INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on April 21, 2026, 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 #5 was admitted on October 27, 2025, and discharged on February 17, 2026. The client record documented communication with another treatment provider on February 9, 2026; however, there was no documentation that an informed and voluntary consent for disclosure of information was obtained from the client.
This is a repeat citation from the October 31, 2025, 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
Plan of Correction:
Patient had given verbal consent for clinic to send transfer paperwork as she was not able to return to the clinic.
Failure to document verbal consent was addressed at staff meeting on 5/7/26. This meeting also included review of the consent process and properly completing and ensuring such is evident with the Pt. record.
CD/CS will follow up timely on all transfer and or new admission ROI completions and conduct weekly chart reviews for same with all staff.
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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 narcotic treatment physician time sheets, the program failed to provide the required number of hours onsite for four of sixteen weeks reviewed. A narcotic treatment physician must provide one-third of the required hours, with a physician's assistant or certified registered nurse practitioner providing the remaining two-thirds of the required hours.
During the weeks of February 15, 2026 through February 21, 2026, and March 8, 2026 through March 14, 2026, the patient census was 364. The narcotic treatment physician was required to provide one-third of the 36.4 hours, which equals 12.13 hours. The narcotic treatment physician did provide 13 hours both weeks; however, the physician assistant only worked 17.5 hours both weeks and therefore, the program was short 5.9 physician hours.
This is a repeat citation from the October 31, 2025, 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
Plan of Correction:
Clinic Director will meet with the Medical Director on 5/20/26 to review the process for medical coverage and establish a sustainable schedule for each month/week to ensure ample coverage is met based on patient census and need; ensuring coverage is in place when Physician or Practitioner may be off or absent.
Clinic Director to review time sheets ahead of each weekly to ensure there is medical coverage during periods when medical practitioners take time off or other variables impact medical coverage.
Additionally, CD/MD will ensure to file timely exception notifications in the event such proves necessary.
A review of staffing needs will be conducted by the CD and MD and proposed adjustments, if deemed appropriate, will be presented to the RD for review/consideration.
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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 regards to the death or serious injury due to trauma, suicide, medication error or unusual circumstances.
On February 13, 2026, the program was notified of a client ' s death. A written unusual incident report was not filed with the Department.
This is a repeat citation from the October 31, 2025, annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Clinic Director will review §715.28 regulations surrounding the timely filing of all incident reports to Licensure and review such during weekly Management Team and Monthly Team meetings to ensure all staff members are aware of the need to ensure timely filing for such items.
The noted February 13th incident was drafted timely yet was not submitted due to operational oversight; it was since filed albeit beyond the regulation time frame.
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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 the review of client records and the project ' s policies and procedures, the project failed to develop an individual treatment and rehabilitation plan with a client within four weeks of admission, in three of seven applicable records reviewed.
Client #1 was admitted on February 3, 2026, and was active at the time of the inspection. A preliminary treatment plan was developed on February 6, 2026, and per the project ' s procedures the comprehensive treatment and rehabilitation plan was to be developed with the client no later than March 6, 2026; however, a comprehensive treatment plan had not been documented in record at the time of the inspection.
Client #2 was admitted March 5, 2026, and was active at the time of the inspection. A preliminary treatment plan was developed on March 5, 2026, and per the project ' s procedures the comprehensive treatment plan was to be developed with the client no later than April 5, 2026; however, a comprehensive treatment plan had not been documented in record at the time of the inspection.
Client #5 was admitted on October 27, 2025 and discharged on February 17, 2026. A preliminary treatment plan was developed on October 27, 2025, and per the project ' s procedures the comprehensive treatment plan was to be developed with the client no later than October 27, 2025; however, a comprehensive treatment plan was not documented in record until December 30, 2025.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction:
During the Clinical Team Staff meeting on 5/7/26, timeliness of Tx plan completion by staff and other documentation was reviewed.
Staff was reminded and re-educated on the dates for all paperwork, including treatment plans and the team reviewed time management and administrative burden resolution plans to be implemented to ensure compliance to same.
Pts #1 and #2 are assigned to a newly hired counselor and time lines are being reviewed during weekly supervision with both the CD and lead counselor.
Ongoing supervision and meetings are in place for all counseling staff as well to ensure continued compliance to §709.92(a).
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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 two of six applicable records reviewed.
Client #6 was admitted on December 22, 2025, and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on January 6, 2026 indicated that the client was to receive one hour of individual counseling sessions and five hours of group counseling sessions per month; however, there were no individual and group counseling sessions documented in the record for the months of February 2026 and March 2026.
Client #7 was admitted on November 12, 2024, and was discharged on March 17, 2026. A comprehensive treatment and rehabilitation plan update, documented in the client record on November 18, 2025, indicated that the client was to receive two hours of individual counseling sessions and three hours of group counseling sessions per month; however, there were no individual or group counseling sessions documented in the record for the month of February 2026.
This is a repeat citation from the October 31, 2025, and October 18, 2024, annual licensing renewal inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction:
During clinical staff team meeting on 5/7/26, Clinic Director reviewed Treatment Plan Frequency and compliance expectations along with reviewing the necessity to ensure counseling services are provided as noted in the type and frequency portion of the Tx plan, or to ensure appropriate documentation is recorded for all no-show appt.'s held.
To the latter, it was reviewed on the use of Hard Holds via the EHR system to ensure Pt.'s reschedule within a reasonable time to their missed appt.
Also reviewed the use of the scheduler in the EHR to assist and help documenting scheduled appointments.
During 5/29/26 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.
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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 31, 2025, 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 April 21, 2026, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Clinic Director meets with clinical staff for group and individual supervision sessions weekly to review Pt. care needs and filed plan(s) of correction. Such is also presented and discussed with all staff during Monthly staff meetings to ensure continued oversight and adherence to improvement efforts are in place and completed.
Copies of the approved POC were provided to all Mgmt. personnel to ensure accountability to areas requiring improvement and correction.
CD will implement weekly Mgmt. Team meetings beginning on 5/18/26 to review progress, updates and modifications or trainings required to ensure compliance.
Areas of improvement and correction are also being reviewed in individual supervision will all staff.
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 along with the RD's presentation and trainings offered to the Team regarding Time mgmt. and Pt. care expectations/initiatives.
The Clinic Director continues to maintain records as to progress via meeting minutes, documentation reviews, etc and shares during supervision with all staff.
Clinic Director has a copy of POC readily available 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 are conducted regularly and identified training needs from reviews will be scheduled and completed timely to ensure sustained compliance.
Annual physical examinations are under a working plan with the Medical Director and all medical staff to ensure timely completions. These are to be officially up to date by June 30, 2026
Completion Date:
Status:
No POC
Date:
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