INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 30, 2025 through October 31, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Huntingdon Valley Comprehensive Treatment Center 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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709.28 (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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of eight client records reviewed.
Client #2 was admitted on May 31, 2017 and discharged on March 13, 2025. Client #2 was then readmitted on April 10, 2025, and was a current client at the time of the inspection. The facility failed to document a release of information for the funding source during the second treatment episode, and it was verified that billing had occurred.
This is a repeat citation from the October 18, 2024, October 13, 2023, January 13, 2022, and November 17, 2022, annual licensing renewal inspections.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
During the All Staff Monthly Team Meeting on 12/16/25, the Clinic Director will provide a review of the Intake/Admission process including Release of Information consents. A specific focus on releases will include the proper completion of releases, setting of term dates and the requirement to updated upon readmission to treatment.
Reviews of all newly admitted, or readmitted, patient charts will be conducted the week of each admission during regular Quality Record Reviews ensuring compliance. Reviews will be conducted by the Clinic Director and counselor designee(s).
Chart cited was updated on 10/31/25.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one applicable client record reviewed.
Client #5 was admitted on April 13, 2023 and was involuntarily discharged on December 2, 2024. There was no documentation in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.
This is a repeat citation from the October 18, 2024 annual licensing renewal inspection
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A review and training of the discharge process will be provided by the Clinic Director to all counseling staff during group supervision on 12/9/25.
The Clinic Director will review and document compliance to written notification having been provided to patient following the facilities decision to involuntarily terminate Pt's. treatment.
As most determinations are reviewed and decisions made during MDT, MDT notations will also be made therein to ensure compliance to §709.33(a).
Clinic Director and lead counselor will continue reviews of staff compliance following any discharges and during weekly individual and group supervision sessions.
Training for all staff to occur by 12/16/25
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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 narcotic treatment physician time sheets, the program failed to provide the required number of hours onsite for the physician based on the census for four 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 weeks of July28, 2025 through August 1, 2025 and August 11, 2025 through August 15, 2025, the patient census was 343. The narcotic treatment physician was required to provide one-third of the 34.3 hours, which equals 11.4 hours. The narcotic treatment physician provided 13 hours both weeks; however, the physician assistant did not work either week and therefore, the program was short 20.3 physician hours.
During the week of September 1, 2025 through September 5, 2025, the patient census was 346. The narcotic treatment physician was required to provide one-third of the 34.6 hours, which equals 11.5 hours. The narcotic treatment physician only provided 4 hours and therefore the program was short 7.5 hours.
During the week of September 15, 2025 through September 19, 2025, the patient census was 352. The narcotic treatment physician was required to provide one-third of the 35.2 hours, which equals 11.7 hours. The narcotic treatment physician provided 13 hours that week; however, the physician assistant only provided 15 hours and therefore the program was short 7.2 physician hours.
This is a repeat citation from the October 18, 2024 and October 13, 2023 annual licensing renewal inspections.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Clinic Director will meet with Medical Director on 12/15/2025 to review medical coverage in case of absence by either a doctor or Physician assistant. This meeting to occur by 12/15/25
Clinic Director will ensure that there is medical coverage during all vacations of PA and/or doctor, during any illness affecting medical coverage, or that an exception notification is filed to cover the period in question.
Clinic Director will work with Medical Director and Physician Assistant to coordinate vacations so that there is not a lapse in coverage. DIrector will work with Regional director to have coverage by "borrowing" from another site if needed. Director will also file an exception if needed
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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 the review of patient records, the program failed to transfer the patient file that included admission date, urinalysis reports or summary, exception requests and current status of the patient in one applicable patient records reviewed.
Patient #2 was admitted on May 31, 2017 and transferred to another program on March 13, 2025, before being readmitted on April 10, 2025. There was no documentation that the program transferred the patient ' s files during the March 13, 2025, transfer.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Plan of Correction:
During group supervision on 12/16/25, Clinic director will review transfer process for patients.
This review will include the addition to a transferring patient record that all transfer paperwork was sent along with ensuring that copies of all sent paperwork is scanned into the Pt. record/chart.
Clinic director will audit all transfer charts, following notification of patient's successful transfer, to ensure paperwork was sent and copies uploaded in the pt. record.
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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 program 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 applicable patient records reviewed.
Patient #3 was admitted on August 4, 2025, and was a current patient at the time of the inspection. The documentation indicated that the program did not notify the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient until October 24, 2025.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Clinic director to meet with intake team by 12/22/25 to review process for transfer patients.
This will include completing and sending the transfer acknowledgement in a timely manner.
The Clinic Director and counselor designees will conduct QRR audits of all intake charts weekly, confirming that all documentation is complete and timely.
Clinic Director will establish a schedule by 12/22/2025, that will ensure QRR audits of intake charts are completed weekly. The schedule will be presented during the meeting with intake and counseling staff members.
The Clinic Director will review a schedule with the Lead Counselor to ensure all discharge records are audited timely and completed by Clinic Director, Lead Counselor or designee. The schedule will be presented during the January 2026 all staff Monthly meeting
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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 program failed to document the results of annual physical examinations given by the narcotic treatment program, which included an annual reevaluation by the narcotic treatment physician in three applicable records reviewed.
Patient #1 was admitted on May 16, 2022 and was a current patient at the time of the inspection. An annual physical exam was documented in the patient record on March 29, 2023 and the next annual physical was due in March 2024; however, an annual physical exam was not documented in the record until June 12, 2025.
Patient #2 was admitted on May 31, 2017 and discharged on March 13, 2025. Patient #2 was then readmitted on April 10, 2025, and was a current client at the time of the inspection. The last annual physical exam documented in the patient record was for a physical exam that occurred on July 20, 2023, there was no physical documented for 2024 during the first treatment episode.
Patient #6 was admitted on September 22, 2021 and was a current patient at the time of the inspection. An annual physical exam was documented in the patient record on October 18, 2023, and the next annual physical exam was not documented in the record until March 11, 2025.
This is a repeat citation from the October 18, 2024, October 13, 2023, January 13, 2022, and November 17, 2022, annual licensing renewal inspections.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
During the monthly staff meeting on 1/13/26, the Clinic Director will review §715.23(b)(5).
The Clinic Director will develop a system to ensure nursing or other medical personnel are scheduling all Annual Medical Assessments/Physical Assessment two weeks prior to the due date listed within the patient record/EMR; such ensuring timely completion of the
required documentation.
Clinic and Medical Director, along with the Charge Nurse will meet on 12/22/25 to develop a schedule that more efficiently ensures Pt. physicals are completed timely, ensuring compliance.
The Clinic Director and Charge Nurse will review the EMR services due report weekly to ensure patients are scheduled for their annual physicals as well as those completed are done so timely and in compliance to §715.23(b)(5).
Compliance to same will also be monitored monthly by the Charge nurse via the Quality record review process with updates being provided to the Clinic Director and Medical Director.
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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 program failed to document an annual evaluation of each patient's status that was completed by the patient's counselor and was reviewed, dated and signed by the medical director in three applicable patient records reviewed.
Patient #1 was admitted on May 16, 2022 and was a current patient at the time of the inspection. An annual evaluation was not documented in the record at the time of the inspection.
Patient #2 was admitted on May 31, 2017 and discharged on March 13, 2025. Patient #2 was then readmitted on April 10, 2025, and was a current client at the time of the inspection. The last annual evaluation was documented in the record on May 4, 2023 for the first treatment episode.
Patient #4 was admitted on November 23, 2009 and was discharged on August 4, 2025. The last annual evaluation was documented in the record on November 20, 2022.
This is a repeat citation from the October 18, 2024, October 13, 2023, January 13, 2022 and November 17, 2022 annual licensing renewal inspections.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
A mandatory training for all staff will be provided by the Clinic Director on
12/16/25 to review documentation requirements surrounding the Annual Clinical Evaluations and the need to ensue such are scheduled two weeks prior to the due date in the EMR, thereby ensuring timely compliance.
The Clinic Director and Lead Counselor will review the services due report in the EMR weekly to ensure annual clinical evaluations are completed timely.
Clinic director will also review the signature pending area in the EMR weekly, to ensure services are being signed by all parties timely.
All missing evaluations to be completed by end of year. All cited charts to be completed by 12/31/25
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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 the review of the unusual incident log, the project failed to file a written unusual incident report with the Department within 48 hours following an incident with potential for negative community reaction which involved an event at the facility requiring the presence emergency services.
On December 24, 2025, and March 24, 2025, law enforcement responded to the facility. Written unusual incident reports were not filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinic Director will review §715.28 regulations surrounding the timely filing of all incident reports to Licensure.
A review of the §715.28 regulations will be conducted during the Clinic Directors supervision with the Regional Director, followed by a presentation of the regulation during the January 2026 Monthly Staff meeting.
The Clinic Director will reach out to the Regional Director and/or the Director of Compliance with any questions related to unusual incidents are reporting compliance.
Clinic Director will complete unusual incident report immediately following any incident at the clinic. A reminder will be placed on incident report binder that reflects the need to file an unusual incident report.
Unreported incidents to be reported to the Department by close of business 12/31/25
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in four of eight records reviewed.
Client #1 was admitted on May 16, 2022 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan update, documented in the client record on November 24, 2024, indicated that the client was to receive two hours of individual counseling sessions and three hours of group counseling sessions per month; however, there was only one hour of individual counseling session documented in the record for the months of December 2024, March 2025, May 2025, and July 2025, and no hours of individual counseling sessions for the months of January 2025, February 2025, June 2025 and August 2025. Additionally, there were no group sessions documented in the record for the months of December 2024, January 2025, February 2025, April 2025, May 2025, June 2025, July 2025, August 2025 and September 2025.
Client #2 was admitted on May 31, 2017 and discharged on March 13, 2025. Client #2 was then readmitted on April 10, 2025, and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan update, documented in the client record on June 16, 2025 for the second treatment episode, indicated that the client was to receive two hours of individual counseling sessions and three group counseling sessions per month; however, there were no individual counseling sessions documented for the month July 2025, only a half hours of individual counseling sessions documented for the month of September 2025, one hour of individual counseling sessions documented for the month of August 2025 and one and a half hours of individual counseling sessions documented for the month of June 2025. Additionally, there were no group sessions documented in the record for the months of June 2025, July 2025, August 2025 and September 2025.
Client #3 was admitted on August 4, 2025 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on August 12, 2025, indicated that the client was to receive six hours of counseling sessions per month; however, there was only one and a half hours documented in the client record for the month of September 2025.
Client #7 was admitted on November 11, 2024 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan update, documented in the client record on June 16, 2025, indicated that the client was to receive two hours of individual counseling sessions and three group counseling sessions per month; however, there were no individual counseling sessions documented for the months of February 2025, March 2025, April 2025, May 2025, June 2025, July 2025, August 2025 and October 2025, only a half hours of individual counseling sessions documented for the month of September 2025, one hour of individual counseling sessions documented for the month of August 2025 and one and a half hours of individual counseling sessions documented for the month of June 2025. Additionally, there were no group sessions documented in the record for the months of June 2025 and August 2025.
This is a repeat citation from the October 18, 2024 annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During group counseling supervision, the Clinic Director will review Treatment Plan Frequency and compliance expectations ensuring counseling services are provided.
During January Monthly staff meeting, a review of patient engagement protocols and expectations in adherence to 42 CFR Part 8 will be presented as a refresher, doing so to ensure staff are re-trained and re-educated on engagement.
This will include a review of treatment plan completion being done in a collaborative manner with patients, ensuring patient ownership of their recovery plan and compliance to same.
A review of proper documentation with regards to a no-show or facility rescheduled service will also be provided.
Clinic Director will review in individual supervision treatment plans with counselors to ensure that services are accurately reflected in the treatment plan. Senior counselor will assist with reviewing of treatment plans. Counselors will be asked to review all of their treatment plans and make corrections according to patient need and what patient can complete.
Training to occur by 1/12/26
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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 obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record was submitted and approved by the Department for the October 18, 2024, October 13, 2023, January 13, 2022, and November 17, 2022 annual licensing inspections. Missing voluntary consent forms were again found to be a deficiency in the October 30, 2025 through October 31, 2025, licensing inspection.
A plan of correction for providing the required number of hours onsite for the physician based on the census was submitted and approved by the Department for the October 18, 2024 and October 13, 2023 annual licensing inspections. Documenting sufficient physician hours was again found to be a deficiency in the October 30, 2025 through October 31, 2025, licensing inspection.
A plan of correction for documenting annual physical examinations was submitted and approved by the Department for the October 18, 2024, October 13, 2023, January 13, 2022 and November 17, 2022 annual licensing inspections. Completing annual physical examinations were again found to be a deficiency in the October 30, 2025 through October 31, 2025, licensing inspection.
A plan of correction for documenting annual clinical evaluations was submitted and approved by the Department for the October 18, 2024, October 13, 2023, January 13, 2022 and November 17, 2022 annual licensing inspections. Completing annual clinical evaluations were again found to be a deficiency in the October 30, 2025 through October 31, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director will ensure that during regular group supervision sessions and various monthly staff meetings a review of the filed plan of correction is completed.
Copies of the approved POC will be provided to all Mgmt. personnel to ensure accountability to areas requiring improvement and correction.
Discussion and review of the filed plan of correction will be added to the Clinic Directors' supervision session(s) with the Regional Director on a regular basis.
Clinic Director and Facility management personnel will follow up on POC regularly and during bi-weekly Mgmt. Team Meetings to ensure progress and corrections are underway made.
The Clinic Director will maintain records as to progress via meeting minutes, documentation reviews, etc and will be shared during supervision with all staff.
Clinic Director to keep a copy of POC readily available on their desk for easy access for review and continued focus, while assisting to ensure updates, changes and progress to corrections are being made.
Reviews of the POC will be conducted regularly and identified training needs from reviews will be scheduled and completed timely to ensure sustained compliance.
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