INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on June 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, 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling rooms.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director applied for an exception 6/24/26 for cameras in the group rooms as a measure of security. The approval was granted by DDAP on 7/6/26. The program will continue to follow internal security camera policies |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from July 2025 - May 2026, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the months of July and August 2025.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Monthly fire drills will be completed by the program director or fiscal manager. The drills will be reviewed monthly in the program quality improvement meetings for compliance as well as areas of improvement. The fire drill log will be maintained in the Health and Safety Manuel. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document what materials were sent to the receiving narcotic treatment program in one out of two applicable records reviewed.
Patient #9 was admitted on August 10, 2018, and transferred to another treatment facility on August 15, 2025. There was no documentation in the patient record of what material was sent to the receiving narcotic treatment program.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review documentation timeline requirements for treatment plans with staff in an in-service scheduled for 8/3/26. Clinical supervisor(s) will monitor service due reports in the electronic health record weekly and do periodic chart reviews to monitor compliance |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation within 30 days of admission, per the facility policy, in two out of five applicable records reviewed.
Client #1 was admitted on November 6, 2025, and was still active at the time of the inspection. A psychosocial evaluation was due no later than December 6, 2025; however, there was no documentation that one was completed.
Client #10 was admitted on August 18, 2025, and discharged on October 23, 2025. A psychosocial evaluation was due no later than September 17, 2025; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review documentation timeline requirements for psychosocial evaluations with staff in an in-service scheduled for 8/3/26. Clinical supervisor(s) will monitor service due reports in the electronic health record weekly and do periodic chart reviews to monitor compliance |
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 a comprehensive treatment plan within thirty days of admission, per facility policy, in two out of five applicable records reviewed.
Client #5 was admitted on July 23, 2025, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than August 23, 2025; however, it was not completed until September 3, 2025.
Client #10 was admitted on August 18, 2025, and discharged on October 23, 2025. A comprehensive treatment plan was due no later than September 17, 2025; however, it was not completed until October 3, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A template "Client Goals Worksheet" for developing a comprehensive treatment plan with clients was developed 7/16/26. Therapists and clients will use this template in session to develop the comprehensive treatment plan together within 30 days of admission. The client and therapist will sign the worksheet upon completion and it will be scanned into the client record after therapist completes the full treatment plan in the EMR. Program Director will review the regulation, the new worksheet, and procedure for utilization with staff in an in-service scheduled for 8/3/26. Clinical supervisor(s) will continue to do periodic chart reviews for compliance which will then be reviewed in monthly supervisions. |
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 update treatment and rehabilitation plans every sixty days in five out of nine applicable records reviewed.
Client #4 was admitted on August 15, 2025, and was still active at the time of the inspection. A treatment plan update was completed on November 4, 2025, and the next one was due no later than January 3, 2026; however, it was not completed until January 14, 2025.
Client #5 was admitted on July 23, 2025, and was still active at the time of the inspection. A treatment plan update was completed on April 2, 2026, and the next update was due no later than June 1, 2026; however, it was not completed until June 8, 2026.
Client #6 was admitted on June 19, 2002, and was still active at the time of the inspection. A treatment plan update was completed on October 31, 2025, and the next update was due no later than December 30, 2025; however, it was not completed until January 5, 2026.
Client #7 was admitted on March 15, 2021, and was still active at the time of the inspection. A treatment plan update was completed on November 19, 2025, and the next update was due no later than January 18, 2026; however, it was not completed until January 21, 2026. The next treatment plan update was due no later than March 22, 2026; however, it was not completed until April 7, 2026.
Client #8 was admitted on June 30, 2025, and discharged on March 30, 2026. A treatment plan update was completed on July 29, 2025, and the next update was due no later than September 27, 2025; however, it was not completed until October 9, 2025. A treatment plan update was completed on November 10, 2025 and the next update was due no later than January 9, 2026; however, it was not completed until January 21, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review documentation timeline requirements for treatment plans with staff in an in-service scheduled for 8/3/26. Clinical supervisor(s) will monitor service due reports in the electronic health record weekly and do periodic chart reviews to monitor compliance |
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 five out of eleven records reviewed.
Client #1 was admitted on November 6, 2025, and was still active at the time of the inspection. The treatment plans dated November 13, and 19, 2025, January 26, March 24 and May 14, 2026, indicated one individual session a week. There was no documentation of the client receiving individual sessions the weeks of November 17, 24, December 1, 8, 15, 22, 29, 2025, January 12, 19, 26, February 2, 9, 16, 23, March 2, 9, 16, 23, 30, April 6, 13, 20, 27, May 4, 11, 18, 25, June 1, and 8, 2026.
Client #4 was admitted on August 15, 2025, and still active at the time of the inspection. The treatment plans dated September 15, November 4, 2025, January 14, March 9, May 1 and June 10, 2026, indicated one individual session a week. There was no documentation that the client received individual sessions the weeks of November 3, 10, 17, 2025, January 5, 12, and 19, 2026
Client #5 was admitted on July 23, 2025, and was still active at the time of the inspection. The treatment plan dated February 9, 2026, indicated one individual session a week. There was no documentation that the client received individual therapy in the weeks of March 2, 9, 16 and 30, 2026.
Client #6 was admitted on June 19, 2002, and was still active at the time of the inspection. The treatment plans dated October 31, 2025, January 5, March 2, 26 and April 30, 2026, indicated one individual and one group sessions a month. There was no documentation that the client received group therapy in the months November, December 2025, January, February, March, April and May of 2026.
Client #11 was admitted on June 27, 2023, and was still active at the time of the inspection. The treatment plan dated January 8, 2026, indicated four individual sessions and group a month.
There was no documentation that the client received four individual sessions in the months of February and March 2026. Additionally, there was no documentation that the client received any group therapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program director and Clinical Supervisor(s) reviewed and updated operating procedures for scheduling clients and documenting progress notes. Staff will be required to use the scheduling system within the EMR to schedule clients per their treatment plan service agreement. Progress notes and/or reason for no show will be documented for each scheduled session. Program Director will review the new process with staff in an in-service scheduled for 8/3/26. Clinical supervisor(s) will continue to do periodic chart reviews for compliance which will then be reviewed in monthly supervisions. |
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 the review of client records, the facility failed to document case consultations within ninety days of admission, per facility policy, in four out nine applicable records reviewed.
Client #1 was admitted on November 6, 2025, and was still active at the time of the inspection. A case consultation was due no later than February 4, 2026; however, it was not completed until March 5, 2026.
Client #4 was admitted on August 15, 2025, and was still active at the time of the inspection. A case consultation was completed on November 12, 2025, and the next one was due no later than February 10, 2026; however, it was not completed until March 4, 2026.
Client #5 was admitted on July 23, 2025, and was still active at the time of the inspection. A case consultation occurred on January 23, 2026, and the next one was due no later than April 23, 2026; however, it was not completed until April 27, 2026.
Client #8 was admitted on June 30, 2025, and discharged on March 30, 2026. A case consultation was completed on July 28, 2025, and the next one was due no later than October 26, 2025; however, there is no record that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review documentation timeline requirements for case consults with staff in an in-service scheduled for 8/3/26. Clinical supervisor(s) will monitor service due reports in the electronic health record weekly and do periodic chart reviews to monitor compliance |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including a discharge summary within seven days of discharge, per facility policy, in two of five applicable records.
Client #8 was admitted June 30, 2025, and discharged on March 30, 2026. A discharge summary was due no later than April 6, 2026; however, it was not completed until May 7, 2026
Client #9 was admitted on August 10, 2018, and discharged on August 15, 2025. A discharge summary was due no later than August 22, 2026; however, it was not completed until September 10, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review documentation timeline requirements for discharge summaries with staff in an in-service scheduled for 8/3/26. Clinical supervisor(s) will monitor service due reports in the electronic health record weekly and do periodic chart reviews to monitor 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 within thirty days of discharge, per facility policy, in three out of five applicable records reviewed.
Client #2 was admitted on June 16, 2016, and discharged on January 22, 2026. A follow up was due no later than February 22, 2026; however, it was not completed until March 4, 2026.
Client #3 was admitted on July 7, 2025, and discharged on August 7, 2025. A follow up was due no later than September 7, 2025; however, it was not completed until October 22, 2025.
Client # 10 was admitted on August 18, 2025, and discharged on October 23, 2025. A follow up was due no later than November 22, 2025; however, it was not completed until November 25, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review documentation timeline requirements for follow up information with staff in an in-service scheduled for 8/3/26. Clinical supervisor(s) will monitor service due reports in the electronic health record weekly and do periodic chart reviews to monitor compliance |