INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted February 14, 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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705.26 (1) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(1) Shall have a heating and cooling ventilation system that is adequate to maintain an indoor temperature of at least 65F in the winter. When indoor temperatures exceed 90F, mechanical ventilation such as fans or air conditioning shall be used.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on February 14, 2025, the facility failed to maintain an indoor temperature of at least 65F in the winter.The facility has three thermostats which were observed to show the following temperatures during the investigation: - HR Manager office was 62 degrees - Administrative Office Area was 68 degrees - Nursing Office/Dosing Area was 72 degrees In addition, the group room was observed to be 62 degrees on a thermometer.
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Plan of Correction
On 2/27/2025, the facility manager installed supplemental wall-mounted heaters in the HR Manager's office, and in the group room. The facility Manager set the thermostats to ensure that the temperature does not drop below 65 degrees. Ongoing compliance will be the responsibility of the Facility Manager who will verify with the the administrative assistant that the temperature in is not below 65 degrees at any time the building is occupied by clients and or staff. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on February 14, 2025, the facility failed to prohibit portable space heaters. An unmounted portable space heater was observed in use in the administrative office area across from the mail slots.This was discussed with staff during the investigation.
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Plan of Correction
On 2/27/2025, the Facility Manager installed a wall-mounted heater in the administrative office area where the portable space heater had been in use. Staff has been reminded that portable heaters are not permitted anywhere in the building. Ongoing compliance will be the responsibility of the Nursing Supervisor and/or her designee through regular monitoring of the office space and ensuring that the temperature in that area is not below 65 degrees. |
715.8(1)(vi) LICENSURE Psychosocial Staffing
A narcotic treatment program shall comply with the following staffing ratios as established in Chapter 704 (relating to staffing requirements for drug and alcohol treatment activities):
(vi) Outpatients. The counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients.
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Observations
Based on a review of the client census and the employee roster during a complaint investigation conducted on February 14, 2025, the facility failed to ensure the counseling caseload for one FTE counselor in an outpatient narcotic treatment program does not exceed 35 active clients.At the time of the investigation, the facility employed one counselor with a caseload of 47 active clients. This exceeds the allowable caseload.This was discussed with the staff at the time of the investigation.
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Plan of Correction
As of January 31st 2025, no new admissions will be accepted until a clinician has been hired to replace the clinician who resigned on 1/30/2025. Beginning on 03/13/2025, a temporary part- time clinician has been hired to ensure that no clinician exceeds the 35:1 Client/Counselor ratio. Five clients in treatment less than two years have been removed from the current clinician's caseload leaving a total of 35 clients in treatment under two years. A permanent clinician has been hired with a start date of 4/10/2025. Ongoing compliance with the regulation will be the responsibility of the Facility Director through continuing the hold on new admissions since January 31,2025 until the permanent replacement has begun to provide services on April 10th 2025. The Nursing Director will be responsible for ongoing weekly monitoring of caseloads to ensure no caseload exceeds the regulatory maximum |