INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 8, 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 Way of Life 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of applicable staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in two of three staff records.
Staff #5 was hired on as a support staff on May 6, 2024 and was still in this position at the time of the inspection. HIV/AIDS training was to be completed no later than May 6, 2026. There was no documentation that this training was completed.
Staff #6 was hired on as a support staff on August 1, 2023 and was still in this position at the time of the inspection. HIV/AIDS and TB/STD trainings were to be completed no later than August 1, 2025. The HIV/AIDS training was not completed until May 28, 2026 and the TB/STD training was not completed until October 29, 2025.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 8/25/26 the staff at NWOL will be re-educated on training requirements for their perspective positions. Staff will review their training plans and know when they must have certain trainings completed by. Staff 1 completed his training on 7/28/26. To ensure future compliance, training will be reviewed during quarterly by the Firetree Director of Training. Any discrepancies identified by the Compliance Team will be communicated to the Facility Director, so the involved staff member can be promptly addressed and/or retrained to ensure continued compliance. |
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
|
Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against facility advice in one of two applicable record.
The facility's inpatient non-hospital residential policy and procedure manual states the client's emergency contact will be notified within 12 hours of the client's decision to leave against facility advice, providing there is consent given in writing for the facility to contact the emergency contact.
Client #7 was admitted to the residential level of care on March 9, 2026 and discharged on May 7, 2026.
There was a consent for the emergency contact in client #7's record. There was no documentation that the emergency contact was notified.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the July 29, 2025 annual licensing inspection.
|
Plan of Correction
By 8/25/26 the clinical and monitor staff will receive retraining on AMA discharge procedures and notifying emergency contact of an AMA discharge within 12 hours of the client leaving treatment. Training included specifics in regards to informed and voluntary consents especially in the area of purpose of disclosure, as well as specific information that could be released for an informed and voluntary consent. To ensure future compliance consents will be reviewed during monthly chart reviews completed by the Firetree compliance team. Any discrepancies identified by the Compliance Team will be communicated to the Facility Director, so the involved staff member can be promptly addressed and/or retrained to ensure continued compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every thirty days in four of seven applicable records.
Client #2 was admitted on February 17, 2026 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on April 20, 2026. The next treatment and rehabilitation plan update was due no later than May 20, 2026; however, this was not completed until May 21, 2026.
Client #4 was admitted on August 11, 2025 and was discharged on September 20, 2025. A treatment and rehabilitation plan was developed on August 18, 2025. The next treatment and rehabilitation plan update was due no later than September 18, 2025; however, this was not completed prior to discharge.
Client #5 was admitted on January 12, 2026 and was discharged on April 21, 2026. A treatment and rehabilitation plan update was completed on March 11, 2026. The next treatment and rehabilitation plan update was due no later than April 11, 2026; however, this was not completed prior to discharge.
Client #6 was admitted on September 23, 2025 and was discharged on March 18, 2026. A treatment and rehabilitation plan update was completed on October 31, 2025. The next treatment and rehabilitation plan update was due no later than December 1, 2025; however, this was not completed until December 15, 2025.
Additionally, the next treatment plan update was due to be completed no later than January 15, 2026; however, this was not completed until January 27, 2026.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 8/25/26, the clinical team will receive retraining on timely treatment plan development, including the required timeframes for initial completion, ongoing updates, and the documentation of active client participation in the treatment planning process. Training will include specific emphasis on regulatory requirements, clinical necessity, and the procedural workflow required to ensure all treatment plans are finalized and signed prior to their due dates.
To ensure future compliance, treatment plans will be monitored during monthly chart reviews completed by the Firetree compliance team to track timeliness and completion rates. Any discrepancies or delayed treatment plans identified by the Compliance Team will be communicated to the Facility Director, so the involved staff member can be promptly addressed and/or retrained to ensure continued compliance.
|