INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection was conducted on August 13, 2025 through August 14, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lebanon 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 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on the review of the fire drill log from June 2024 through July 2025, the facility failed to conduct fire drills during normal staffing conditions. The fire drills conducted in the months of September 2024, December 2024 and May 2025 were conducted when the facility was closed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
CD will review Emergency Drill policy 9.2 with health and safety committee to ensure that fire drills are scheduled during business hours and how to complete the emergency drill report fully. CD will review monthly to ensure paperwork is submitted fully completed. |
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 June 2024 through July 2025, the facility failed to maintain written fire drill records that indicated whether the fire alarm or smoke detector was operative for the months of October 2024, February 2025, March 2025 and June 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
CD will review Emergency Drill policy 9.2 with health and safety committee to ensure that fire drills are scheduled during business hours and how to complete the emergency drill report fully. CD will review monthly to ensure paperwork is submitted fully completed. |
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.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of nine client records reviewed.
Client #6 was admitted on May 26, 2021 and was discharged on March 26, 2025. The funding source for this client changed on August 1, 2024; however, the facility failed to document a release of information for the new funding source, and it was verified that billing had occurred.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
CD will conduct a training on Confidentiality in September 2025 to review how to complete a valid signed consent and will review the various examples of when patients will need to update consents. CS will complete monthly chart audits and progress on this to CD monthly via the Quality Record Reviews. |