INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 22 & 23, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Williamsport Family Medical 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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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 readmitted on April 25, 2025 and still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ROI for client #9 was entered into EMR on 10/27/2025. ED held staff meeting on 10/29/25, to review DDAP citations with staff. It was determined that in order to ensure all patients' have an ROI for their funding source, the front desk receptionist will enter an ROI for the patients' funding source when the patient presents their insurance card upon admission (as well as anytime they present a new card). This will also be added to the admissions check list, as a secondary measure, so that staff completing paperwork can also ensure this has been completed. Also, the ED must sign off on all out-going documentation to ensure that proper documentation has been completed. RN and CS continue to complete both intake and monthly chart audits to ensure ROIs have been obtained as required. |
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 eleven client records reviewed. Client #9 was initially admitted on October 3, 2024 and discharged on April 8, 2024. Client #9 was readmitted on April 25, 2025 and still active at the time of the inspection. A release of information form for a substance use facility dated March 25, 2025, did not have documentation that the client was offered a copy of the consent form. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
ED held staff meeting on 10/29/25 to review DDAP citations with staff. It was determined that although the EMR consent form contains a required checkbox for "accept/ declined," staff were not consistently selecting this field at the time of consent completion. Effective immediately, staff completing consents in the EMR must ensure this box is selected prior to submitting the form. This expectation was added to the written consent workflow and reviewed with staff. Also, CS will verify during monthly chart audits to ensure this documentation is completed appropriately, and ED will review audit findings in supervision to ensure ongoing compliance |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information for clients that occur at seven, thirty and sixty days after discharge, per facility policy, in three out of seven applicable records reviewed. Client #4 was initially admitted on January 23, 2025 and discharged on May 15, 2025. Client #4 was readmitted on June 30, 2025, and still active at the time of the inspection. A seven day follow up was due no later than May 22, 2025; however, there is no documentation that one was completed. The thirty-day follow-up was due no later than June 15, 2025; however, there is no documentation that one was completed. Client #5 was initially admitted on March 28, 2025 and discharged on August 25, 2025. Client # 5 was readmitted on September 2, 2025, and still active at the time of the inspection. A seven day follow up was due no later than September 1, 2025; however, it was completed on September 3, 2025. Client #9 was initially admitted on October 3, 2024 and discharged on April 8, 2025. Client #9 was readmitted on April 25, 2025, and still active at the time of the inspection. A seven day follow up was due no later than April 15, 2025; however, it was completed on April 21, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ED held staff meeting on 11/3/25 to review this citation. EMR already auto-generates the due dates for follow-ups upon discharge. Effective 11/3/25, counselors will review the EMR follow-up due date list each Monday morning and identify any follow-ups due in the upcoming week. Counselors are required to complete those follow-ups prior to the due date.
This proactive weekly review has been built into the standing weekly clinical meeting agenda so the due-date check occurs routinely. CS will confirm completion through the monthly chart audits already performed, and ED will address any lapses immediately with the individual staff to ensure ongoing compliance and sustainability. |