INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone/buprenorphine monitoring inspection conducted on June 29, 2026 through June 30, 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:
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Plan of Correction
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential 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, the facility failed to ensure all facility heaters were permanently mounted or installed.
At the time of the inspection, conducted on June 29, 2026 at approximately 10:30 am, there was a portable space heater sitting on top of a filing cabinet located in the hallway.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/30/2026, The portable space heater was immediately removed from the hallway and taken out of service. Facility leadership reviewed the physical plant area to confirm that no other portable or non-permanently mounted heaters were in use. Staff were reminded that portable space heaters are not permitted in hallways, offices, client areas, or any other facility location unless specifically authorized and permanently installed in accordance with applicable safety requirements.
Beginning on 7/01/2026, the Facility Director, or designee, will be responsible for ensuring that all heating equipment used in the facility is permanently mounted or installed and that portable space heaters are not used in any area of the facility. The Administrative Assistant will conduct monthly physical plant safety checks after the monthly fire drills to verify that no portable space heaters or other non-permanently mounted heating devices are present or in use. Any noncompliance identified will be corrected immediately, documented, and reviewed with staff to prevent recurrence.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to ensure an annual written individual staff performance evaluation was completed, then reviewed and signed by the employee, in one of two applicable personnel records reviewed.
Employee # 1 was hired as project director and facility director on December 28, 2013. There was no 2025 individual performance evaluation documented in the record as of the date of the inspection. The most recent performance evaluation documented was dated July 1, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of July 24, 2026, the Project Director/Facility Director will remind the Board Members of the regulatory requirement to complete the annual written individual staff performance evaluation for the Facility Director in accordance with 28 Pa. Code § 709.26(b)(3). Ongoing compliance will be the responsibility of the Board President, who will receive a reminder before the end of each fiscal year and will ensure that the required evaluation is completed annually.
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709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their regulatory client rights, in one of one applicable client record reviewed.
Client # 3 was admitted on November 11, 2025 and was discharged on December 4, 2025. There was no documentation of the client rights acknowledgment in the client record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By July 22, 2026, the Facility Director, or designee will remind staff of the regulatory requirement to ensure that written acknowledgement that the client has received a copy of the Clients Rights is obtained, reviewed for completion, and retained in the client record. Intake staff will review the client rights acknowledgment form before the completion of the intake process to verify that it is signed and dated by the client.
The Clinical Supervisor, or designee, will conduct an audit of all newly admitted client records to verify that the client rights acknowledgment is completed and filed in the client record. The Clinical Supervisor will ensure ongoing compliance with the regulation during random monthly record review. Any missing or incomplete acknowledgement will be corrected immediately when possible, documented, and reviewed with the responsible staff member to prevent recurrence. Because client #3 was discharged on December 4, 2025, the facility was unable to obtain the client's signature after discharge.
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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review and a client record review, the facility failed to maintain a data collection and recordkeeping system that allowed for the efficient retrieval of data needed to measure the project ' s performance.
At the time of the inspection, the facility's client list, presented to the Licensing Representative, stated there were no pregnant clients since the last annual inspection. The Licensing Representative also received verbal confirmation from facility staff during the onsite inspection that the client list was accurate. However, during the course of the client record review, it was discovered that there was documentation in client #3's record indicating the client was pregnant during the course of their treatment episode. Client #3 was admitted on November 11, 2025 and was discharged on December 4, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 08/01/2026, the facility will ensure that the client tracking process will consistently capture and verify the pregnancy status of applicable clients in the medical record to ensure pregnancy status is available for submission during licensing or other audits to comply with 28 Pa. Code § 709.31(a),
The IT Director will create a field to track the patient's status as pregnant, post-partum or N/A, that can be available as a pregnancy status report prior to licensing or other audits. The Clinical Supervisor/designee will review the current client records to identify any clients who are pregnant or who were pregnant during treatment since the last annual inspection. Any discrepancies identified will be corrected in the facility's data collection system. Client #3's current pregnancy status will be amended in the record to accurately reflect the client's pregnancy status in the discharged client record. The Project Director/designee will be responsible for ongoing compliance with the requirement through regular record reviews and during individual and group supervision.
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715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records, the facility failed to document the narcotic treatment physician's review of dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient's therapeutic dosage in one of six applicable patient record reviewed.
Patient # 6 was admitted on April 6, 2016 and was still active at the time of inspection. A dosage level review was documented on March 18, 2025 and the next one was not completed until May 12, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. By 08/01/2026, the IT Director will implement a dose review tracking log that notifies the prescribing physician 30 days in advance of the semi-annual dose review date for active clients. The dose review reminder will remain active in the EMR until the review has been completed and documented in the patient file. Ongoing compliance with regulation 715.15(a)e will be the responsibility of the Nursing Director who will ensure that semi-annual dose reviews are scheduled and completed in accordance with the regulation by the prescribing physician through a monthly review of a random sample of the medical records of each active patient. Patient #6 will be scheduled for and receive a dosage level review by the narcotic treatment physician by 08/01/2026. |
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 it notified the transferring narcotic treatment program of the date of the admission of the patient and the date the initial dose was given to the patient in one of one applicable patient record reviewed.
Patient # 3 was transferred in and admitted from another narcotic treatment program on November 11, 2025 and was discharged on December 4, 2025. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the client's date of admission and the date the initial dose was given.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 08/01/2026 Nursing Staff will be reminded of the regulatory requirement of 15.20(4), that written notification of the admission and initial dose must be provided to the transferring provider when transferred clients are admitted to the facility. The Transfer Confirmation Form will be submitted to the transfer program and a copy of the transfer confirmation will be retained in the medical record. Ongoing compliance with the regulation will be the responsibility of the Nursing Supervisor through ongoing audits of all incoming transfer patient records to verify that written notification to the transferring program is documented and filed in the record. |
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 one of three applicable patient records reviewed.
Patient # 6 was admitted on April 6, 2016 and was still active at the time of the inspection. The last and most recent annual evaluation documented in the record was completed on April 6, 2024.
This is a repeat citation from August 1, 2025 annual renewal licensing inspection and the February 19, 2026 plan of correction follow up inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/14/2026 clinicians were reminded of the regulatory requirement to review and document a summary of each client's treatment progress every 12 months throughout treatment. Clinicians were instructed to ensure that upon completion of the Annual Evaluation of patients' progress in treatment, the completed evaluation is routed to the Medical Director for review and signature. The IT Coordinator will create automated alerts in the EMR that notify clinicians of upcoming Annual Evaluation due dates. The EMR workflow will be modified so that Annual Evaluations cannot be closed without mandatory routing to the Medical Director. The Clinical Supervisor will ensure ongoing compliance with the regulation through monthly audit of the clinical records and corrective action if reviews are not completed and signed in accordance with the regulation. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation of the disclosure to the client of criteria for admission, treatment, completion, and discharge, in one of one applicable record reviewed.
Client # 3 was admitted on November 11, 2025 and was discharged on December 4, 2025. There was no documentation of the criteria disclosure to the client in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 08/01/2026, the IT Director will modify the Client Orientation Checklist in the EMR to include the client's signed acknowledgement of the orientation topics reviewed during Intake prior to admission to the program. Staff will be oriented to the revised Client Orientation Checklist and reminded of the requirement to witness the client's acknowledgement with dated signature. The workflow will be modified to require that the signed Client Orientation document is included in the clinical record prior to admission. Ongoing compliance will be the responsibility of the QA Manager/Clinical Supervisor through timely review of all required intake documentation prior to clients' treatment initiation. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation that the client was oriented to the project's policies in one of one applicable record reviewed.
Client # 3 was admitted on November 11, 2025 and was discharged on December 4, 2025. There was no documentation of client orientation in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 08/01/2026, the IT Director will modify the Client Orientation Checklist in the EMR to include the client's signed acknowledgement of receipt of orientation to the project's policies outlined in the Client Handbook during Intake. Staff will be oriented to the revised Client Orientation Checklist and reminded of the requirement to witness the client's acknowledgement of orientation to the program policies and receipt of a a copy of the Client Handbook with dated signature. The workflow will be modified to require that the signed and revised Client Orientation document is included in the clinical record prior to admission. Ongoing compliance will be the responsibility of the QA Manager/Clinical Supervisor through timely review of required orientation to the program policies included in the Client Handbook.
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709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation that the client was oriented to the project's hours of operation in one of one applicable record reviewed.
Client # 3 was admitted on November 11, 2025 and was discharged on December 4, 2025. There was no documentation of client orientation in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 08/01/2026, the IT Director will modify the Client Orientation Checklist in the EMR to include the client's signed acknowledgement of receipt of orientation to the project's hours of operation outlined in the Client Handbook during Intake. Staff will be oriented to the revised Client Orientation Checklist and reminded of the requirement to witness the client's acknowledgement of orientation to the program hours of operation and receipt of a copy of the Client Handbook outlining the hours of operation with dated signature. The workflow will be modified to require that the signed and revised Client Orientation document is included in the clinical record prior to admission. Ongoing compliance will be the responsibility of the QA Manager/Clinical Supervisor through timely review of required orientation to the program hours of operation included in the Client Handbook.
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709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation that the client was oriented to the project's fee schedule in one of one applicable record reviewed.
Client # 3 was admitted on November 11, 2025 and was discharged on December 4, 2025. There was no documentation of client orientation in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 08/01/2026, the IT Director will modify the Client Orientation Checklist in the EMR to include the client's signed acknowledgement of receipt of orientation to the project's fee schedule outlined in the Client Handbook during Intake. Staff will be oriented to the revised Client Orientation Checklist and reminded of the requirement to witness the client's acknowledgement of orientation to the project's fee schedule and receipt of a copy of the Client Handbook that outlines the project's fee schedule with dated signature. The workflow will be modified to require that the signed and revised Client Orientation Checklist is included in the clinical record prior to admission. Ongoing compliance will be the responsibility of the QA Manager/Clinical Supervisor through timely review of required orientation to the program's fee schedule that is outlined in the Client Handbook.
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709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation that the client was oriented to the project's services provided in one of one applicable record reviewed.
Client # 3 was admitted on November 11, 2025 and was discharged on December 4, 2025. There was no documentation of client orientation in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 08/01/2026, the IT Director will modify the Client Orientation Checklist in the EMR to include the client's signed acknowledgement of receipt of orientation to the project's services provided outlined in the Client Handbook during Intake. Staff will be oriented to the revised Client Orientation Checklist and reminded of the requirement to witness the client's acknowledgement of orientation to the program services provided and receipt of a copy of the Client Handbook that outlines the services provided with dated signature. The workflow will be modified to require that the signed and revised Client Orientation document is included in the clinical record prior to admission. Ongoing compliance will be the responsibility of the QA Manager/Clinical Supervisor through timely review of required orientation to the program services provided as outlined in the Client Handbook.
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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 ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of three applicable client records reviewed.
Client # 5 was admitted on September 8, 2020 and was still active at the time of the inspection. A treatment plan update was completed on April 1, 2026 and the next update was due no later than June 1, 2026; however, the update was not completed as of the date of the inspection.
Client # 6 was admitted on April 6, 2016 and was still active at the time of the inspection. A treatment plan update was completed on January 20, 2026 and the next update was due no later than March 20, 2026; however, the update was not completed until May 26, 2026.
This is a repeat citation from the August 1, 2025 annual renewal licensing inspection and the February 19, 2026 plan of correction follow-up inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 07/30/2026, clinicians were reminded of the regulatory requirement to complete Treatment Plan Reviews and Updates at least every 60 days. Clinicians were instructed to schedule an individual counseling session with each client on their caseload prior to the upcoming Treatment Plan Review due date. If a client is unwilling or unable to attend an appointment before the scheduled due date, clinicians are required to complete the Treatment Plan Review and Update no later than every 60 days and document the reason the client was not present. Treatment Plan Reviews and Updates will be reviewed and signed by the client when the client is present. Ongoing compliance with 28 Pa. Code § 709.92(b) will be the responsibility of the Clinical Supervisor/QA Manager through monthly audits of a random sample of Treatment Plan Reviews and Updates.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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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 an aftercare plan when applicable, in one of one applicable client record reviewed.
The facility policy and procedure manual stated an aftercare plan will be completed for all successful discharges within 7 days of discharge.
Client # 4 was admitted on June 10, 2015 and was successfully discharged on April 10, 2026. The aftercare plan was due to be completed by April 17, 2026, but the plan was not completed until April 20, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 08/01/2026, clinical staff will be reminded of the facility policy requiring an aftercare plan to be completed for all successful discharges within 7 days of discharge. The IT Director will modify the EMR discharge workflow to include an aftercare-plan due-date alert for successful discharges. The alert will notify the assigned clinician and Clinical Supervisor of the 7-day completion deadline and will remain active until the aftercare plan is completed and documented in the record.
Ongoing compliance will be the responsibility of the Clinical Supervisor/designee through review of all successful discharge documentation to verify that aftercare plans were completed within 7 days of discharge. Any late, missing, or incomplete aftercare plans identified during this review will be addressed immediately through staff follow-up and corrective documentation in the client record.
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709.93(a)(10) 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:
(10) Discharge summary.
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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 a discharge summary, in two of four applicable client records reviewed.
The facility policy and procedure manual stated the discharge summary will be completed within 7 days of discharge.
Client # 3 was admitted on November 11, 2025 and was discharged on December 4, 2025. The discharge summary was due to be completed by December 11, 2025, but the summary was not completed until April 28, 2026.
Client # 4 was admitted on June 10, 2015 and was discharged on April 10, 2026. The discharge summary was due to be completed by April 17, 2026, but the summary was not completed until April 20, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 08/01/2026, clinical staff will be reminded of the facility policy requiring that a Discharge Summary must be completed within 7 days of discharge. The IT Director will modify the EMR discharge workflow to include a Discharge Summary due-date alert for all patients who are no longer active in the the program. The alert will notify the Primary Therapist and the Clinical Supervisor of the 7-day completion deadline and will remain active until the aftercare plan has been documented in the record. Ongoing compliance will be the responsibility of the Clinical Supervisor/designee through review of a random sample of discharge documentation to verify that Discharge Summaries were completed within 7 days of discharge. Any late, missing, or incomplete Discharge Summaries identified during the QA review will be addressed immediately through staff follow-up and corrective documentation in the client record. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for failing to ensure the completion of treatment plan updates within the regulatory timeframe were submitted and approved by the Department for the August 1, 2025 annual licensing inspection and the February 19, 2026 plan of correction follow-up inspection. Failing to complete treatment plan updates within the regulatory timeframe was again found to be a deficiency in the June 30, 2026 annual licensing inspection.
Plans of correction for failing to ensure the completion of annual evaluations of patient status were submitted and approved by the Department for the August 1, 2025 annual licensing inspection and the February 19, 2026 plan of correction follow-up inspection. Failing to complete annual evaluations was again found to be a deficiency in the June 30, 2026 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 08/01/2026, the Project Director/Facility Director will conduct a corrective-action review with the Supervisory and clinical staff to address the lack of compliance with previously approved plans of correction related to Treatment Plan Reviews and Updates and Annual Reviews. The review will include the requirements of the plans of correction, deficiencies identified during licensing inspections, and the potential licensing consequences of failing to comply with an approved plan of correction under 28 Pa. Code § 709.17(a)(3).
The Performance Improvement Committee will implement an enhanced compliance tracking process for Treatment Plan Reviews and Updates and Annual Evaluations. This process will include active due-date alerts and supervisory reports in the EMR. The Clinical Supervisor/QA Manager will conduct ongoing record audits, flag items approaching their due dates, and immediately escalate overdue items to the Supervisor for corrective action.
Clinicians will receive individual follow-up and coaching for late or incomplete documentation. Repeated failure to complete required documentation within regulatory timeframes will result in progressive corrective action in accordance with facility policy. Ongoing compliance will be the responsibility of the Performance Improvement Committee through review of audit findings during monthly PI meetings, with corrective action implementation as indicated.
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