INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on June 5, 2025 - June 6, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation Inc., 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of eight personnel records, the facility failed to ensure that one employee had a written individual training plan that was developed according to facility to policy. The facility policy states that a written individual training plan is to be completed within 30 days of hire.
Employee # 4 was hired as a counselor on October 7, 2024 and was current in that position at the time of the inspection. Employee # 4 should have had an initial individual training plan developed within 30 days of the date of hire; however, a written individual training plan was not developed until December 16, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the matter with the Clinical Director. The requirement to have a training plan completed within 30 days of hire was reinformed and also addressed with staff responsible for onboarding new employees. The Clinical Director will establish a tickler file to ensure that the annual training plan is developed with staff input, signed, and dated within 30 days of hire. The CEO will reinforce compliance at monthly management meetings. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of eight personnel records, the facility failed to ensure that one applicable employee received a minimum of 4 hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee # 6 has been in the position of counselor since October 23, 2023 and was due to have the communicable disease trainings no later than October 23, 2024; however, the TB/STD training was not completed as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The subject employee had made many attempts to register for the training, but was unable to do so due to slots not being available. The subject employee did complete the training on 6/17/25, which was the first available date.
Notwithstanding the above, the CEO has discussed with matter with the employee responsible for tracking and coordinating staff trainings. Efforts will be made to register new staff for required DDAP trainings upon hire. If no openings are available within six months, alternatives will be pursued including having an Aldie staff member conduct the training with DDAP approval.The CEO will review the status on a monthly basis with the administrative assistant to ensure compliance. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from June 2024 through April 2025, the facility failed to conduct unannounced fire drills during the 2024 months of July and September.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the matter with the two employees responsible for conducting and documenting monthly fire drills. Staff turnover was reported as a likely cause of the deficiency. A new reporting system has since been developed and has been achieving the desired outcomes since October 2024. This system will continue. If staff turnover occurs, two additional employees have been training to conduct the fire drills if necessary. The CEO will review compliance with the staff on a monthly basis. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the facility fire drill logs from June 2024 through April 2025, the facility failed to conduct fire drills during normal staffing conditions. All documented fire drills occurred after dosing hours ended at 11:45 a.m. when less staff members were at the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with staff responsible for conducting fire drills. Staff will conduct the drills at various times throughout the day. The issue was corrected as of today as a fire drill was conducted at 8:00 am. This pattern of varying times will be conducted and documented throughout the year. The CEO will monitor compliance with the subject staff on a monthly basis. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the June 2024 through April 2025 fire drill logs, the facility failed to document the time of the drill and the length of time to evacuate during the June 2024 fire drill.
This is a repeat citation from the June 14, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with staff responsible for conducting fire drills. A new procedure was developed in July 2024 to tract the length of time to evacuate the building. The process as achieved the desired results as no deficiencies have occurred since. The CEO will continue to monitor compliance during monthly management meetings. |
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 seventeen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client # 4 was admitted to the outpatient level of care on November 7, 2024 and was active at the time of the inspection. The record contained documentation of a disclosure of information to a lab on November 11, 2024, however, the consent to release information form to the lab was not signed by the client until November 15, 2024.
This is a repeat citation from the June 14, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As is referenced in the citation, Aldie did not fail to obtain an informed voluntary consent. The informed voluntary consent was obtained, but was signed by the client four days after the release.
The CEO has addressed the issue with the employee that manages intake and assessments. The requirement not to release information was reinforced and was understood by the supervisor. The supervisor will ensure through a document check list that no records are released without a signed consent. This will allow Aldie to improve upon the 95% succuss rate achieved during this inspection. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of sixteen weeks of physician and physician assistant timesheets, the facility failed to provide at least one hour of physician time a week on site for every ten patients in one week reviewed.
During the week of January 8, 2025 through January 14, 2025, the patient census was 195. The facility was required to provide at least 19.5 hours of narcotic treatment physician services. There were only 16 hours documented.
This is a repeat citation from the June 14, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Aldie has submitted an Exception Request to DDAP regarding this outdated regulation. Due to the advent of telehealth Aldie is able to ensure that patients have access to a physician well in excess of the one hours for every 10 patient requirement.
If the Exception Request is granted the matter is resolved. If denied, Aldie will either increase the hours of the physician assistant or pursue the services of a contracted physician to provide coverage during time period when the medical director is on vacation or otherwise not on site for sufficient hours to comply. The CEO will be responsible for taking the appropriate actions to ensure compliance. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of sixteen narcotic treatment physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census for two weeks reviewed. A narcotic treatment physician must provide one-third of the required hours, with a certified registered nurse practitioner or physician's assistant providing the remaining two-thirds of the required hours.
During the week of January 8, 2025 through January 14, 2025, the patient census was 195. The narcotic treatment physician was required to provide one-third of the 19.5 hours, which equals to 6.4 hours. The narcotic treatment physician provided 0 hours.
During the week of February 12, 2025 through February 18, 2025, the patient census was 193. The narcotic treatment physician was required to provide one-third of the 19.5 hours, which equals to 6.36 hours. The narcotic treatment physician only provided 6 hours.
This is a repeat citation from the June 14, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Aldie has made an Exception Request to DDAP for this outdated regulation. When not physically on-site, the narcotic treatment physician is available via telehealth for hours far in excess of the requirement.
If the Exception Request is denied, Aldie will pursue contracting with a physician to be physically on site during times when NTP is unavailable to do so. The CEO will take the appropriate action to ensure compliance. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to ensure that the narcotic treatment physician determined the initial dose and schedule. It was documented in the patient record that the facility's physician assistant (PA) rather than the narcotic treatment physician, determined the initial dose in one of one applicable patient record reviewed.
Patient # 6 was admitted on February 18, 2025 and was active at the time of the inspection. The initial medication order was written by the PA on February 28, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will review the deficiency with the medical director, physician assistant, and chief nursing officer. The medical director will ensure the he determines the initial dose and schedule. The PA will completely refrain from initial dose determination and will pause the induction process to obtain approval from the medical director. The Chief Nursing Officer will assist the CEO in monitoring compliance by overseeing documentation during inductions. |
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 the review of patient records, the facility failed to document a completed annual evaluation that was reviewed, dated and signed by the medical director in two of four applicable records.
Patient # 5 was admitted on July 3, 2019 and was discharged on October 7, 2024. The annual clinical evaluation was not completed until July 15, 2024.
Patient # 8 was admitted on June 30, 2023 and was discharged on March 17, 2025. The record did not contain any annual clinical evaluations.
This is a repeat citation from the June 2, 2023 and June 14, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with the Clinical Director and with the clinical staff at a meeting on June 16, 2025. If was decided that the Clinical Director will maintain a master spreadsheet listing all clients and the due dates for various documentation. The Clinical Director will send an email to the primary therapist informing them of the due date for the annual evaluation at least 30 days in advance. Action steps will be discussed in supervision and completion will be verified by the Clinical Director. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within 30 days of admission, per the facility policy, in four of six applicable records reviewed.
Client # 1 was admitted on May 2, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by June 1, 2025; however, it was not completed as of the date of the inspection.
Client # 4 was admitted on November 7, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by December 7, 2024; however, it was not completed until December 13, 2024.
Client # 6 was admitted on February 18, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by March 20, 2025; however, it was not completed as of the date of the inspection.
Client # 9 was admitted on August 15, 2024 and was discharged on December 16, 2024. The individual treatment and rehabilitation plan was completed on September 15, 2024; however, there was no documentation that the client participated in the development of the plan.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with the Clinical Director and with the clinical staff at a meeting on June 16, 2025. It was decided that the Clinical Director will maintain a master spreadsheet listing all clients and the due dates for various documentation. The Clinical Director will send an email to the primary therapist informing them of the due date for the treatment plan upon admission of the client. Action steps will be discussed in supervision, including the requirement that the client participated in the development of the treatment plan, and completion will be verified by the Clinical Director. |
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 patient records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing an annual evaluation was submitted and approved by the Department for the June 2, 2023 and June 14, 2024 annual licensing inspections. Completing annual clinical evaluations was again found to be a deficiency in the June 5, 2025 through June 6, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Aldie did make efforts to comply with prior correction action plans regarding this deficiency. However, the actions taken have not yet fully yielded the desired outcomes. Adjustments have been made to the previously submitted corrective action plans to include a more detailed tracking mechanism, regular communication with clinical staff, and oversight by the Clinical Director who is responsible to compliance. |
709.42(a)(4) LICENSURE Prompt delivery of services
709.42. Project management.
(a) The intake project shall have a written procedure for the performance of the following functions:
(4) Prompt arrangement for delivery of the requested services.
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Observations
Based on a review of seven client records, the facility failed to ensure the prompt arrangement for delivery of the requested services in two of five applicable records reviewed.
Client # 16 was admitted to the Intake, Evaluation, and Referral level of care on October 11, 2024. The record did not contain documentation of the prompt arrangement for the delivery of the requested services.
Client # 17 was admitted to the Intake, Evaluation, and Referral level of care on October 17, 2024. The record did not contain documentation of the prompt arrangement for the delivery of the requested services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with the Clinical Director and the Assessment Manager. The requirement to documentation the prompt delivery of services subsequent to the initial Intake was explained and reinforced. Any barriers to the prompt delivery of services will be documented in the client record. Compliance will be monitored as part of supervision and chart audits. The Assessment Manager will ensure compliance. |