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 23, 2026 through June 24, 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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705.28 (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 the facility's August 2025 through May 2026 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, the log for the fire drill conducted on May 29, 2026 had an email attached that was sent to facility staff on May 28, 2026. The email announced that the fire drill was going to occur the next day; thus the fire drill during the month of May 2026 was not unannounced.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, fire drills will be conducted as unannounced drills at least once per month in accordance with 28 Pa. Code § 705.28(d)(1). Staff will not be notified in advance of the date or time of any monthly fire drill. As of July 02, 2026, the Facility Director/designee reminded administrative and supervisory staff that fire drills must remain unannounced and that no advance email, verbal notice, calendar invitation, or other communication may be issued to staff prior to the drill. The fire drill log will continue to document the date, time, evacuation time, exit route used, number of persons in the facility, any problems encountered, and whether the fire alarm or smoke detector was operative. Ongoing compliance will be the responsibility of the Clinical Supervisor /designee through monthly review of the fire drill log to verify that each required monthly drill was completed and that no advance notice was provided. Any deviation from this requirement will be addressed immediately through staff retraining and corrective action as needed. |
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 facility's August 2025 through May 2026 fire drill logs, the facility failed to a written fire drill record, which is to include documentation of which exit route was used and whether the fire alarm or smoke detector is operative.
At the time of the inspection, the logs for the fire drills conducted on October 28, 2025, December 30, 2025, January 23, 2026, and May 29, 2026 were missing the exit route that was used during the fire drill. Additionally, the log for the fire drill conducted on May 29, 2026 was missing whether the fire alarm or smoke detector was operative during the fire drill.
This is a repeat citation from the July 29, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the facility will ensure that all monthly fire drill records are fully completed in accordance with 28 Pa. Code § 705.28(d)(4). The fire drill record will include, at minimum, the date and time of the drill, the amount of time required for evacuation, the exit route used, the number of persons in the facility at the time of the drill, any problems encountered, and whether the fire alarm or smoke detector was operative. By July 17, 2026, the Facility Director/designee will review the fire drill documentation checklist with applicable staff and reinforce that each required field must be completed at the time of the drill. The facility will update and use the revised fire drill log that clearly identifies all required documentation fields, including the exit route used and confirmation that the fire alarm or smoke detector was operative. Because this is a repeat citation, the Clinical Supervisor/designee will conduct a monthly review of each completed fire drill record to verify that all required elements are documented. Any incomplete fire drill record will be corrected immediately when possible, and staff responsible for the omission will receive additional retraining. Ongoing compliance will be monitored by the Clinical Supervisor/designee through monthly review of the fire drill log and corrective follow-up as needed. |
715.9(a)(3) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(3) Obtain a drug use history and current drug use status of the individual.
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Observations
Based on a review of patient records, the facility failed to obtain, prior to administration of an agent, a drug use history and current drug use status of the individual in one of two applicable patient records reviewed.
Patient # 7 was admitted on September 22, 2025 and was still active at the time of inspection. There was no documentation in the record indicating a drug use history and current status was obtained prior to the patient's first dose of medication on September 22, 2025. There was a drug use history completed by the counselor on September 26, 2025 documented in the record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the facility will ensure that a drug use history and current drug use status are obtained and documented prior to the administration of an agent for every applicable patient. As of July 17, 2026, nursing and clinical staff were re-educated on the requirement that this information must be obtained prior to medication administration and may not be delayed until a later counseling assessment. Ongoing compliance with the regulation will be the responsibility of the Nursing Director who will be responsible for ensuring that the nurse administering the first dose will verify with the prescriber that the drug use history and current drug use status have been documented prior to administration of the first dose. The Nursing Director/designee will review the records of for all new admissions to confirm that documentation is completed before administration of the first dose. Any identified omission will be addressed immediately through corrective follow-up, staff retraining, and review by the Nursing Director/designee.
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug prior to the administration of a maintenance agent in one of two applicable patient records reviewed.
Patient # 7 was admitted on September 22, 2025 and was still active at the time of inspection. There was no documentation in the record of an initial face-to-face meeting with the physician prior to the first dose of medication on September 22, 2025. The first documented face-to-face meeting was completed by the physician on October 6, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/6, the Facility Director has reminded the Narcotic Treatment Physician that the face-to-face determination of Opioid Use Disorder must be completed and documented prior to admission for maintenance treatment in accordance with 28 Pa. Code § 715.9(a)(4). The medication order will not be entered in the record until the physician's determination has been completed, documented in the patient record, and reviewed as part of the admission dosing approval process.
By July 17, 2026, medical, nursing, and admissions staff were re-educated on the requirement that the physician determination must be completed and signed by the physician prior to the first dose. Any additional information provided after induction will be recorded as an Addendum to the Physical Examination record.
The admission workflow will be updated to require verification of the signed physician's face-to-face determination before the first dose is approved or administered. The Nursing Director/designee will be responsible for ongoing compliance with the regulation by confirming that the required physician's signed documentation is present prior to administration of the first dose.
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715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of patient records, the facility failed to document an initial physical examination within the timeframe established in their policy and procedures manual, in one of two applicable records.
At the time of the inspection, the facility policy and procedure manual stated the initial physical examination shall be completed within 14 days after admission.
Patient # 6 was admitted on March 31, 2026 and was still active at the time of the inspection. An initial physical examination was due to be completed by April 14, 2026; however, the examination was completed on April 26, 2026
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the facility will ensure that each patient record includes documentation of the initial physical examination within 14 days after admission. Medical, nursing, and admissions staff were reminded of this requirement to prevent late completion.
The Nursing Director/designee will maintain a tracking process for all new admissions to identify the required physical examination due date and will review upcoming due dates with medical staff to ensure timely completion. If a patient misses or reschedules an appointment, the missed appointment and follow-up efforts will be documented in the patient record, and the examination will be rescheduled as soon as possible within the required timeframe whenever feasible. Ongoing compliance will be monitored by the Nursing Director/designee through review of all new admission records to verify that the initial physical examination is completed and documented within 14 days after admission.
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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 ensure an annual evaluation of the patient's status was completed by the patient's counselor and reviewed, dated, and signed by the medical director in one of five applicable patient records reviewed.
Patient # 4 was admitted on February 12, 2020 and was discharged on May 1, 2026. The annual evaluation of the patient's status was completed by the counselor on March 25, 2026; however, the evaluation was not signed by the medical director or mid-level practitioner.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the facility will ensure that when the annual evaluation of each patient's status is completed by the patient's counselor it will be reviewed, dated, and signed by the Medical Director in accordance with 28 Pa. Code § 715.23(c)(1-7).
As of July 17, 2026, counseling, medical, and supervisory staff were re-minded of the requirement that annual evaluations must be reviewed, dated, and signed by the Medical Director to comply with the regulation. The IT Director will route all Annual Reviews to the Medical Director with a tracking alert to review and sign all Annual Reviews.
Ongoing compliance will be monitored by the Clinical Supervisor/designee through monthly audits of patient records to verify that each annual evaluation has been reviewed, dated, and signed by the Medical Director. Audit findings and corrective actions will be documented and reviewed with facility Performance Improvement Committee to prevent recurrence.
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of the facility's unusual incident reports, the facility failed to notify the Department within 48 hours of an incident involving death or serious injury due to trauma, suicide, medication error or unusual circumstances.
The facility was notified of an off-site patient death on March 9, 2026; however, the unusual incident was not reported to the Department until March 16, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the facility will ensure that all unusual incidents requiring Department notification are reported to DDAP within 48 hours in accordance with 28 Pa. Code § 715.28(c)(1-5). As of 7/22/26, clinical, nursing and administrative staff were reminded by the Program Director that Unusual Incidents must be reported within the 48-hour reporting timeframe that begins when the facility becomes aware of the unusual incident. Staff were instructed to immediately notify the Facility Director/designee upon learning of any incident that may meet the reporting criteria. The Facility Director/designee will be responsible for determining whether an incident is reportable, completing or assigning completion of the written Unusual Incident Report, and ensuring submission to DDAP within the required timeframe. The facility will maintain an unusual incident record that documents the date and time the facility became aware of the incident, the type of incident, the date and time the report was submitted to DDAP. Ongoing compliance will be monitored by the Facility Director/designee through monthly review of the unusual incident records to verify timely reporting.
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