INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring 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, RHJ Medical Center, Inc. /Vandergrift, LLC 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to collect feedback on completed trainings in one of four records.
The facility policy and procedures state that feedback is to be collected for completed trainings, both internal and external.
The training year beginning January 1, 2025, through December 31, 2025, was reviewed.
Staff #1 was hired as project director on November 25, 2002, and still employed at the time of inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The chart missing the information will be reviewed and the staff member will be provided with staff feedback forms. The staff member will also be instructed to complete a feedback form for all future trainings to be turned in to the project director. The project director is responsible to ensure implementation and monitoring of compliance with this regulation. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient in two of two applicable records.
There was no verification in the records that transfer paperwork was sent.
Patient #4 was admitted on June 6, 2024, and discharged on June 24, 2025.
Patient #5 was admitted on September 5, 2014, and discharged on August 25, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In order to correct this citation the Project director and clinical supervisor will hold a meeting to review and discuss the discharge procedures particularly patient transfers to ensure that all staff is aware of the procedure and completes the transfer of records upon all client transfers. Transfer charts will be reviewed to ensure completion of the patient transfer documentation. The project director is responsible to ensure implementation and monitoring of compliance with this regulation. |
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 facility failed to 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 in one of two applicable records.
Patient #2 was admitted on August 7, 2025, and was still active at the time of the inspection. A fax was sent to the transferring facility on August 7, 2025, and did not contain the date of the initial dose given to the patient.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
In order to correct this citation the Project director and clinical supervisor will hold a meeting to review and discuss the discharge procedures particularly patient transfers to ensure that all staff is aware of the procedure and completes the transfer of records upon all client transfers. Transfer charts will be reviewed to ensure completion of the patient transfer documentation. The project director is responsible to ensure implementation and monitoring of compliance with this regulation. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to include the results of an annual physical evaluation by the narcotic treatment physician in three of four applicable records.
Patient #1 was admitted on July 8, 2019, and was still active at the time of the inspection. The annual physical evaluation was due no later than July 8, 2025; however, there was no annual physical documentation in the record.
Patient #4 was admitted on June 6, 2024, and discharged on June 24, 2025. The annual physical evaluation was due no later than June 6, 2025; however, there was no annual physical documentation in the record.
Patient #6 was admitted on October 13, 2023, and successfully discharged December 12, 2025. The annual physical evaluation was due no later than October 13, 2025; however, it was documented on October 20, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director and clinical supervisor will develop a tracking method to track all annual physicals for patients. Then a staff meeting will be held to remind staff of this regulation and review the tracking of patient's annual physicals to ensure that they are completed on or before the annual admission date. |
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 facility failed to include the results of an annual clinical evaluation in two of four applicable records.
Patient #1 was admitted on July 8, 2019, and was still active at the time of the inspection. The annual clinical evaluation was due no later than July 8, 2025; however, it was documented on July 10, 2025.
Patient #4 was admitted on June 6, 2024, and discharged on June 24, 2025. The annual clinical evaluation was due no later than June 6, 2025; however, there was no annual clinical documentation in the record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director and clinical supervisor will develop a tracking method to track all annual clinical evaluation for patients. Then a staff meeting will be held to remind staff of this regulation and review the tracking of patient's annual evaluations to ensure that they are completed on or before the annual admission date.
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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 document treatment plan updates every 60 days in three of seven records.
Client #1 was admitted on July 8, 2019, and was still active at the time of the inspection. A treatment plan update was completed on July 11, 2025, and the next update was due no later than September 11, 2025; however, was completed on September 19, 2025. The next update was due no later than November 19, 2025; however, it was completed November 21, 2025. The next update was due no later than January 21, 2026; however, it was completed January 28, 2026.
Client #6 was admitted on October 13, 2023, and discharged December 12, 2025. A treatment plan update was completed on April 16, 2025, and the next update was due no later than June 16, 2025; however, it was completed on June 18, 2025. The next update was due no later than August 18, 2025; however, it was completed August 20, 2025.
Client #7 was admitted on June 12, 2013, and discharged on November 25, 2025. A treatment plan update was completed on April 15, 2025, and the next update was due no later than June 15, 2025; however, it was completed on June 26, 2025. A treatment plan update was completed on August 7, 2025, and the next update was due no later than October 7, 2025; however, it was completed on November 6, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director and clinical supervisor will conduct a meeting to review and discuss the completion of treatment plans every 60 days. Tracking of the treatment plan due dates will also be reviewed. Chart audits will be conducted in order to ensure future compliance with this regulation. The project director is responsible to ensure implementation and monitoring of compliance with this regulation. |
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 document an aftercare plan in two of two applicable records.
The facility's policy and procedures state an aftercare plan will be formulated to assist clients to sustain and build on progress achieved during treatment.
Client #6 was admitted on October 13, 2023, and successfully discharged December 12, 2025.
Client #7 was admitted on June 12, 2013, and successfully discharged on November 25, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director and clinical supervisor will conduct a meeting in which we will review and discuss the policies and procedures for aftercare planning upon patient discharge. Discharge charts will be reviewed in order to ensure future compliance with this regulation. The project director is responsible to ensure implementation and monitoring of compliance with this regulation. |