INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 20, 2025, 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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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 on November 20, 2025, the facility failed to keep the grounds in good repair at all times. It was observed that the cove base molding was missing from a section of wall in the visitor waiting area.It was observed that the paint was chipped and scraped off in the hallway near the nurse ' s station.It was observed that there is a hole in the wall inside the first stall in the bathroom near the nurse ' s station.
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Plan of Correction
As of 12/02/2025 maintenance staff have replaced the missing cove base molding, painted the hallway near the nurse's station, repaired the hole in the wall in the women's bathroom and installed a doorstop on the bathroom door to prevent wall damage in the future. Staff has been notified to immediately report any deficiency noted or damage caused at the facility to the Office Manager. The Office Manager will verify that the facility is in good repair during a monthly walk-through tour of facility and will notify maintenance staff to repair damage and renew painting as needed to keep the facility in good repair at all times. |
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 the patient record, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.Client # 1 was admitted on September 26, 2023, and was still an active client at the time of the complaint investigation. Treatment plan updates dated 6/30/25 and 10/2/25 indicated there should be 1 individual counseling session per month for 1 hour. There was no individual counseling note for August 2025. Also, there was one October 2025 individual counseling note. This note, dated 10/2/25, reported the session lasting 30 minutes.
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Plan of Correction
By 12/03/2025, the Clinical Supervisor will remind staff to ensure that services are provided in accordance with the service goals outlined in all treatment plans, in the treatment plan updates and in treatment plan amendments. The Clinical Supervisor will remind clinicians to document in the record whenever a patient does not show for scheduled appointments and to ensure that the type and/or frequency of the services agreed upon in the treatment plan is being provided. Ongoing compliance with the regulation will be the responsibility of the QA Manager through a monthly review of a random selection of service records from each clinician to ensure that services are provided and documented in accordance with the Individual Treatment Plans, Updates and Amendments. |