INITIAL COMMENTS
|
This report is a result of an unannounced on-site plan of correction follow-up inspection conducted on February 19, 2026, 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:
|
Plan of Correction
|
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.
|
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 #2 was admitted on March 10, 2021 and was still active at the time of the inspection. There was confirmed evidence of disclosures to the funding source during the client ' s treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the funding disclosures.This is a repeat citation from the July 31, 2025 through August 1, 2025 annual renewal licensing inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
By 3/14/2026, the Facility Director will notify staff that a Consent to Release Confidential information must be obtained by the clinician prior to submission of an application for funding. By 3/14, the Primary Therapist will obtain a completed Consent to Release Confidential Information to the funder from patient #2. Ongoing compliance with the regulation will be the responsibility of the Clinical Supervisor during regular reviews of the records of new applications for services before the applicant has been approved for admission. |
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.
|
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 #6 was admitted on February 9, 2022 and was discharged on January 20, 2026. There were two consent to release information forms to another treatment provider which were signed and dated by the client on January 20, 2026; however, there was no documentation in the record indicating a copy of both consent forms were offered to the client.Client #9 was admitted on September 23, 2024 and was still active at the time of the inspection. There was a consent to release information form to a healthcare service provider signed and dated by the client on September 16, 2025; however, there was no documentation in the record indicating a copy of the consent form was offered to the client.This is a repeat citation from the July 31, 2025 through August 1, 2025 annual renewal licensing inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
By 3/14/2026, the IT Director will request a change in the EMR so that either "Client accepted a copy" or "Client declined a copy" will be a required field on all electronic Consents to Release Confidential Information. By 3/14/2026, Clinical and Support staff will be notified of the change to a required field in the EMR. Ongoing compliance with the regulation will be accomplished through the required designation of "accepted copy" or "declined copy" on all releases and through random record reviews by QA/UR staff. |
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.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to maintain onsite a picture of patients that are updated every three years that included the patient's name and birth date in two of ten patient records reviewed.Patient #4 was admitted on May 11, 2015 and was still active at the time of the inspection. There was a photograph ID in the record, originally issued March 12, 2019, that was required to be updated by March 12, 2022. There was no updated photograph in the record as of the date of the inspection.Patient #9 was admitted on September 23, 2024 and was still active at the time of the inspection. There was a photograph ID in the record, originally issued July 31, 2016, that was required to be updated by July 31, 2019. There was no updated photograph in the record as of the date of the inspection.This is a repeat citation from the July 31, 2025 through August 1, 2025, annual renewal licensing inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
By 3/14/2026, QA Staff will create a tracking system that will post an alert message in the clinical record before the third-year anniversary of patients' admission dates. Dispensing staff will be notified of the alert and directed to update patients' photographs in the EMR before the three-year expiration date when patients present for medication. Ongoing compliance with the regulation will be the responsibility of the Nursing Director during random reviews of the date of the ID photographs stored in the EMR. |
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.
|
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 five of nine applicable patient records reviewed.Patient #1 was admitted on December 5, 2008 and was still active at the time of the inspection. The last documented annual evaluation was completed on January 16, 2025. There were no additional annual evaluations documented in the record as of the date of the inspection.Patient #3 was admitted on October 12, 2020 and was still active at the time of the inspection. The last documented annual evaluation was due to be completed no later than the patient ' s admission anniversary date of October 12, 2025; however, the annual evaluation was completed on October 23, 2025.Patient #5 was admitted on January 10, 2024 and was still active at the time of the inspection. The last documented annual evaluation was completed on January 10, 2025. There were no additional annual evaluations documented in the record as of the date of the inspection.Patient #8 was admitted on July 28, 2017 and was still active at the time of the inspection. The last documented annual evaluation was completed on August 29, 2024. There were no additional annual evaluations documented in the record as of the date of the inspection.Patient #9 was admitted on September 23, 2024 and was still active at the time of the inspection. The last documented annual evaluation was due to be completed no later than the patient ' s admission anniversary date of September 23, 2025; however, the annual evaluation was completed on October 16, 2025. Additionally, there was no documentation in the record indicating the October 16, 2025 annual evaluation was reviewed, signed, and dated by the medical director. This is a repeat citation from the July 31, 2025 through August 1, 2025 annual renewal licensing inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
By 03/14/2026,clinicians will be reminded of the regulatory requirement to review and document a summary of each client's progress every 12 months throughout treatment. The QA Manager will enter Annual Review due dates into the clinical record, and the Facility Director will remind staff of the requirement to complete and document a review of each patient's progress in no later than the patients' admission anniversary dates. Annual reviews of clients #1, and #8, will be completed and signed by the Medical Director by 3/14/26. Ongoing compliance with the regulation will be the responsibility of the Clinical Supervisor through a review of randomly selected clinical 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.
|
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 seven of ten client records reviewed.Client #2 was admitted on March 10, 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 19, 2026; however, there was no documentation in the record indicating a treatment plan update was completed as of the date of the inspection.Client #4 was admitted on May 11, 2015 and was still active at the time of the inspection. A treatment plan update was completed on October 15, 2025 and the next update was due no later than December 15, 2025; however, there was no documentation in the record indicating a treatment plan update was completed as of the date of the inspection.Client #5 was admitted on January 10, 2024 and was still active at the time of the inspection. A treatment plan update was completed on September 5, 2025 and the next update was due no later than November 5, 2025; however, the update was not completed until November 7, 2025.Client #7 was admitted on August 29, 2025 and was still active at the time of the inspection. A treatment plan update was completed on October 15, 2025 and the next update was due no later than December 15, 2025; however, there was no documentation in the record indicating a treatment plan update was completed as of the date of the inspection.Client #8 was admitted on July 28, 2017 and was still active at the time of the inspection. A treatment plan update was completed on October 15, 2025 and the next update was due no later than December 15, 2025; however, there was no documentation in the record indicating a treatment plan update was completed as of the date of the inspection.Client #9 was admitted on September 23, 2024 and was still active at the time of the inspection. A treatment plan update was completed on July 18, 2025 and the next update was due no later than September 18, 2025; however, the update was not completed until October 16, 2025. Additionally, the next update was due no later than December 16, 2025; however, the update was not completed until January 12, 2026.Client #10 was admitted on March 6, 2019 and was discharged on December 11, 2025. A treatment plan update was completed on July 11, 2025 and the next update was due no later than September 11, 2025; however, the update was not completed until September 29, 2025. Additionally, the next update was due no later than November 29, 2025; however, there was no documentation in the record indicating a treatment plan update was completed prior to discharge.This is a repeat citation from the July 31, 2025 through August 1, 2025 annual renewal licensing inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
By 03/14/2026, the QA Manager will post Treatment Plan Review due date alerts in the EMR. The Facility Director will remind clinicians that reviews must be completed every 60 days, and must be completed on time. Treatment plans that were missing for active clients # 2, #4, #5, #7, #8 and #9 will be completed by 3/14/2026. The Clinical Supervisor will be responsible for ensuring ongoing compliance with the regulation through regular record review and during clinical supervision.
|
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.
|
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 three of ten client records reviewed.The facility policy stated a case consultation will occur within the patient ' s first 90 days of treatment, then once a year afterward.Client #1 was admitted on December 5, 2008 and was still active at the time of the inspection. There was no documentation in the record indicating a case consultation occurred since the last consultation was documented on January 16, 2025.Client #7 was admitted on August 29, 2025 and was still active at the time of the inspection. There was no documentation in the record of a case consultation occurring since the client was admitted to treatment.Client #9 was admitted on September 23, 2024 and was still active at the time of the inspection. There was no documentation in the record of a case consultation occurring since the client was admitted to treatment.This is a repeat citation from the July 31, 2025 through August 1, 2025 annual renewal licensing inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
By 03/14/2026, the Facility Director will remind staff of the regulatory requirement to document a Case Consultation every 90 days for the first year in treatment and annually thereafter. The QA manager has recorded an alert of the due dates of the Annual Case Consultations and the 90 Day Case Consultations due during the first year of treatment. Ongoing compliance with the regulation will be the responsibility of the Clinical Supervisor through random record review and during individual and/or group clinical supervision.
|
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.
|
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 facility policy stated follow-up information will be completed and documented in the client record by the clinician within 7 days of discharge.Client #6 was admitted on February 9, 2022 and discharged on January 20, 2026. There was no follow-up information documented in the record at the time of the inspection.Client #10 was admitted on March 6, 2019 and was discharged on December 11, 2025. There was no follow-up information documented in the record at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
By 3/14/2026, clinicians will be reminded by the Facility Director of the regulatory requirement to document the client Follow Up contact within seven days of discharge from the program. Clinicians have been directed to reach out to discharged clients within seven days of discharge and to document the outcome of the contact in a Non-billable Note in the EMR.
Ongoing compliance with the regulation will be the responsibility of the Clinical Supervisor through a review of the Follow Up contacts prior to the closeout of the clinical record for all discharged clients.
|