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 August 4, 2026 through August 5, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Behavioral Wellness Center at Girard DD/FIR 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in three of three applicable client records reviewed. The facility policy and procedure manual stated the emergency contact will be notified, with a signed consent, after a client is discharged from the facility against medical advice.Client # 5 was admitted to the inpatient non-hospital detoxification activity on June 18, 2026 and was discharged against medical advice on June 25, 2026. There was no documentation in the record indicating the emergency contact was notified the client was discharged against medical advice at the time of the inspection. Client # 7 was admitted to the inpatient non-hospital detoxification activity on February 6, 2026 and was discharged against medical advice on February 13, 2026. There was no documentation in the record indicating the emergency contact was notified the client was discharged against medical advice at the time of the inspection. Client # 13 was admitted to the inpatient non-hospital activity on December 15, 2025 and was discharged against medical advice on December 18, 2025. There was no documentation in the record indicating the emergency contact was notified the client was discharged against medical advice at the time of the inspection. This is a repeat citation from the September 5, 2025 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will work with the Information Technology (IT) Department to incorporate in the electronic discharge information a section regarding emergency contact notification if the participant discharge status is against medical advice/ against facility advice (AMA/AFA). This will be a "hard stop" and unless staff answer a series of questions related to emergency contact notification the computer will not allow them to continue.
Additionally, the Clinical Supervisor will review the Emergency Contact Policy to respective staff during supervision and document accordingly.
a). Responsible Party:
Clinical Supervisor, Behavioral Specialists, and support staff (Community Recovery
Specialist, and Addiction Recovery Assistants)
b). Completion Date: 9/11/26
Staff will document in the client's discharge record the attempt to notify emergency contact when a client leaves the facility AMA/AFA.
a). Responsible Party:
Clinical Supervisor, Behavioral Specialists, and support staff (Community Recovery
Specialist, and Addiction Recovery Assistants)
b). Completion Date: 9/11/26
Clinical Supervisor will conduct focus review of 90% or 5 charts of clients who leave the facility AMA/AFA during a 2-month period to ensure that the client emergency contact was notified.
a). Responsible Party:
Clinical Supervisor and Director of Recovery Services
b). Completion Date: 11/30/2026
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715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility failed to ensure the narcotic treatment physician determining the proper dosage level for a patient consulted with , as well as failing to ensure if the narcotic treatment physician determining the initial dose was not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient's initial dose and schedule in six of six patient records reviewed.Patient # 2 was admitted to the inpatient non-hospital detoxification activity on April 28, 2026 and was discharged on May 12, 2026. A certified registered nurse practitioner conducted the patient examination on April 28, 2026 and a narcotic treatment physician determined the initial dose and schedule on April 28, 2026; however, there was no consultation between the certified registered nurse practitioner and the physician documented in the record at the time of the inspection. Patient # 3 was admitted to the inpatient non-hospital detoxification activity on October 31, 2025 and was discharged on November 11, 2025. A certified registered nurse practitioner conducted the patient examination on October 31, 2025 and a narcotic treatment physician determined the initial dose and schedule on November 1, 2025; however, there was no consultation between the certified registered nurse practitioner and the physician documented in the record at the time of the inspection. Patient # 4 was admitted to the inpatient non-hospital detoxification activity on December 10, 2025 and was discharged on December 11, 2025. A certified registered nurse practitioner conducted the patient examination on December 10, 2025 and a narcotic treatment physician determined the initial dose and schedule on December 11, 2025; however, there was no consultation between the certified registered nurse practitioner and the physician documented in the record at the time of the inspection. Patient # 5 was admitted to the inpatient non-hospital detoxification activity on June 18, 2026 and was discharged on June 25, 2026. A certified registered nurse practitioner conducted the patient examination on June 18, 2026 and a narcotic treatment physician determined the initial dose and schedule on June 19, 2026; however, there was no consultation between the certified registered nurse practitioner and the physician documented in the record at the time of the inspection. Patient # 6 was admitted to the inpatient non-hospital detoxification activity on May 5, 2026 and was discharged on May 7, 2026. A certified registered nurse practitioner conducted the patient examination on May 5, 2026 and a narcotic treatment physician determined the initial dose and schedule on May 6, 2026; however, there was no consultation between the certified registered nurse practitioner and the physician documented in the record at the time of the inspection. Patient # 7 was admitted to the inpatient non-hospital detoxification activity on February 6, 2026 and was discharged on February 13, 2026. A certified registered nurse practitioner conducted the patient examination on February 7, 2026 and a narcotic treatment physician determined the initial dose and schedule on February 7, 2026; however, there was no consultation between the certified registered nurse practitioner and the physician documented in the record at the time of the inspection. This is a repeat citation from the September 5, 2025 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure compliance with the requirement that the narcotic treatment physician consult with the physician who conducted the patient examination before determining the patient's initial dose and schedule, the electronic health record will be modified to require completion of physician consultation attestation fields prior to entry of the initial MAT order. The ordering CRNP will document the dose consultation which will reflect the initial dose recommendation, record of consulting physician's name and date/time of consultation. The system will prevent order entry unless the response is affirmative.
a). Responsible Party:
IT Manager, NTP Physician and CRNP
Completion Date: 9/30/2026
Monitoring:
PI Department will conduct focus review of 100% or of all clients on MAT for a 3-month period to ensure compliance that physician was consulted regarding the client's initial dosage.
b). Completion Date: 12/30/2026
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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 of the initial dose given to the patient in two of two applicable patient records reviewed. Patient # 6 was admitted to the inpatient non-hospital detoxification activity on May 5, 2026 and was discharged on May 7, 2026. 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. Patient # 7 was admitted to the inpatient non-hospital detoxification activity on February 6, 2026 and was discharged on February 13, 2026. 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.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor, Director of Recovery Services and Director of Nursing will review the program transfer policy with all counselors and nurses to ensure understanding and compliance. Counselors will ensure that any client requesting transfer to another NTP for maintenance, detoxification, or another treatment activity is transferred within seven (7) days of the request. When the program receives a client from another NTP, the nurse or counselor will obtain dose verification, written documentation will be provided to the transferring NTP confirming the client's admission and the date the client received the initial dose.
a). Responsible Party:
Clinical Supervisors, Director of Recovery Services, Director of Nursing, Counselors and Nurses
b). Completion Date: 9/30/26
Clinical Supervisor will conduct focus chart review of 100% of transfers during a 3-month period to ensure adherence with the transfer policy.
a). Responsible Party:
Clinical Supervisor and Director of Recovery Services, Director of Nursing
b). Completion Date: 12/30/2026
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a psychosocial evaluation was completed during the intake and admission process in three of seven client records reviewed. The policy and procedure manual stated the facility will assess the participant's current and historical medical, psychiatric/mental health, psycho-social and addictive disease history and service needs in order to complete the admissions process and safely evaluate and assist the participant in prompt engagement in the treatment process.Client # 10 was admitted to the inpatient non-hospital activity on June 28, 2026 and active at the time of the inspection. The psychosocial evaluation was due to be completed during the admissions process; however, the evaluation was completed on July 29, 2026.Client # 11 was admitted to the inpatient non-hospital activity on April 14, 2026 and was active at the time of the inspection. The psychosocial evaluation was due to be completed during the admissions process; however, the evaluation was completed on May 1, 2026.Client # 12 was admitted to the inpatient non-hospital activity on September 12, 2025 and was discharged on November 24, 2025. The psychosocial evaluation was due to be completed during the admissions process; however, there was no evaluation completed prior to discharge. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake and Admission
(b) Intake procedure shall include documentation of the psychosocial evaluation
Counselors will complete the psychosocial evaluation within three (3) days of the client's admission. In the event that staff are unavailable to do this work, the clinical supervisor will complete the client's psychosocial evaluation.
a). Responsible Party:
Counselors and clinical supervisor
b). Completion Date: 9/11/26
Clinical Supervisor will conduct focus chart review of 100% of admissions during a 3month period to ensure timely completion of psychosocial evaluation.
a). Responsible Party:
Clinical Supervisor and Director of Recovery Services
b). Completion Date: 12/30/2026
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