INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 18-20, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, New Directions Treatment Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of employee files and the Staffing Requirements Facility Summary Report completed on March 19, 2026, the facility failed to document that the interim Clinical Supervisor met both the education and experiential qualifications for that position.
Employee # 1 who was hired as a physician on 8/23/24 and was documented as the Interim Clinical Supervisor as of 9/17/25 on the Staffing Requirements Facility Summary Report. Employee # 1 did not meet the experience requirements of a Clinical Supervisor. The employee does not have 2 years of clinical experience.
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Plan of Correction
As of 04/06/2026 the Project Director appointed a Clinical Supervisor who meets the educational and clinical experience requirements in the regulations to take over responsibility for clinical supervision of the clinicians at this program.
Ongoing compliance with the regulation will be the responsibility of the Program Director who will ensure that the Clinical Supervisor meets the regulatory educational and clinical experience requirements.
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential 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 clients, 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 during a complaint investigation on March 18-20, 2026, the facility failed to keep the grounds in good repair at all times.
There were two chairs observed in the group room that were in disrepair. One chair had a leather-like material that was ripped and shredded on the back rest and seat. Another chair appeared to have pieces missing from both armrests.
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Plan of Correction
Effective 04/01/2026: Following each monthly fire drill, the Administrative Assistant will conduct a brief internal physical plant inspection. When repair or disposal needs are identified, the Administrative Assistant will notify the Finance Director. The Finance Director will be responsible for scheduling and coordinating all necessary repair and disposal activities to maintain ongoing compliance with physical plant regulations. As of 04/01/2026, the two chairs in the group room that were in disrepair have been removed from the facility. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of patient records and the Discharge Criteria and Summary policy, the facility failed to follow its written procedures of their policy.
The Discharge Criteria and Summary policy indicates that the counselor will complete a discharge summary within 7 days of the final interview.
Patient # 5 was admitted on July 27, 2021, and discharged on February 19, 2026. The discharge summary should have been completed on or before February 26, 2026. The discharge summary was dated March 3, 2026.
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Plan of Correction
As of 4/16/2026, Clinicians will be notified that the date of discharge for a patient will be recorded as one day after the date of the last staff contact with the patient. The IT coordinator will create an alert that is triggered when the Discharge Date has been entered into the medical record with reminders to complete the Discharge Summary within seven days. Ongoing compliance with the regulation will be the responsibility of the Clinical Supervisor during random record review and during Clinical Supervision. |
715.2(a)(b) LICENSURE Relationship of Federal and State Regulations
(a) A narcotic treatment program shall comply with Federal regulations and requirements governing the administration, dispensing and storage of agents.
(b) This chapter is intended to supplement the Federal regulations governing narcotic treatment programs in 21 CFR Chapter II, 1300-1399 (relating to Drug Enforcement Administration, Department of Justice).
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Observations
Based on a review of patient records, the facility failed to comply with Federal regulations and requirements governing the administration of agents.
42 CFR Part 8 indicates that patient refusal of counseling shall not preclude them from receiving medication for opioid use disorder.
Patient # 1 was admitted on February 9, 2022, and discharged on January 20, 2026. A progress note dated 10/3/25 indicates that the patient will be placed on a hold daily until the patient complies with treatment attendance requisites.
Patient # 6 was admitted on February 6, 2017, and was still an active patient at the time of the investigation. A nonbillable note dated 3/6/26 indicates that the patient attends group sessions when methadone is held.
Patient # 7 was admitted on August 15, 2018, and was still an active patient at the time of the investigation. A nonbillable note dated 3/6/26 indicates that the patient attends group sessions when methadone is held.
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Plan of Correction
As of 3/27/2026, clinical and nursing staff have been reminded that medication doses cannot be suspended until after counseling sessions for individuals who refuse to attend the counseling sessions they agreed to in the Treatment Plan. Individuals who refuse to comply with counseling outlined in their treatment plans will be subject to discharge from the program in accordance with agency policies. Ongoing compliance with the regulations will be the responsibility of the Nursing Supervisor and the Clinical Supervisor through review of dosing records and Discharge Notices on an ongoing basis.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records during a complaint investigation conducted March 18-20, 2026, the facility failed to follow the administration of medication as determined by a narcotic treatment physician.
Patient # 4 was admitted on August 27, 2012, and discharged on February 23, 2026. The doctor ' s order dated 2/12/26 indicated this patient was to begin a taper from his current dosage of 66 mg. The initial taper was to begin on 2/13/26 at 60 mg and then decrease daily by 5 mg. By 2/16/26, the dosage given was 45 mg. On 2/17/26 the patient was given 55 mg. of methadone. There was no doctor ' s order to increase the amount of methadone the patient was to receive.
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Plan of Correction
On April 10, 2026, the Facility Director consulted with the Medical Director and Nursing Director to review the protocols governing dosing exceptions for verbal medication orders.
Dispensing staff have been informed that any dosing exception based on a verbal order must be verified by a Nursing Supervisor before dispensing a dose that has been altered by exception. Staff are required to document the supervisor's approval for such exceptions in a Note to File. The Nursing Director will be responsible for ongoing compliance, conducting monthly reviews of dosing exceptions to confirm supervisor approval. The staff member involved in this issue is no longer employed with the program.
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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 record documentation which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current stats of the patient.
Patient # 5 was admitted on July 27, 2021, and discharged on February 19, 2026. There was no documentation of the facility sending patient record documentation to the Narcotic Treatment Program this patient transferred to in the patient record.
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Plan of Correction
As of 04/14/2026 clinical staff has been reminded of the regulatory requirement to transfer patient files including admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status?within seven days of a patient's request for transfer. All transfer documentation?including confirmation of the list of records sent, will be scanned into the EMR for review and verification of compliance with the regulation. The Clinical Supervisor will be responsible for ensuring ongoing compliance with these requirements through review of transfer documentation during individual and group supervision meetings.
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715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
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Observations
Based on a review of patient records, the patient grievance binder, and the Patient Formal Complaints/Grievances policy, the facility failed to follow its patient grievance procedure.
The Patient Formal Complaints/Grievances policy indicates that all formal complaints will be submitted to the Program Director or Executive Director. The Program Director will make a formal complaint resolution within 21 days of receipt and notify the grievant by letter.
A written complaint was filed by a patient on 2/19/26. This complaint had no written resolution by the Program Director within 21 days nor was there documentation that the grievant was notified of a resolution by letter.
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Plan of Correction
By 04/16/2026 staff involved in the grievance process will be reminded of the requirements of timely review, resolution, documentation of grievances, and written notification to patients.
The Administrative Assistant will create a tracking system in the Grievance binder of Grievances presented to record the dates of submission, dates of resolution actions, and notifications sent. This system will ensure accountability and timely follow-up. Ongoing compliance will be the responsibility of the Clinical Supervisor through monthly audit of the grievance binder to verify compliance with policy requirements. If a patient leaves the program prior to the date of the scheduled Grievance Hearing, that will be noted in the record by the Clinical Supervisor or his/her designee.
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715.22(c) LICENSURE Patient grievance procedures
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
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Observations
Based on a review of patient records and the patient grievance binder during a complaint investigation conducted March 18-20, 2026, the facility failed to not initiate penalties prior to final resolution of a grievance.
Patient # 5 was admitted on July 27, 2021, and discharged on February 19, 2026. A written complaint was filed by the patient on 2/19/26. The patient was terminated from treatment for non-compliance with their individualized treatment plan. There was no documentation of a final resolution on the grievance form.
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Plan of Correction
By 04/16/2026 clinical and support staff will be reminded of the agency policy that prohibits initiation of program sanctions prior to final grievance resolution. The Administrative Assistant will ensure that the grievance binder records the dates of the grievance submission, resolution actions, notifications sent, and any sanctions imposed. This will ensure that penalties are not initiated until final resolution is documented, except in cases involving physical violence. The Clinical Supervisor will conduct monthly audits of the grievance binder and disciplinary actions to verify ongoing compliance with the regulatory requirements.
All grievance resolutions and disciplinary actions, including exceptions for physical violence, will be documented and maintained in the grievance binder for review during regulatory inspections.
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715.23(f) LICENSURE Patient records
(f) If a narcotic treatment program keeps patient information in more than one file or location, it is the responsibility of the narcotic treatment program to provide the entire patient record to authorized persons conducting narcotic treatment program approval activities at the narcotic treatment program, upon request.
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Observations
Based on a review of patient records during a complaint investigation conducted March 18-20, 2026, the facility failed to provide the entire patient record when patient information was kept in more than one location. Documentation of termination notices submitted to the Medical Director by clinical personnel were unable to be found when requested.
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Plan of Correction
As of April 20, 2026, all staff who work in more than one NDTS location have been reminded that original clinical documentation must remain stored at the location where the client receives services. Staff who require access to records for individuals served at another site have been instructed to access those records remotely through the EMR, rather than transporting or relocating any physical documentation.
Staff at all locations have also received a written reminder that clinical records may not be removed from the service location at any time, to comply with agency policy and to ensure that all documentation remains available for review by auditors and regulatory authorities.
Ongoing compliance with the regulation will be the responsibility of the Clinical Supervisor through random review of a sample of clinical records across all locations. Any deviations from the record‑retention requirement will be addressed immediately through staff retraining and corrective action as needed.
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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 patient records, the facility failed to assure counseling services were provided according to the individual treatment and rehabilitation plan.
Patient # 6 was admitted on February 6, 2017, and was still an active patient at the time of the investigation. A treatment plan dated 11/17/25 indicates the patient is to have individual counseling on a monthly basis. There was no documentation of an individual counseling session held in December 2025, January 2026, or February 2026.
Patient # 7 was admitted on August 15, 2018, and was still an active patient at the time of the investigation. A treatment plan dated 11/28/25 indicates the patient is to have group once per week and a minimum of one hour bi-monthly individual session. There was no documentation of an individual counseling session held in December 2025, January 2026, or February 2026.
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Plan of Correction
Beginning on 3/27/2026, clinicians will be required to collaborate with their patients to determine their preferred counseling type and frequency. The type and frequency agreed to will be documented in each patient's treatment plan. Patients who do not follow their agreed schedule will be referred elsewhere and discharged per agency policy. Ongoing compliance with the regulatory requirement will be the responsibility of the Clinical Supervisor through regular review of Treatment Plans and the records of services provided generated monthly by the EMR.
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