abuse and harassment by an employee were made known to facility staff. Documentation appears to show these patients, were not offered any type of counseling nor told they have the right to contact the authorities. Furthermore, there was no documentation of an investigation being conducted into the employees ' actions.
The Patient Rights indicates patients are to be protected from abuse by staff at all times including sexual abuse or harassment, sexual or financial exploitation, racism or racial/ethnic harassment, psychological abuse, and physical abuse or punishment. The patient has the right to have any reported infringement of rights investigated and receive a resolution to those concerns.
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Plan of Correction
In response to item 709.17, any allegations or written documentation related to grievances or complaints will be documented in the patient's chart immediately following the incident, by their assigned counselor and escalated to their direct supervisor, who will also document the incident. Patients will be informed by their primary counselor and clinical supervisor about their rights, including the right to contact appropriate authorities if there is a need or desire for the patient to do so. Our agency is committed to ensuring that patients are fully aware of their rights, which not only encompass the ability to lodge a grievance or complaint but extends to protection from any form of abuse by staff. This includes, but is not limited to, sexual abuse, harassment, financial exploitation, racism, psychological abuse, physical abuse, and punitive measures. During the intake process, the patient's counselor will clearly communicate that patients have the right to report any infringement of their rights. In such cases, a thorough investigation will be initiated, and a resolution will be sought within 72 hours. Any abuse allegations will be reported by the director, to regional leadership and an unusual incident report will be done within 48 hours and submitted to the department. |