INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring inspection conducted on June 23, 2025 through June 24, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD Montgomery County Methadone 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) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in two of eight client records reviewed.
Client #2 was admitted on November 15, 2024 and was active at the time of the inspection. A release of information form to a human services agency was signed and dated by the client on November 15, 2024; however, there was no specific information to be disclosed documented on the release form.
Client #8 was admitted on December 16, 2024 and was discharged on April 25, 2025. A release of information form to a human services agency was signed and dated by the client on December 16, 2024; however, there was no specific information to be disclosed documented on the release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Releases for necessary stakeholders such as lab, and funders have templates in the electronic health record. These templates were reviewed and updated by the program director on 6/25/2025 to ensure they are all compliant with regulations. Program Director also reviewed confidentiality regulations, the use of templates, and releases in general during a group supervision 7/1/2025. Counselors will continue to do periodic reviews of client charts for compliance for releases of information. Clinical supervisor(s) will also review chart audits in monthly supervisions. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a consent to release information form in one of eight client records reviewed.
Client #4 was admitted on January 13, 2011 and was discharged on November 14, 2024. A release of information form to another treatment provider was signed and dated by the client on November 12, 2024; however, there was no purpose of the disclosure documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Releases for necessary stakeholders such as lab, and funders have templates in the electronic health record. These templates were reviewed and updated by the program director on 6/25/2025 to ensure they are all compliant with regulations specifically for purpose of disclosure. Program Director also reviewed confidentiality regulations, the use of templates, and releases in general during a group supervision 7/1/2025. Counselors will continue to do periodic reviews of client charts for compliance for releases of information. Clinical supervisor(s) will also review chart audits in monthly supervisions. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the narcotic treatment program failed to obtain an informed, voluntary, written consent to treat with an agent, before an agent may be administered to the patient for maintenance of detoxification treatment, in one of four applicable patient records reviewed.
Patient #3 was admitted on July 25, 2024 and was active at the time of the inspection. The patient's first dose of maintenance medication was prescribed by the physician on July 29, 2024; however, there was no consent to treat with an agent documented in the patient record prior to the first dose.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review required consent to treat documentation with medical providers 7/3/2025. Program Director will also discuss with intake coordinator on 7/2/2025 utilizing a hard hold placed at intake on client to remind medical provider to complete this form during initial physical exam (prior to initial dose). This process will begin immediately. Clinical Supervisor(s) will continue to monitor for compliance during standard chart audits. |
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 narcotic treatment program failed to transfer patient files, which is to include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, to the receiving narcotic treatment program in one of four applicable patient records reviewed.
Patient #5 was admitted on June 26, 2002 and was transferred out to another narcotic treatment program on November 19, 2024. There was no documentation in the patient record indicating the receiving narcotic treatment program was notified of the date of admission of the patient, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program utilizes an outgoing transfer fax cover sheet with all necessary documentation needed in transfer packets. The program director reviewed this cover sheet as well as the regulation, and transfer requirements with staff during a group staff supervision on 7/1/2025. Clinical supervisor(s) will continue to do periodic chart reviews for compliance which will then be reviewed in monthly supervisions. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of two applicable patient records reviewed.
Patient #8 was transferred in from another narcotic treatment program on December 16, 2024 and was transferred out to another narcotic treatment program on April 25, 2025. There was no documentation in the patient record indicating when the patient was transferred in that the transferring narcotic treatment program was notified of the date of admission and the date the initial dose was given to the patient.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program director reviewed the regulation and transfer requirements with staff during a group staff supervision on 7/1/2025. The Program Director also reviewed the regulation specifically with the intake coordinator 7/2/2025 who will send the confirmation of admission back to the transferring program within 24 hours of the patients initial dose at MCRC. Clinical supervisor(s) will continue to do periodic chart reviews for compliance which will then be reviewed in monthly supervisions. |