INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on July 28, 2025 through July 31, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Eagleville Hospital 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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704.11(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 personnel records, the facility failed to document an individual training plan for each employee, with the plan being appropriate to that employee's skill level and developed annually with input from both the employee and the supervisor in thirty-five of fifty-seven applicable personnel records reviewed.Employee # 1 was hired as the project director on January 21, 2021. There was no current individual training plan documented in the employee record at the time of the inspection. Employee # 2 was hired as the facility director on April 15, 2019. The most recent individual training plan documented in the employee record was completed on December 18, 2023. It was not updated for the current training year. Employee # 3 was hired as a clinical supervisor on May 25, 2021. The most recent individual training plan documented in the employee record was completed on June 12, 2024. It was not updated for the current training year. Employee # 4 was hired as a clinical supervisor on March 20, 2020. The most recent individual training plan documented in the employee record was completed on June 12, 2024. It was not updated for the current training year. Employee # 5 was hired as a clinical supervisor on September 11, 2023. The individual training plan was completed by the supervisor on June 23, 2025, however, there was no verification that it was developed with the employee. Additionally, the training plan was not individualized appropriate to the employee's skill level. Employee # 6 was hired as a clinical supervisor on March 25, 2021. The individual training plan was developed by the employee on November 11, 2024 but it was not developed with the supervisor until June 23, 2025. Additionally, the training plan was not individualized appropriate to the employee's skill level. Employee # 7 was hired as a clinical supervisor on June 3, 2024. The most recent individual training plan documented in the employee record was completed on September 28, 2023. It was not updated for the current training year. Employee # 9 was hired as a clinical supervisor on December 17, 2024. The individual training plan was completed by the supervisor on June 23, 2025, however, there was no verification that it was developed with the employee. Additionally, the training plan was not individualized appropriate to the employee's skill level. Employee # 10 was hired as a counselor on June 13, 2024. The individual training plan was developed by the employee on November 1, 2024 but it was not developed with the supervisor until June 23, 2025. Additionally, the training plan was not individualized appropriate to the employee's skill level. Employee # 11 was hired as a counselor on June 24, 2024. The most recent individual training plan documented in the employee record was completed on June 6, 2024. It was not updated for the current training year. Employee # 14 was hired as a counselor on March 3, 2025. The most recent individual training plan documented in the employee record was completed during a previous episode of employment on March 20, 2022. It was not updated upon rehire or for the current training year. Employee # 15 was hired as a counselor on September 30, 2024. The individual training plan was developed by the employee on November 3, 2024 but it was not developed with the supervisor until June 23, 2025. Additionally, the training plan was not individualized appropriate to the employee's skill level. Employee # 19 was hired as a counselor on February 19, 2024. The individual training plan was completed by the supervisor on December 27, 2024, however, there was no verification that it was developed with the employee. Additionally, the training plan was not individualized appropriate to the employee's skill level. Employee # 21 was hired as a counselor on May 13, 2024. The individual training plan was completed by the supervisor on June 23, 2025, however, there was no verification that it was developed with the employee. Additionally, the training plan was not individualized appropriate to the employee's skill level. Employee # 23 was hired as a counselor on June 24, 2024. The individual training plan was completed by the employee on May 12, 2024, however, there was no verification that it was developed with the supervisor. Employee # 24 was hired as a counselor on May 28, 2024. The individual training plan was completed by the employee on May 15, 2024, however, there was no verification that it was developed with the supervisor. Employee # 27 was hired as a counselor on January 23, 2024. The individual training plan was developed by the employee on October 30, 2024 but it was not developed with the supervisor until June 23, 2025. Additionally, the training plan was not individualized appropriate to the employee's skill level. Employee # 28 was hired as a counselor on April 1, 2024. The most recent individual training plan documented in the employee record was completed on June 12, 2024. It was not updated for the current training year. Employee # 35 was hired as a counselor on December 27, 2024. The individual training plan was completed by the supervisor on June 23, 2025, however, there was no verification that it was developed with the employee. Additionally, the training plan was not individualized appropriate to the employee's skill level. Employee # 36 was hired as a counselor on March 18, 2024. The individual training plan was completed by the employee on February 27, 2024, however, there was no verification that it was developed with the supervisor. The training plan was not updated for the current training year.Employee # 37 was hired as a counselor on May 13, 2024. The most recent individual training plan documented in the employee record was completed on June 12, 2024. It was not updated for the current training year. Employee # 38 was hired as a counselor on October 4, 2021. The individual training plan was completed by the supervisor on June 23, 2025, however, there was no verification that it was developed with the employee. Additionally, the training plan was not individualized appropriate to the employee's skill level. Employee # 39 was hired as a counselor on September 13, 2007. The individual training plan was completed by the supervisor on June 23, 2025, however, there was no verification that it was developed with the employee. Additionally, the training plan was not individualized appropriate to the employee's skill level. Employee # 40 was hired as a counselor on February 26, 2005. The individual training plan was developed by the employee on October 25, 2024 but it was not developed with the supervisor until June 23, 2025.Employee # 41 was hired as a PRN clinical supervisor on September 19, 2023. The most recent individual training plan documented in the employee record was completed on August 22, 2022. It was not updated for the current training year. Employee # 42 was hired as a PRN clinical supervisor on September 18, 2020. The individual training plan was developed by the employee on November 10, 2024 but it was not developed with the supervisor until June 23, 2025.Employee # 44 was hired as a PRN counselor on November 25, 2024. The individual training plan was not completed until July 24, 2025.Employee # 47 was hired as a PRN counselor on October 31, 2022. The individual training plan was completed by the supervisor on June 16, 2025, however, there was no verification that it was developed with the employee. Additionally, the training plan was not individualized appropriate to the employee's skill level. Employee # 48 was hired as a PRN counselor on July 11, 2022. The individual training plan was developed by the employee on December 3, 2024 but it was not developed with the supervisor until June 23, 2025. Additionally, the training plan was not individualized appropriate to the employee's skill level. Employee # 49 was hired as a PRN counselor on January 16, 2023. The individual training plan was developed by the employee on November 2, 2024 but it was not developed with the supervisor until June 23, 2025. Additionally, the training plan was not individualized appropriate to the employee's skill level. Employee # 50 was hired as a PRN counselor on May 31, 2022. The individual training plan was completed by the supervisor on June 23, 2025, however, there was no verification that it was developed with the employee. Additionally, the training plan was not individualized appropriate to the employee's skill level. Employee # 52 was hired as a PRN counselor on May 31, 2023. There was no current individual training plan documented in the employee record at the time of the inspection. Employee # 53 was hired as a PRN counselor on May 12, 2025. The individual training plan was completed by the employee on May 17, 2025, however, there was no verification that it was developed with the supervisor.Employee # 54 was hired as a PRN counselor on October 16, 2023. The individual training plan was completed by the supervisor on June 16, 2025, however, there was no verification that it was developed with the employee.Employee # 56 was hired as a PRN counselor on December 27, 2022. The individual training plan was developed by the employee on November 15, 2024 but it was not developed with the supervisor until June 23, 2025. Additionally, the training plan was not individualized appropriate to the employee's skill level. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Eagleville Hospital provided annual performance evaluations along with individual training plans to all staff and managers on a calendar year basis. Post survey leadership discussed the lack of efficiency this process provided and made the decision to perform the evaluations and individual training plans on a yearly basis on the anniversary date of hire. This will allow for a more focused and less chaotic process that will be more meaningful to the staff. This process will begin September 1. This will provide an opportunity for the employee and manager to individualize the training plans and annual goals. Managers and employees will be trained in the new process by the end of August 2025, and the policy will be redistributed to all staff within two weeks, by August 24th. The process will ensure that the employee and manager discuss and sign the documents: both the evaluations and Training Plans timely.
The missing training plans will be provided to each employee that was identiifed, discussed and signed. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in five of thirty-two applicable personnel records reviewed. Employee # 47 was hired as a PRN counselor on October 31, 2022 and was due to have HIV/AIDs training no later than October 31, 2023. The HIV/AIDS training was not completed until June 10, 2024.Employee # 50 was hired as a PRN counselor on May 31, 2022 and was due to have HIV/AIDS training no later than May 31, 2023. The HIV/AIDS training was not completed until June 17, 2024.Employee # 52 was hired as a PRN counselor on May 31, 2023 and was due to have HIV/AIDS training no later than May 31, 2024. The HIV/AIDS training was not completed until June 16, 2024.Employee # 54 was hired as a PRN counselor on October 16, 2023 and was due to have HIV/AIDS training no later than October 16, 2024. The HIV/AIDS training was not completed at the time of the inspection.Employee # 56 was hired as a PRN counselor on December 27, 2022 and was due to have TB/STD training no later than December 27, 2023. The TB/STD training was not completed at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All PRN staff will have a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum completed by 9/15/25. EH Human Resources and Department of Education have begun the process to ensure it is completed by 9/15/25. Human Resources will report findings out to the Quality Improvement Committee biannually. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually, during the facility's July 1, 2024 through June 30, 2025 training year, in five of nineteen applicable personnel records reviewed.Employee # 23 was hired as a counselor on June 24, 2024. The personnel record documented 23.03 hours of training received during the training year reviewed. Employee # 47 was hired as a PRN counselor on October 31, 2022. The personnel record documented 15 hours of training received during the training year reviewed. Employee # 50 was hired as a PRN counselor on May 31, 2022. The personnel record documented 10.78 hours of training received during the training year reviewed. Employee # 54 was hired as a PRN counselor on October 16, 2023. The personnel record documented 9.78 hours of training received during the training year reviewed. Employee # 56 was hired as a PRN counselor on December 27, 2022. The personnel record documented 10.3 hours of training received during the training year reviewed. These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Staff who are missing the required training will complete the training by September 15, 2025. Once all staff are trained, Clinical Leaders will monitor the training reports and will ensure that no staff member will work unless required training is completed. Any non-compliance will be reported out at the Quarterly Quality Meetings. Monthly supervision form has been updated to include formal tracking of required training hours; supervisor will total monthly and assign trainings as necessary. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, conducted on July 30, 2025 between 10:00 AM and 12:00 PM, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees, and visitors.At the time of the inspection, there was graffiti written on the walls of bedroom # 121 and in the bathroom of room # 140. Additionally, the railings of the entrance to the administrative building had peeling paint and exposed areas of rust.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Eagleville Hospital has an electronic system that staff can utilize in order to request maintenance incident reporting system.
1. There was a repair request submitted to the incident reporting system and the area where the graffiti was identified was fully repaired within several hours of identification. The surveyors were provided photographs of the area as proof of repair.
2. Eagleville Hospital had identified the railings in front of the Patient Care building as part of the capital improvements for FY 2026. Three estimates were obtained and sample railings have been previewed. The repairs had been planned prior to the survey and the process will continue. The rust on the railing do not present any danger to the patients, staff or visitors.
4. We will continue to provide staff with ongoing education on the use of the incident reporting system and the Environmental Care Department will continue to respond to the reporting system requests timely.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, conducted on July 30, 2025 between 10:00 AM and 12:00 PM, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times. At the time of the inspection, the bathrooms in bedrooms # 217, # 222, and # 441 had toilets which were not flushed. Additionally, the floor and base of the toilet in bathroom # 222 had areas that were covered in what appeared to be fecal matter.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Eagleville Hospital has an electronic system that staff can utilize in order to request maintenance intervention (The incident reporting system system).
1. The survey team identified clogged/unflushed toilets during the survey rounds. The staff had already informed the plumber of the clogged toilets and the plumber was on his way over to the unit to make the repair at the time of rounds. The toilets were unclogged and the orders that were placed were provided to the surveyors noting the completion of the work.
We will continue to provide staff with ongoing education on the use of the incident reporting system and the Environmental Care Department will continue to respond to the requests timely.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the August 2024 through July 2025 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.At the time of the inspection, there was no documentation indicating monthly fire drills were completed for the CTW building during the months of August 2024, and October 2024 through May 2025.These finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Monthly fire drills have begun in the Creative Wellness Building. They are being conducted monthly. The Director of Support Services is maintaining a log and the compliance will be monitored monthly and reviewed at the Environment of Care meetings. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the August 2024 through July 2025 fire drill logs, the facility failed to ensure a fire drill was conducted during sleeping hours at least one time every six months. The facility currently has an approved exception to complete partial overnight fire drills one time every six months where they are not required to evacuate the building, and the fire alarm or smoke detectors are not required to be set off. The facility completed partial drills more often than every six months, in violation of the approved exception for the campus buildings listed below.overnight fire drills were conducted for the D'Arclay building during the months of September 2024, November 2024, January 2025, and June 2025.overnight fire drills were conducted for the Oak building during the months of August 2024, October 2024, March 2025, and May 2025.overnight fire drills were conducted for the Birch building during the months of August 2024, October 2024, March 2025, and May 2025.overnight fire drills were conducted for the Cedar building during the months of October 2024, December 2024, February 2025, and April 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Overnight "during sleeping hours" fire drills will be help every 6 months per the regulation and the approved exception. Logs will be maintained as proof that these drills are being held. Director of Operational Support will schedule the unannounced fire drills every 6 months on the overnight shift. the Director of Operational support will maintain logs of the fire drills as proof of compliance. They will be reviewed every 6 months by the EOC committee during the EOC committee meetings. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on an administrative review of the August 2024 through July 2025 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills for each monthly fire drill conducted during that timeframe. Each fire drill conducted during the reviewed period for the Birch building indicated that the front/main entrance was utilized as the exit route. Facility staff confirmed that the front/main entrance is the same exit.Additionally, each fire drill conducted during the reviewed period for the Cedar building indicated that the front/main entrance was utilized as the exit route. Facility staff confirmed that the front/main entrance is the same exit.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be instructed to use all available exits during fire drills. Staff will utilize the exit that is the closest to their location. This process will be monitored by using a checklist and monitoring it during the drills. The Director of Operational Support will be responsible for providing the education to the staff. Logs will indicate the exits used. These will be monitored every 6 months during the EOC committee meetings to ensure compliance and will be maintained by the Director of Operational Support. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to maintain, in the record, verification of the individual's identity, which is to include the name, address, date of birth, emergency contact and other identifying data in eight of eighteen patient records reviewed. Patient #1 was admitted to the inpatient hospital detoxification activity on July 24, 2025 and was active at the time of the inspection. The facility's release of information form to notify a patient contact designated three separate contact notification reasons; however, the section for the emergency contact notification was not completed or selected as declined. Patient #5 was admitted to the inpatient hospital detoxification activity on July 23, 2025 and was discharged on July 27, 2025. The facility's release of information form to notify a patient contact designated three separate contact notification reasons; however, the section for the emergency contact notification was not completed or selected as declined. Patient #8 was admitted to the inpatient hospital rehabilitation activity on June 3, 2025 and was active at the time of the inspection. The facility's release of information form to notify a patient contact designated three separate contact notification reasons; however, the section for the emergency contact notification was not completed or selected as declined. Patient #16 was admitted to the inpatient non-hospital detoxification activity on July 25, 2025 and was discharged on July 28, 2025. The facility's release of information form to notify a patient contact designated three separate contact notification reasons; however, the section for the emergency contact notification was not completed or selected as declined. Patient # 19 was admitted to the inpatient non-hospital detoxification activity on June 5, 2025 and was discharged on June 10, 2025. The facility's release of information form to notify a patient contact designated three separate contact notification reasons; however, the section for the emergency contact notification was not completed or selected as declined. Patient #22 was admitted to the inpatient non-hospital rehabilitation activity on July 28, 2025 and was active at the time of the inspection. The facility's release of information form to notify a patient contact designated three separate contact notification reasons; however, the section for the emergency contact notification was not completed or selected as declined. Patient # 23 was admitted to the inpatient non-hospital activity on June 6, 2025 and was still active at the time of the inspection. The facility's release of information form to notify a patient contact designated three separate contact notification reasons; however, the section for the emergency contact notification was not completed or selected as declined. Additionally, there was no verification of the patient's identity in the record. Patient # 28 was admitted to the inpatient non-hospital activity on June 13, 2025 and was discharged on June 25, 2025. The facility's release of information form to notify a patient contact designated three separate contact notification reasons; however, the section for the emergency contact notification was not completed or selected as declined. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The IT department will update consent form to accept or decline emergency contact separately from other notifications. Director will review 10 patient records for September to ensure changes were made and staff is completing the forms properly |
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 facility failed to document informed and voluntary consent in a patient record prior to the administration of an agent in three of eighteen patient records reviewed.Patient #2 was admitted to the inpatient hospital detoxification activity on July 21, 2025 and was active at the time of the inspection. There was no documentation of informed and voluntary consent in the record prior to the administration of a narcotic agent. Patient #12 was admitted to the inpatient hospital rehabilitation activity on March 24, 2025 and was discharged on April 4, 2025. There was no documentation of an informed and voluntary consent in the record prior to the administration of a narcotic agent. Patient #27 was admitted to the inpatient non-hospital rehabilitation activity on May 12, 2025 and was discharged on May 17, 2025. There was no documentation of an informed and voluntary consent in the record prior to the administration of a narcotic agent.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The registered nurse assessor will obtain a signed consent for administration of a narcotic agent prior to administering the said agent. Quality will audit 10 randomly selected charts monthly to ensure that the process is working. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of patient records, the narcotic treatment program failed to maintain an onsite photograph of each patient, which is to include the patient's name and date of birth in one of eighteen patient records reviewed. Patient #16 was admitted to the inpatient non-hospital detoxification activity on July 25, 2025 and was discharged on July 28, 2025. There was no onsite photograph documented in the record at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program will conduct an immediate review of all current patient records to ensure each includes a photograph in the chart with correlating name and date of birth in the record. Admissions staff will receive refresher training on the process for obtaining and updating patient photographs at minimum every 3 years. Director will review 10 patient records for September to monitor compliance and address any missing documentation. Completion of these actions and ongoing monitoring will be reported to Quality Management and discussed at the Quality Management Committee meetings. All actions will be completed by October 1, 2025. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility failed to ensure that the narcotic treatment physician determined the proper dosage level for a patient and if the narcotic treatment physician determining the initial dose was not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient's initial dose and schedule in three of eighteen patient records reviewed.Patient #5 was admitted to the inpatient hospital detoxification activity on July 23, 2025 and was discharged on July 27, 2025. The initial methadone dose was determined and ordered by a physician assistant, not a narcotic treatment physician. Patient #14 was admitted to the inpatient hospital rehabilitation activity on March 24, 2025 and was discharged on April 4, 2025. The medical director conducted the patient examination on March 24, 2025. A narcotic treatment physician determined the initial dose and schedule on March 25, 2025; however, there was no consult, between the two doctors, documented in the record at the time of the inspection. Patient #22 was admitted to the inpatient non-hospital rehabilitation on July 28, 2025 and was active at the time of the inspection. The initial methadone dose was determined and ordered by a physician assistant, not a narcotic treatment physician. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The providers have been notified that the prescribing provider of the initial does of Methadone must be a DO or MD. Additionally, they have been notified that the prescriber of the initial dose must see the patient face to face prior to ordering the Methadone. The medical providers have been notifies that only MD or DO can prescribe the initial dose of Methadone.
The provider who orders the MAT narcotic dose will conduct a face to face examination prior to placing the order.
The Director of Quality or designee will monitor for compliance by reviewing 10 charts a month for compliance and will report the results quarterly at the Quality Meeting until which time we have 2 consecutive audits showing 100% compliance. |
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, in two of two applicable patient records reviewed. Patient #13 was admitted to the inpatient hospital rehabilitation on February 22, 2025 and was transferred to another narcotic treatment program on March 12, 2025. There was no documentation in the record indicating the program transferred 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. Patient #25 was admitted to the inpatient non-hospital rehabilitation on December 11, 2024 and was transferred to another narcotic treatment program on February 5, 2025. There was no documentation in the record indicating the program transferred 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.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Case Managers will be reminded that they need to provide a listing of what files are transferred with the patient. They will list the documents including but not limited to last dose, current vitals, etc. in the medical record specifically in the discharge paperwork. If they do not itemize the documents then they will scan the packet into the chart as documentation of the information provided for the transfer. The training will be completed by September 15th.
A random review of 25 records will be completed in December to ensure that the staff is complying with the requirements. |
711.53(a)(7) LICENSURE Follow-up Information
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in two of two applicable client records reviewed.The project's written procedures stated that clinicians will ask patients to sign a referral follow-up consent form and staff shall attempt to contact the patient by telephone at their discharge address within seven (7) days of discharge. Client #25 was admitted to the inpatient non-hospital rehabilitation activity on December 11, 2024 and was discharged on February 5, 2025. The follow-up agreement form was signed by the client prior to discharge. The facility had until February 12, 2025 to complete the follow-up; however, there was no documentation of follow-up information in the record at the time of the inspection. Client #26 was admitted to the inpatient non-hospital rehabilitation activity on May 6, 2025 and was discharged on May 29, 2025. The follow-up agreement form was signed by the client prior to discharge. The facility had until June 5, 2025 to complete the follow-up; however, there was no documentation of follow-up information in the record at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Management to designate Clinical Lead to complete aftercare and follow-up requirements. Monitoring will take place weekly to track compliance. This will be reported out to Quality Management bi-annually. Staff will begin the process by October 1, 2025. |
711.56(a) LICENSURE Written Termination Notice
711.56. Notification of termination.
(a) The project director shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client records reviewed.Client # 27 was admitted to the inpatient non-hospital rehabilitation activity on May 12, 2025 and was administratively discharged on May 17, 2025. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will receive formal training on requirement to complete Notice of Discharge form in EMR for all discharges from facility. Training to be completed by 9/30/25. Director of Clinical Services/designee will be responsible for ensuring compliance. They will review 10 charts a month for compliance and will follow up on any non-compliance with staff responsible for completing the discharge paperwork. If there is a continued <85% compliance, we will add the review to the Quarterly Performance Improvement meeting schedule. |
710.42(a)(3) LICENSURE Treatment and Rehabilitation Services
§ 710.42. Treatment and rehabilitation services.
(a) The director shall be responsible for a written plan for the coordination of patient treatment and rehabilitation services which shall include, but not be limited to:
(3) Written procedures for the development, approval, and ongoing management of treatment/rehabilitation services of patients.
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Observations
Based on a review of patient records, the facility failed to follow written procedures for the development, approval and ongoing management of treatment/rehabilitation services in two of two applicable patient records reviewed. The written procedures stated that clinicians will ask patients to sign a referral follow-up consent form and staff shall attempt to contact the patient by telephone at their discharge address within seven (7) days of discharge. Patient #13 was admitted to the inpatient hospital rehabilitation activity on February 22, 2025 and discharged on March 12, 2025. The follow-up agreement form was signed on March 11, 2025. The facility had through March 19, 2025 to complete the follow-up; however, there was no documentation of follow-up information in the record at the time of the inspection. Patient #14 was admitted to the inpatient hospital rehabilitation activity on March 24, 2025 and discharged on April 4, 2025. The follow-up agreement form was signed on April 3, 2025. The facility had through April 11, 2025 to complete the follow-up; however, there was no documentation of follow-up information in the record at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Management to designate Clinical Lead to complete aftercare and follow-up requirements. Monitoring will take place weekly to track compliance. This will be reported out to Quality Management bi-annually. The staff member will begin assignment no later than the end of September. |
710.42(b)(2) LICENSURE Treatment and Rehabilitation Services
§ 710.42. Treatment and rehabilitation services.
(b) An individual treatment and rehabilitation plan shall be developed with each patient. This plan shall include, but not be limited to, written documentation of the following:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of patient records, the facility failed to document the type and frequency of treatment and rehabilitation services on the patient's individual treatment and rehabilitation plan in four of seven patient records reviewed.Patient #8 was admitted to the inpatient hospital rehabilitation activity on June 3, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on June 10, 2025, did not include type and frequency of treatment and rehabilitation services. Patient #10 was admitted to the inpatient hospital rehabilitation activity on June 27, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on July 3, 2025, did not include type and frequency of treatment and rehabilitation services.Patient #11 was admitted to the inpatient hospital rehabilitation activity on May 20, 2025 and was discharged on May 23, 2025. The individual treatment and rehabilitation plan was completed May 23, 2025, did not include type and frequency of treatment and rehabilitation services.Patient #14 was admitted to the inpatient hospital rehabilitation activity on March 24, 2025 and was discharged on April 4, 2025. The individual treatment and rehabilitation plan was completed March 28, 2025, did not include type and frequency of treatment and rehabilitation services.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff who completed the treatment plans that were reviewed and found to have issues have been terminated or provided training. Treatment plans are randomly reviewed by senior leadership and issues identified are addressed immediately. Any issues that are identified will be reported out at the QI quarterly meetings. |