INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring conducted on July 31, 2025 through August 1, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Directions Treatment Services 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) 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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information contained in the record in three of fourteen client records reviewed.Client # 9 was admitted on March 9, 2022 and was discharged on June 9, 2025. A release of information form to a funding source was signed by the client on April 29, 2024 and the release expired on April 29, 2025. There was no updated release of information form signed by the client in the record; however, there was evidence of billing disclosures to the funding source between the date the release form expired and the date of the client ' s discharge.Client # 12 was admitted on December 5, 2008 and was active at the time of the inspection. A release of information form to a funding source was signed by the client on December 18, 2024 and the release expired on December 18, 2025. An updated release of information form was signed by the client on January 16, 2025; however, there was evidence of billing disclosures to the funding source between the date the release form expired and the date the client signed the updated release form.Client # 13 was admitted on October 27, 2021 and was discharged on June 17, 2025. A release of information form to a funding source was signed by the client on December 18, 2024 and the release expired on December 18, 2025. An updated release of information form was signed by the client on January 16, 2025; however, there was evidence of billing disclosures to the funding source between the date the release form expired and the date the client signed the updated release form.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/09/2025, the Program Sponsor will revise the Agency Policy & Procedure Manual to indicate that Consents to Release Confidential Information will designate an expiration date that is 90 days after the client's discharge from the program. The policy revision will be shared with staff by 09/09/2025. The QA Manager will be responsible for ensuring ongoing compliance with the regulation and the revised agency policy during regular record auditing reviews.
Releases for Client #12 and Client # 13 are still active until December 18,2025 and will be revised in accordance with the agency revised policy before the expiration date. |
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 a release of information form in one of fourteen client records reviewed.Client # 2 was admitted on October 12, 2020 and was still active at the time of the inspection. The release of information form to a funding source was signed by the client on October 2, 2024; however, the specific information to be disclosed was not documented on the release form.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/09/2025, the Program Director will remind staff that Consents to Release Information must contain specific details regarding what information will be disclosed, to satisfy regulatory requirements. The clinician will revise Client #2's release to clearly state the purpose of disclosure, and will present the updated document to the client for their signature. The QA Manager will be responsible for ongoing compliance by conducting random clinical record audits to verify adherence to regulations. |
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 release of information form in one of fourteen client records reviewed.Client # 2 was admitted on October 12, 2020 and was still active at the time of the inspection. The release of information form to a funding source was signed by the client on October 2, 2024; however, the purpose of the disclosure was not documented on the release form.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/09/2025, the Program Director will remind staff that Consents to Release Information must specify the purpose of the disclosure of confidential information, to meet regulatory requirements. The clinician will revise Client #2's release to clearly state the purpose of the disclosure, and will present the updated document to the client for their signature. The QA Manager will be responsible for ongoing compliance by conducting random clinical record audits to verify adherence to regulations. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent was offered to the client in two of fourteen client records reviewed.Client # 2 was admitted on October 12, 2020 and was still active at the time of the inspection. The release of information form to a funding source was signed by the client on October 2, 2024; however, there was no documentation in the record indicating a copy of the release form was offered to the client.Client # 14 was admitted on March 10, 2021 and was still active at the time of the inspection. The release of information form to a urinalysis laboratory was signed by the client on August 5, 2024; however, there was no documentation in the record indicating a copy of the release form was offered to the client.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/09/2025, the Program Director will remind staff that Consent to Release Information forms must clearly indicate that a copy of the signed consent has been offered to the client. Clinicians will provide copies of the releases signed by Client #2 and Client #14, documenting on each consent form that the clients were offered these copies. The QA Manager will ensure ongoing compliance by conducting random clinical record reviews on an ongoing basis. |
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 onsite a photograph of the patient, which is to be 3 years old or less and also include the patient ' s name and birth date in one of thirteen patient records reviewed.Patient #10 was admitted on December 13, 2022 and was discharged on July 3, 2025. There was a photograph in the record, which was originally issued May, 5, 2020 and expired on May 5, 2024. There wasn ' t an updated photograph documented in the record until May 5, 2025.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/12/2025, a tracking list will be created in the EMR to alert dispensing staff before patients' ID photographs reach their expiration date. Nursing staff will be advised to update client photographs in the EMR so that no client ID photograph is older than three years. Ongoing monitoring of compliance with the regulation will be conducted by the QA Manager during regularly scheduled audits of clinical records. |
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 they 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 in one of one applicable patient record reviewed.Patient #5 was admitted on December 24, 2024 and was still active at the time of the inspection. There was no written documentation in the record indicating the facility notified the transferring narcotic treatment program of the admission date and initial dose of the patient.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/09/2025, the Nursing Director will inform the dispensing nurses that when a transfer client is admitted to the program, the dispensing nurse who administers the first dose will be responsible for documenting a Note to File in the clinical record. This Note to File will verify that the dispensing nurse has sent confirmation of the client's admission to the transferring narcotic treatment program. The documentation will include verification of the client's admission and will specify the date and the first dose that was administered.
Ongoing compliance with the regulation will be the responsibility of the Clinic Supervisor through a review of the clinical documentation whenever a client is transferred from another narcotic treatment program.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure an annual evaluation of each patient ' s status was completed by the patient ' s counselor and reviewed, dated, and signed by the medical director in nine of twelve applicable patient records reviewed.Patient #1 was admitted on March 3, 2017 and was still active at the time of the inspection. The annual evaluation was completed on March 27, 2025; however, the evaluation was not reviewed, signed, and dated by the medical director and was completed after the patient ' s admission date anniversary.Patient #3 was admitted on August 24, 2020 and was discharged on July 9, 2025. The annual evaluation was completed on August 27, 2024; however, the evaluation was not reviewed, signed, and dated by the medical director and was completed after the patient ' s admission date anniversary.Patient #4 was admitted on April 6, 2022 and was discharged on July 3, 2025. The annual evaluation was completed on April 25, 2025; however, the evaluation was not reviewed, signed, and dated by the medical director and was completed after the patient ' s admission date anniversary.Patient #6 was admitted on August 24, 2012 and was still active at the time of the inspection. The annual evaluation was completed on August 30, 2024; however, the evaluation was completed after the patient ' s admission date anniversary.Patient #8 was admitted on November 8, 2021 and was still active at the time of the inspection. The annual evaluation was completed on December 5, 2024; however, the evaluation was completed after the patient ' s admission date anniversary.Patient #9 was admitted on March 9, 2022 and was discharged on June 9, 2025. The last annual evaluation was completed on March 29, 2024, which was completed after the patient ' s admission anniversary date. There was no documentation indicating an annual clinical evaluation was completed for the 2025 year.Patient #10 was admitted on December 13, 2022 and was discharged on July 3, 2025. The annual evaluation was completed on April 25, 2025; however, the evaluation was completed after the patient ' s admission date anniversary.Patient #11 was admitted on July 6, 2021 and was discharged on May 5, 2025. The annual evaluation was completed on July 29, 2024; however, the evaluation was completed after the patient ' s admission date anniversary.Patient #14 was admitted on March 10, 2021 and was still active at the time of the inspection. The annual evaluation was completed on April 25, 2025; however, the evaluation was completed after the patient ' s admission date anniversary.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/12/2025, the IT Administrator will route the Annual Evaluation to the Medical Director for review and signature in the EMR. The Program Director will remind clinical staff that the Annual Evaluation must be completed by the patient's admission anniversary and subsequently reviewed and signed by the Medical Director. The QA Manager will ensure ongoing compliance with regulations by establishing an annual reminder in the EMR and conducting routine record audits. |
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 review and update treatment and rehabilitation plans at least every 60 days in ten of fourteen client records reviewed.Client #1 was admitted on March 3, 2017 and was still active at the time of the inspection. A treatment plan update was completed on July 18, 2024 and the next update was due no later than September 18, 2024; however, the update was completed on March 29, 2025. Additionally, a treatment plan update was completed on March 29, 2025 and the next update was due no later than May 29, 2025; however, the update was completed on June 25, 2025. Client #3 was admitted on August 24, 2020 and was discharged on July 9, 2025. A treatment plan update was completed on March 5, 2025 and the next update was due no later than May 5, 2025; however, the update was completed on May 15, 2025.Client #4 was admitted on April 6, 2022 and was discharged on July 3, 2025. A treatment plan update was completed on September 2, 2024 and the next update was due no later than November 2, 2024; however, the update was completed on November 10, 2024. Also, a treatment plan update was completed on November 2, 2024 and the next update was due no later than January 10, 2025; however, the update was completed on April 28, 2025. Additionally, a treatment plan update was completed on April 28, 2025 and the next update was due no later than June 28, 2025; however, the update was completed on July 3, 2025. Client #5 was admitted on December 24, 2024 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on December 24, 2024 and the first update was due no later than February 24, 2025; however, the update was completed on July 22, 2025. Client #7 was admitted on September 3, 2024 and was still active at the time of the inspection. A treatment plan update was completed on December 10, 2024 and the next update was due no later than February 10, 2025; however, the update was completed on March 3, 2025. Additionally, a treatment plan update was completed on March 3, 2025 and the next update was due no later than May 3, 2025; however, the update was completed on June 5, 2025.Client #8 was admitted on November 8, 2021 and was still active at the time of the inspection. A treatment plan update was completed on December 5, 2024 and the next update was due no later than February 5, 2025; however, the update was completed on May 23, 2025.Client #9 was admitted on March 9, 2022 and was discharged on June 9, 2025. A treatment plan update was completed on January 17, 2025 and the next update was due no later than March 17, 2025; however, there was no documentation indicating an update was completed prior to discharge.Client #10 was admitted on December 13, 2022 and was discharged on July 3, 2025. A treatment plan update was completed on November 8, 2024 and the next update was due no later than January 8, 2025; however, the update was completed on April 25, 2025. Additionally, a treatment plan update was completed on April 25, 2025 and the next update was due no later than June 25, 2025; however, there was no documentation indicating an update was completed prior to discharge.Client #11 was admitted on July 6, 2021 and was discharged on May 5, 2025. A treatment plan update was completed on October 29, 2024 and the next update was due no later than December 29, 2024; however, the update was completed on January 13, 2025. Additionally, a treatment plan update was completed on January 13, 2025 and the next update was due no later than March 13, 2025; however, there was no documentation indicating an update was completed prior to discharge.Client #14 was admitted on March 10, 2021 and was still active at the time of the inspection. A treatment plan update was completed on August 5, 2024 and the next update was due no later than October 5, 2024; however, the update was completed on October 30, 2024. Additionally, a treatment plan update was completed on October 30, 2024 and the next update was due no later than December 30, 2024; however, the update was completed on July 8, 2025.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Starting 9/09/2025, the QA Manager will post a Treatment Plan Review tracking list in the EMR. The Program Director will inform clinicians that reviews must be completed every 60 days, even if clients cannot attend on the due date. Reviews will be signed by clients when present at the clinic. The QA Manager will oversee ongoing compliance with the regulation through regular record reviews. |
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 assure counseling services were provided to the client according to their individual treatment and rehabilitation plan in five of fourteen client records reviewed.Client #4 was admitted on April 6, 2022 and was discharged on July 3, 2025. The April 28, 2025 treatment plan update stated the client would receive individual sessions one time per month; however, there was no documentation in the record indicating the client received any individual sessions during the months of May 2025 and June 2025.Client #7 was admitted on September 3, 2024 and was still active at the time of the inspection. The March 3, 2025 treatment plan update stated the client would receive individual sessions one time per month and a total of six group sessions; however, there was no documentation in the record indicating the client received any individual or group sessions during the month of May 2025.Client #9 was admitted on March 9, 2022 and was discharged on June 9, 2025. The January 17, 2025 treatment plan update stated the client would receive two and a half hours of therapeutic sessions per month; however, there was documentation in the record indicating the client only received one and a half hours of therapeutic sessions during the month of May 2025.Client #10 was admitted on December 13, 2022 and was discharged on July 3, 2025. The April 25, 2025 treatment plan update stated the client would receive two and a half hours of therapeutic sessions per month; however, there was no documentation in the record indicating the client received any therapeutic sessions during the months of December 2024, March 2025, May 2025, and June 2025.Client #14 was admitted on March 10, 2021 and was still active at the time of the inspection. The October 30, 2024 treatment plan update stated the client would receive two and a half hours of therapeutic sessions per month; however, there was no documentation in the record indicating the client received any therapeutic sessions during the months of November 2024, December 2024, March 2025, April 2025, and June 2025.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/09/2025 the Program Director will remind clinicians to provide and document the type and frequency of services outlined in the treatment plan for each client on their caseload. Clinicians will be reminded to document in the record whenever a client misses a mutually agreed upon service appointment. Ongoing compliance with the regulation will be the responsibility of the QA Manager and the Clinical Supervisor through random and scheduled record reviews. |
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 a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of case consultation notes, in six of thirteen client records reviewed.The facility policy states that case consultations will occur once a year for clients in treatment more than one year, but during the first year, they will occur every ninety days.Client #6 was admitted on August 24, 2012 and was still active at the time of the inspection. There was no documentation of a case consultation occurring since the last consultation was documented on July 17, 2024.Client #9 was admitted on March 9, 2022 and was discharged on June 9, 2025. There was no documentation of a case consultation occurring since the last consultation was documented on March 9, 2024.Client #10 was admitted on December 13, 2022 and was discharged on July 3, 2025. There was no documentation of a case consultation occurring since the last consultation was documented on August 27, 2024.Client #12 was admitted on December 5, 2018 and was still active at the time of the inspection. There was documentation of a case consultation occurring on January 16, 2025; however, the consult note indicated only the counselor was present.Client #13 was admitted on October 27, 2021 and was discharged June 17, 2025. There was documentation of a case consultation occurring on July 9, 2024; however, the consult note indicated only the counselor was present.Client #14 was admitted on March 10, 2021 and was still active at the time of the inspection. There was documentation of a case consultation occurring on April 24, 2025; however, the consult note indicated only the counselor was present.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/12/2025, the IT Administrator will ask the EMR vendor to update the attendance dropdown menu to allow selection of multiple attendees for Case Consultation meetings. The Program Director has reminded staff to complete a Case Consultation for all clients annually and every ninety days during the first year of treatment and to document all attendees in the Case Consultation Notes. The QA Manager will set up electronic due date reminders and will be responsible for ensuring ongoing compliance through regular record audits. |