INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on July 23-24, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Foundations Medical Services, LLC, 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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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records and incident reports, the facility failed to inform the Department of an unusual incident within the required three business days. The facility was informed of the death of a client on February 24, 2026, and an incident report was due to be filed no later than February 27, 2026; however, it was filed July 29, 2026.The facility was informed of the death of a client on March 17, 2026, and an incident report was due to be filed no later than March 20, 2026; however, it was filed July 29, 2026.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
This regulation was reviewed with Pyramid Healthcare's Quality and Compliance team on the date of the inspection (7/24/2026). This regulation was misinterpreted as deaths to be reported are in the following categories: trauma, suicide, medication error or unusual circumstances. This has been clarified and corrected. All deaths will be reported moving forward. Compliance team will monitor.
Executive Director re-educated staff during team meeting 8/13/2026 on expectation of unusual incidents.
Both reports were submitted to the online portal on 7/29/2026 and accepted.
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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 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 in two of two applicable records. Patient #4 was admitted on May 13, 2024, and discharged on May 21, 2026. There was no documentation that any transfer paperwork was sent.Patient #8 was admitted on August 26, 2024, and discharged on July 9, 2026. There was no documentation that any transfer paperwork was sent.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Correct procedure of documents to be uploaded to chart when a client transfers in or out of our clinic was reviewed with all staff on 8/13/2026. Executive Director created a checklist for reference. The Lead Counselor will review charts with clinicians during supervisions to ensure all correct documentation is uploaded. |
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 a review of patient records, the facility failed to include the results of an annual physical examination by the narcotic treatment physician in one of four applicable records.Patient #4 was admitted on May 13, 2024, and discharged on May 21, 2026. The annual physical examination was due no later than May 13, 2026; however, it was completed on May 15, 2026.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed H&P schedules and regulations with nursing on 8/10/2026. Nursing will schedule H&Ps at least 2 weeks prior to due date to ensure clients can be seen by a PA or physician on or by their annual date. Executive Director will follow up by completing random chart audits. |
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 include the results of an annual clinical evaluation in two of three applicable records.The facility's policy and procedures state that a clinical evaluation must be completed annually by the patient ' s anniversary date.Patient #4 was admitted on May 13, 2024, and discharged on May 21, 2026. The annual clinical evaluation was due no later than May 13, 2026; however, there was no evaluation documented in the record.Patient #6 was admitted on September 30, 2024, and discharged on April 6, 2026. The annual clinical evaluation was due no later than September 30, 2025; however, it was completed on December 4, 2025.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed process for completing annual evaluations with clinicians on 8/13/2026 during the weekly team meeting. Each clinician will keep record of due dates for each annual evaluation and will review with the Lead Counselor during monthly supervision. These dates will be noted and expected to be completed by the intended due date. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in two of six applicable records.Client #3 was admitted on October 2, 2025, and was still active at the time of the inspection. A treatment plan was completed on January 2, 2026, and an update was due no later than March 2, 2026; however, it was completed on April 3, 2026. The next update was due no later than June 3, 2026; however, it was completed on June 26, 2026.Client #6 was admitted on September 30, 2024, and discharged on April 6, 2026. A treatment plan update was completed on January 13, 2026, and the next update was due no later than March 13, 2026; however, it was completed on March 24, 2026.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed process for completing treatment plans with clinicians on 8/13/2026 during the weekly team meeting. Each clinician will keep record of due dates for each treatment plan and will review with the Lead Counselor during monthly supervision. These dates will be noted and expected to be completed by the intended due date. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in two of six applicable records. The facility's policy and procedures state that a case consultation must be completed every 90 days for the first year and then annually.Client #3 was admitted on October 2, 2025, and was still active at the time of the inspection. There were no case consultations documented in client record #3.Client #5 was admitted on December 4, 2025, and was still active at the time of the inspection. A case consultation was due no later than March 4, 2026; however, it was completed on June 23, 2026. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed process for completing case consultations with clinicians on 8/13/2026 during the weekly team meeting. Each clinician will keep record of due dates for each case consultation and will review with the Lead Counselor during monthly supervision. These dates will be noted and expected to be completed by the intended due date. |