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 November 18 & 19, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Duncansville 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of nine personnel records, the facility failed to document that one counselor met the education qualifications for the position.
Employee #5, who was hired as a counselor on August 25, 2025 and was still employed in that position at the time of the inspection. Employee #5 did not have a qualifying degree to be a counselor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1) An exception was filed based on this employee's experience in the field.
2) A response was received on November 20, 2025 requesting the employee's college transcripts, degree, and an updated resume. Those items were sent, and I am awaiting response.
3) In the meantime, this employee is serving as an assistant counselor, and everything she does is being supervised by the clinical supervisor. She does not meet with clients alone.
4) In the event the requested exception is not approved, this employee will be given the option of remaining a counselor's assistant, or moving into the position of case manager.
5) Future potential hires will be more carefully screened by the clinic director to ensure the credentials meet or exceed provision of having a qualified degree. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the personnel records, the facility failed to provide a written individual training plan annually or within 30 days of hire for each employee, appropriate to that employee's skill level in seven out of nine personnel records reviewed.
Employee #2 was hired on July 14, 2025 as a facility director and was still in the position as of the date of the inspection. The individual training plan was due no later than August 14, 2025; however, there is no documentation that one was developed.
Employee #3 was hired as counselor on September 6, 2022 and promoted to clinical supervisor on September 9, 2025, and was still in the position as of the date of the inspection. The individual training plan was due no later than October 9, 2025; however, there is no documentation that one was developed.
Employee #4 was hired on July 1, 2025 as a counselor and was still in the position as of the date of the inspection. The individual training plan was due no later than August 1, 2025; however, there is no documentation that one was developed.
Employee #5 was hired on August 25, 2025 as a counselor and was still in the position as of the date of the inspection. The individual training plan was due no later than September 25, 2025; however, there is no documentation that one was developed.
Employee #6 was hired on September 8, 2025 as a counselor and was still in the position as of the date of the inspection. The individual training plan was due no later than October 8, 2025; however, there is no documentation that one was developed.
Employee #7 was hired on April 14, 2025 as a counselor and was still in the position as of the date of the inspection. The individual training plan was due no later than May 14, 2025; however, there is no documentation that one was developed.
Employee #8 was hired on October 6, 2025 as a counselor and was still in the position as of the date of the inspection. The individual training plan was due no later than November 6, 2025; however, there is no documentation that one was developed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1) Immediately following receipt of this citation, the director, clinical supervisor, and nursing supervisor met to discuss this provision. This rule was highlighted in the facility's policy manual.
2) Training plans were written, and approved by the director.
3) The director, clinical supervisor, and nursing supervisor each met with their subordinates and reviewed the training plans pertinent to their respective positions.
4) All employees now have individual training plans.
5) All employees will meet with their supervisors every quarter for training plan reviews.
6) The director has added training plan development to the list of what new hires need in order for this to not reoccur. It is part of a check off list. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of staff records, the facility failed to instruct all staff in the use of fire extinguishers upon staff employment in five out of seven applicable records reviewed.
Employee #2 was hired on July 14, 2025 as a facility director and was still in the position as of the date of the inspection. Employee #2 was to be instructed in the use of a fire extinguisher upon employment but was not trained until August 1, 2025.
Employee #4 was hired on July 1, 2025 as a counselor and was still in the position as of the date of the inspection. Employee #4 was to be instructed in the use of a fire extinguisher upon employment but was not trained until September 23, 2025.
Employee # 6 was hired on September 8, 2025 as a counselor and was still in the position as of the date of the inspection. Employee #6 was to be instructed in the use of a fire extinguisher upon employment but was not trained until October 3, 2025.
Employee #8 was hired on October 6, 2025 as a counselor and was still in the position as of the date of the inspection. Employee #8 was to be instructed in the use of a fire extinguisher upon employment but was not trained until October 21, 2025.
Employee # 9 was hired on November 3, 2025 as a counselor and was still in the position as of the date of the inspection. Employee #9 was to be instructed in the use of a fire extinguisher upon employment but was not trained until November 13, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1) The director conducted a training for all staff on the use of fire extinguishers, and where these could be found.
2) New staff will be trained in the same manner by the director.
3) Fire extinguisher training has been added to the checklist for new hires, which is approved by the director.
4) The Health and Safety Committee will also offer refresher training every quarter to ensure all employees know how to use fire extinguishers. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of employee records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in five out of seven applicable records reviewed.
Employee #2 was hired on July 14, 2025 as a facility director and was still in the position as of the date of the inspection. Employee #2 was to be trained to perform assigned tasks during emergencies prior to working a shift. Documentation in the records shows the training did not occur until July 29, 2025.
Employee #4 was hired on July 1, 2025 as a counselor and was still in the position as of the date of the inspection. Employee #4 was to be trained to perform assigned tasks during emergencies prior to working a shift. Documentation in the records shows the training did not occur until September 23, 2025.
Employee # 6 was hired on September 8, 2025 as a counselor and was still in the position as of the date of the inspection. Employee #6 was to be trained to perform assigned tasks during emergencies prior to working a shift. Documentation in the records shows the training did not occur until October 3, 2025.
Employee #8 was hired on October 6, 2025 as a counselor and was still in the position as of the date of the inspection. Employee #8 was to be trained to perform assigned tasks during emergencies prior to working a shift. Documentation in the records shows the training did not occur until October 21, 2025.
Employee # 9 was hired on November 3, 2025 as a counselor and was still in the position as of the date of the inspection. Employee #9 was to be trained to perform assigned tasks during emergencies prior to working a shift. Documentation in the records shows the training did not occur until November 13, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1) All new hires who were missing this training have now been trained by the director and clinical supervisor to perform assigned tasks during emergencies.
2) The director and/or clinical supervisor will document these trainings in each employee's folder, and a review of each new employee will occur three weeks after the date of hire to ensure no trainings have been missed.
3) The director and clinical supervisor will also meet quarterly to review employee files to ensure all needed training is completed, and to note what might be coming due.
4) a to do list for each new employee is now generated with timelines that much be fulfilled and these timelines are reviewed DAILY until all points on the timelines are fulfilled to ensure that nothing is missed. The director and the clinical supervisor will perform the daily reviews of new employee records. |
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 October 2024 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 October 16, 2024, February 26 and May 20, 2025 failed to include documentation if the fire alarm or smoke detector was activated during the drill.
The fire drill record dated October 31, 2025, failed to include the length of time it took for evacuation, the exit route used, and if the fire alarm or smoke detector was activated during the drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) The director has established a new Health and Safety Committee, made up of employee volunteers.
2) The Health and Safety Committee will plan fire drills, execute the fire drills, time the fire drills, and review the outcome of the fire drills.
3) The Health and Safety Committee will provide documentation to the director.
4) The facility cannot use the fire alarm, as it is tied into the other businesses within the complex, and it also triggers emergency personnel to come to the location. An exception has been filed to replace a fire alarm with an internal alarm which will only be triggered by a member of the Health and Safety Committee and will sound only in clinic facilities.
5) The director will review, monthly, the fire drill documentation to ensure the facility is missing nothing.
6) Components of the fire drill report will include date of fire drill, length of evacuation, evacuation route and exit used, and what was used to trigger the alarm. |
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 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 one out of eleven records reviewed.
Client #9 was admitted on February 18, 2022 and was discharged on October 15, 2025. The client record documented contact with a legal entity on May 21, 2025; however, there was no documentation that the facility obtained an informed and voluntary consent for the legal entity.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1) Each counselor has been trained, or retrained by the clinical supervisor, regarding having every client sign the informed and voluntary consent form for the disclosure of information contained in the client record.
2) The clinical supervisory will review new client paperwork, weekly, with each counselor to ensure all of the required documents have been signed. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of requested administrative information and personnel records, the facility failed to ensure that their data collection and recordkeeping system allowed for the efficient retrieval of the data to measure the project's performance in relationship to its stated goals and objectives.
Information was requested from the facility to begin the licensing process and that information was not provided timely to evaluate the project ' s performance to its stated goals and objectives. The inspection process was extended to enable a full review of all regulatory requirements.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1) The director reviewed the previously requested administrative information and personnel records requests, and the data collection processes were reviewed.
2) The director now knows where such information can be found. Missing information was corrected.
3) The requests for information were reviewed after the inspection, in order to ensure the requested data could be located.
4)The director is no longer new, and now fully understands this entire process. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of physician hours, the facility was unable to provide verification of hours worked by all physicians, as a result the facility failed to demonstrate it provided narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
During the week of June 29- July 5, 2025, the patient census was 414. The facility was required to provide at least 41.4 physician hours. There were 3.5 physician hours documented.
During the week of July 6- 12, 2025, the patient census was 415. The facility was required to provide at least 41.5 physician hours. There were 3.5 physician hours documented.
During the week of July 13-19, 2025, the patient census was 413. The facility was required to provide at least 41.3 physician hours. There were 11 physician hours documented.
During the week of July 20-26, 2025, the patient census was 417. The facility was required to provide at least 41.7 physician hours. There were 7.5 physician hours documented.
During the week of July 27- August 2, 2025, the patient census was 423. The facility weas required to provide at least 42.3 physician hours. There were 7.5 physician hours documented.
During the week of August 3- 9, 2025, the patient census 414. The facility was required to provide at least 41.4 physician hours. There were 7.5 physician hours documented.
During the week of September 14-20, 2025, the patient census was 416. The facility was required to provide at least 41.6 physician hours. There were 40 physician hours documented.
During the week of September 21-27, 2025, the patent census was 410. The facility was required to provide at least 41 physician hours. There were 40 physician hours documented.
During the week of October 26- November 1, 2025, the patient census was 405. The facility was required to provide at least 40.5 physician hours. There were 40 physician hours documented.
This is a repeat citation from October 17, 2024, annual licensing inspection and the April 1, 2025, follow up licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) The director now requires physicians to sign-in, and to submit timesheets weekly, instead of at random times.
2) The facility now has a fulltime nurse practitioner.
3) The director will monthly review physicians' hours to ensure the facility is providing narcotic treatment physician services at least 1 hour per week onsite for every 10 patients.
4) At the end of every week, the following week's caseloads will be reviewed and compared against scheduled hours for physicians and for the certified nurse practitioner. This will ensure that the census is met.
5) When the physicians or the nurse practitioner are on leave for any reason, the remaining physician and nurse practitioner will be asked to extend his/her hours to accommodate the census.
6) Should an emergency arise that leaves the facility without medical staff to meet the census, we can pull a temporary physician from another facility nearby, if necessary. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of physician hours, the facility was unable to provide verification of hours worked by all physicians, the facility failed to document they provided the required number of hours onsite for the physician based on the census. The facility has been granted an exception request which permits the physician to provide one-fifth of the required hours with a certified registered nurse practitioner or physician's assistant providing the remaining four-fifths of the required hours.
During the week of June 29- July 5, 2025, the patient census was 414. The physician was required to provide one-fifth of the 41.4 hours, which equals 8.28 hours. There were 3.5 physician hours documented.
During the week of July 6- 12, 2025, the patient census was 415. The physician was required to provide one-fifth of the 41.5 hours, which equals 8.3 hours. There were 3.5 physician hours documented.
During the week of July 20-26, 2025, the patient census was 417. The physician was required to provide one-fifth of the 41.7 hours, which equals 8.34 hours. The physician only provided 7.5 hours.
During the week of July 27- August 2, 2025, the patient census was 423. The physician was required to provide one-fifth of the 42.3 hours, which equals 8.46 hours. The physician only provided 7.5 hours.
During the week of August 3- 9, 2025, the patient census was 414. The physician was required to provide one-fifth of the 41.4 hours, which equals 8.28 hours. The physician only provided 7.5 hours.
During the week of August 10-16, 2025, the patient census was 416. The physician was required to provide one-fifth of the 41.6 hours, which equals 8.32 hours. The physician only provided 7.5 hours.
During the week of September 14-20, 2025, the patient census was 416. The physician was required to provide one-fifth of the 41.6 hours, which equals 8.32 hours. There were no physician hours documented.
During the week of September 21-27, 2025, the patient census was 410. The physician was required to provide one-fifth of the 41.0 hours, which equals 8.20 hours. There were no physician hours documented.
During the week of September 28- October 4, 2025, the patient census was 411. The physician was required to provide one-fifth of the 41.1 hours, which equals 8.22 hours. The physician only provided 3.5 hours.
During the week of October 5-11, 2025, the patient census was 408. The physician was required to provide one-fifth of the 40.8 hours, which equals 8.16 hours. The physician only provided 3.5 hours.
During the week of October 12-18, 2025, the patient census was 405. The physician was required to provide one-fifth of the 40.5 hours, which equals 8.10 hours. The physician only provided 3.5 hours.
During the week of October 19-25, 2025, the patient census was 406. The physician was required to provide one-fifth of the 40.6 hours, which equals 8.12 hours. The physician only provided 3.5 hours.
During the week of October 26- November 1, 2025, the patient census was 405. The physician was required to provide one-fifth of the 40.5 hours, which equals 8.10 hours. There were no physician hours documented.
This is a repeat citation from October 20, 2023, October 27, 2024, annual licensing inspections and the April 1, 2025, follow up licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) The director has mandated that physician submit hours worked daily, via a written timesheet, to the director for proper documentation.
2) The physicians now receive a weekly schedule provided by the director.
3) The physicians must now sign-in and out so that there are verifiable hours.
4) Physicians must now submit their timesheets weekly, instead of randomly, so there is consistency in their timesheet submissions for validation of hours.
5) Physicians are now required to maintain their posted hours.
6) When a physician is on a scheduled leave, the hours of the other physician will be modified to accommodate the census.
7) This facility is also actively seeking a third physician as a pro-active measure. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to document that transfer patient files included admission date, medical and psychological summaries, dosage levels, urinalysis reports or summary, exceptions requests and current status of the patient, and contain written consent of the patient in one out of two applicable records reviewed.
Patient #4 was admitted on July 14, 2022 and transferred to another treatment facility on July 28, 2025. There was no documentation in the patient record that the facility had written consent for the facility the patient was transferred to or that they transferred documents to the receiving facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1) The director and clinical supervisor reviewed documentation needs of transfer patients with the counselors to include admission dates, medical and psychological summaries, dosage levels, urinalysis reports or summaries, exceptions requests and current status of the patients, and contain written consent of the patient.
2) The clinical supervisor will weekly review any transfer patient files to ensure the required information is complete. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to document an annual physical examination by the narcotic treatment physician within the regulatory timeframe in three out of four applicable records reviewed.
Patient #2 was admitted on December 30, 2014 and discharged on March 11, 2025. An annual physical was due no later than December 30, 2024; however, there was no documentation that one was completed.
Patient #10 was admitted on February 5, 2017 and was still active at the time of the inspection. An annual physical was due no later than February 5, 2025; however, it was completed on February 28, 2025.
Patient #11 was admitted on March 22, 2013 and discharged on May 13, 2025. An annual physical was due no later than March 22, 2025; however, it was completed on April 14, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) The director and clinical supervisor conducted a training for counselors and physicians on the timeframe required for an annual physical examination by the narcotic treatment physician within the regulatory timeframe.
2)The clinical supervisor will review patient files monthly to ensure such scheduling and documentation is no longer missed, and is scheduled within the mandated timeframe. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure that the annual evaluation of each patient's status was completed by the patient's counselor and was reviewed, dated and signed by the medical director in one out of four applicable records reviewed.
Patient #10 was admitted on February 5, 2017 and was still active at the time of the inspection. An annual evaluation was due no later than February 5, 2025; however, it was completed on February 28, 2025.
This is a repeat citation from December 11, 2020, December 3, 2021, November 3, 2022, September 26, 2023, and October 17, 2024, annual licensing inspections and April 1, 2025 for a follow up licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) The director and clinical supervisor met with the counselors and reviewed this requirement.
2) In said meeting, it was stressed that the annual evaluations MUST be completed within the required timeframe, was reviewed, and signed by the medical director.
3) The director and the clinical supervisor will review patients monthly to ensure this requirement is getting met. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan within seven days of admission, per the facility's policy and procedures manual, in three out of five records reviewed.
Client #1 was admitted on January 16, 2025 and was still active at the time of the inspection. The preliminary treatment plan was due no later than January 23, 2025; however, it was completed on February 13, 2025.
Client #7 was admitted on June 5, 2025 2025 and was still active at the time of the inspection. The preliminary treatment plan was due no later than June 12, 2025; however, it was completed on June 13, 2025.
Client #8 was admitted on April 8, 2025 and still active at the time of the inspection. The preliminary treatment plan was due no later than April 15, 2025; however, it was completed on April 22, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) The director and the clinical supervisor met with the counselors to provide training on this requirement, highlighting the timeframe requirement.
2) The facility's policy and procedures manual was given to each counselor to show where this could be found.
3) The clinical supervisor will review new patient records daily to ensure that counselors do not miss providing the required preliminary treatment plans within seven days of admission. |
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:
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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 five applicable records reviewed.
Client #1 was admitted on January 16, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on February 14, 2025; however, the plan was not reviewed and signed by the client until March 3, 2025.
Client #5 was admitted on March 6, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 6, 2025; however, it was completed on April 9, 2025, and not reviewed and signed by the client until May 5, 2025.
Client #6 was admitted on May 6, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 13, 2025; however, it was not reviewed and signed with the client until November 4, 2025.
Client #7 was admitted on June 5, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than July 5, 2025. The treatment plan was completed on July 13, 2025; however, it was not reviewed and signed with the client until August 28, 2025.
Client #8 was admitted on April 8, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 8, 2025; however, it was not reviewed and signed with the client until May 14, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) The director and the clinical supervisor reviewed this requirement with the counselors.
2) The clinical supervisor will review, every week, new clients and meet with the counselors regarding the treatment plans and completion of those.
3) All personnel now understand that deadlines are actual times that must be observed and tasks must be fulfilled.
4) Each new client generates a timeline with a list of mandatory items that must be completed by certain dates.
5) Both the director and the clinical supervisor will review, daily, the folders of all new patients to verify that timelines are being met.
6) The director or clinical director will return any client folder with deficiencies to the appropriate CS for corrections, and the CS will have one day to make the corrections, or there will be disciplinary actions taken. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in nine out of eleven applicable records reviewed.
Client #1 was admitted on January 16, 2025 and was still active at the time of the inspection. The treatment plans dated May 16, July 16 and September 16, 2025, indicated two and half hours of counseling a month with at least one hour as individual counseling session. There was no documentation of the client receiving counseling services in the months of May, June, July, August, September and October 2025.
Client #3 was admitted on September 17, 2024 and discharged on April 22, 2025. The treatment plans dated January 17 and March 18, 2025, indicated two and half hours of counseling a month with at least one hour as individual counseling session. The client only received one hour of individual counseling for the month of January and there was no documentation that the client received any counseling in March 2025.
Client #4 was admitted on July 14, 2022 and discharged on July 28, 2025. The treatment plans dated March 14 and May 14, 2025, indicated one hour of individual or group counseling a month. The client only received a half hour of counseling in May 2025.
Client #5 was admitted on March 6, 2025 and was still active at the time of the inspection. The treatment plans dated May 6, July 10, and September 5, 2025, indicated two and half hours of counseling a month with at least one hour as individual counseling. There was no documentation that the client received any counseling in the months of June, July, August and September 2025.
Client #6 was admitted on May 6, 2025 and was still active at the time of the inspection. The treatment plans dated May 13, June 6, July 17, and September 5, 2025, indicated two and half hours of counseling a month with at least one hour as individual therapy. There was only one hour of individual counseling documented in June and July and no documentation that the client received any counseling in the months of August, September and October 2025.
Client #7 was admitted on June 5, 2025 and was still active at the time of the inspection. The treatment plans dated June 13, July 3, and August 11, 2025, indicated two and half hours of counseling a month with at least one hour as individual therapy. There was no documentation that the client received any counseling sessions in the months of July and August 2025.
Client #8 was admitted on April 8, 2025 and was still active at the time of the inspection. The treatment plans dated May 8, June 19, August 8 and October 8, 2025, indicated two and half hours a month counseling with at least one hour as individual therapy. There is no documentation that the client received any counseling in the month of June, September or October 2025. Additionally, the client only received one half hour of counseling in July and one hour in August 2025.
Client #9 was admitted on February 18, 2022 and discharged on October 15, 2025. The treatment plans dated April 18, June 18 and August 18, 2025, indicated two and half hours a month counseling with at least one hour as individual therapy. There is no documentation that the client received counseling in the months of May, June, July, August or September 2025.
Client #10 was admitted on February 5, 2017 and was still active at the time of the inspection. The treatment plans dated April 9, June 6, August 18 and October 3, 2025, indicated half an hour of counseling each month or one hour every other month. There was no documentation that the client received counseling in the months of May, June, July and August 2025.
Client #11 was admitted on March 22, 2013 and discharged on May 13, 2025. The treatment plans dated January 22 and March 19, 2025, indicated half an hour of counseling each month or one hour every other month. There is no indication that the client received any counseling in the month of February and only half an hour in the months of January and March 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) The director and clinical supervisor met with the counselors to discuss this citation and how to remedy it.
2) Highlighted were counseling requirements, as well as how to document when a client misses a session, when a client cannot be reached but efforts were made to reach the client, and how to document when a client does not want to do as much counseling as is recommended.
3) Moving forward, when client files are reviewed by the director or clinical supervisor, this will be something that is thoroughly examined to ensure this requirement is being met.
4) Client records are reviewed weekly at a treatment team meeting. The physicians, nurse practitioner, counselors, clinical supervisor, and the director are all a part of the treatment team which addresses 'where' clients are in their respective treatment plans and if there are any problems. Issues such as this should come up in this meeting.
5) The clinical supervisor will review client files weekly in one-on-ones with each counselor to ensure nothing is missed. |
709.17(a)(3) 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:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting annual evaluation was submitted and approved by the Department for the December 11, 2020, December 13, 2021, November 3, 2022, September 26, 2023, and October 16, 2024, annual licensing inspections and April 1, 2025, follow up inspection. Completing and documenting annual evaluations was again found to be a deficiency in the November 18 & 19, 2025 licensing inspection.
A plan of correction for physician providing the required narcotic physician services was submitted and approved by the Department for the December 11, 2020, December 13, 2021, November 3, 2022, September 26, 2023, and October 16, 2024, annual licensing inspections and April 1, 2025, follow up inspection. Physicians providing the required narcotic physician services was again found to be a deficiency in the November 18 & 19, 2025 licensing inspection.
A plan of correction for physician providing required number of hours for the physician based on the census was submitted and approved by the Department for October 20, 2023, and October 27, 2024, licensing inspections, and April 1, 2025, follow up inspection. Providing the required number of hours onsite for the physician based on the census was again found to be a deficiency in the November 18 & 19, 2025 licensing inspection.
This is a repeat citation for the October 20, 2023, October 27, 2024 and April 1, 2025 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1) The regional director will be made aware of everything by the director.
2) The regional director and the director meet once a week to review all plans of corrections and to monitor all outcomes as well as to discuss pending items, any problems, deadlines, and so on.
3) The director meets with the clinical supervisor and the nursing supervisor and will also share these items with these persons. |