INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on December 9, 2025 through December 10, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Family Center of Thomas Jefferson University (MATER) 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure an individual training plan was developed annually for each employee, with the plan being appropriate to that employee's skill level and developed with input from both the employee and the supervisor, in four of eight applicable personnel records reviewed.Employee # 2 was hired as the project director and facility director on June 12, 2023. The individual training plan was completed on December 2, 2024; however, there was no documentation indicating the plan was developed with input from the supervisor.Employee # 5 was hired as a counselor on October 10, 2023. There was no current individual training plan documented in the personnel record at the time of the inspection. The facility did provide the 2023 individual training plan; however, the plan was not updated for the current training year.Employee # 8 was hired as a counselor on December 24, 2024. The individual training plan was completed on January 9, 2025; however, there was no documentation indicating the plan was developed with input from the supervisor.Employee # 9 was hired as a counselor on May 27, 2025. The individual training plan was completed on June 2, 2025; however, there was no documentation indicating the plan was developed with input from the supervisor.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All individual training plans will be developed with input from the employee's supervisor. To ensure this happens consistently and timely, the agency administrative assistant who is responsible for gathering individual training plans will only accept individual training plans in cases when the supervisor's and the employees signatures are present. If the signature of the supervisor or employee is missing, the administrative assistant will inform the program director who then will ensure that a missing signature is obtained and documented.
The deficiencies noted during the audit will be corrected in the identified employee files by March, 2026. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training, during the facility's January 1, 2024 through December 31, 2024 training year, in one of three applicable personnel records reviewed.Employee # 4 was hired as a counselor on February 12, 2002. The personnel record documented 6.64 hours of training received during the training year reviewed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The agency administrative assistant will conduct a semi annual review of counselors' training hours to ensure timely recognition of whenever the counselor is on track for the required annual training hours. The administrative assistant will provide the program director with findings of the audit. The program director will then follow up with counselor's supervisor to ensure a plan is in place to attain the required annual training hours.
If there are extenuating circumstances preventing a counselor from attaining annual hours (e..g, FMLA) , the program director will request the DDAP for a waiver for that counselor. |
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 January 2025 through October 2025 fire drill logs, the facility failed to ensure their written fire drill records included documentation of the exit route used during the drill and the amount of time it took for evacuation. At the time of the inspection, the March 2025 fire drill log did not include documentation of the amount of time it took to evacuate during the drill and the October 2025 fire drill log did not include documentation of which exit route was used during the drill. These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The business manager will review the fire drill log for accuracy on a quarterly basis. |
711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance 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. Plans of correction for failing to ensure each patient received an annual evaluation, which is completed by the counselor and signed by the medical director, were submitted and approved by the Department for the January 11, 2023, December 13, 2023, and December 18, 2024 annual licensing inspections. Failing to ensure an annual clinical evaluation for each patient was completed was again found to be a deficiency in the December 9, 2025 through December 10, 2025 annual licensing inspection. Plans of correction for failing to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug were submitted and approved by the Department for the December 13, 2023 and December 18, 2024 annual licensing inspections. Failing to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug was again found to be a deficiency in the December 9, 2025 through December 10, 2025 annual licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a measure of QI/Compliance, the Clinical Program Director will conduct quarterly chart audits through 2026 to assess for compliance with the agency's stated plans of correction.
The findings from the audit will be documented, reviewed, and, if necessary, addressed, with appropriate department leads and supervisors, including the medical director. |
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 in two of three applicable patient records reviewed.Client # 2 was admitted on September 16, 2025 and was still active at the time of the inspection. At the time of the inspection, there was no face-to-face determination documented in the record prior to the administration of the patient's first dose. Client # 4 was admitted on November 25, 2025 and was still active at the time of the inspection. At the time of the inspection, there was no face-to-face determination documented in the record prior to the administration of the patient's first dose.This is a repeat citation from the December 13, 2023 and December 18, 2024 annual licensing renewal inspections. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The agency will only schedule intakes for new patients for days when a physician is available to complete make a face-to-face determination of whether the individual is physiological dependence on opioids.
The program director will conduct quarterly chart audits to monitor compliance with the stated regulation.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to complete an initial drug-screening urinalysis for each prospective patient in one of three patient records reviewed. Client # 4 was admitted on November 25, 2025 and was still active at the time of the inspection. There was no documentation in the patient record indicating an initial drug-screening urinalysis was completed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The care coordination manager who oversees the staff completing intakes will review the intake process with her team during their group supervision by February, 2026. This review will be documented in the group supervision note, to specifically reflect the process for collecting and documenting urine drug screens at intake.
During client intake, the Navigation team completes the intake and creates the file, then administers the UDS, ensures it is properly labeled, and hands it off to Nursing before closing the intake. Nursing verifies client identifiers, logs the UDS in the nursing log, processes the specimen, and submits it for lab pickup either the same day or the next day if after the cutoff time. At the end of each day, the Care Coordination Manager or Lead Navigator reviews the nursing log to confirm that a UDS was completed at intake and that it has been processed or is awaiting lab pickup, and follows up on any missing or incomplete items.
The action step being implemented is the Care Coordination Manager or Lead Navigator will cross check the nursing log as well as checking file for pending and processed UDS to confirm UDS was completed on all intakes. |
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 the results of an initial intake physical examination in the patient record in three of three applicable patient records reviewed.Client # 2 was admitted on September 16, 2025 and was still active at the time of the inspection. At the time of the inspection, there was no initial intake physical examination documented in the record. Client # 3 was admitted on September 15, 2025 and was still active at the time of the inspection. At the time of the inspection, there was no initial intake physical examination documented in the record. Client # 4 was admitted on November 25, 2025 and was still active at the time of the inspection. At the time of the inspection, there was no initial intake physical examination documented in the record. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All initial physical examinations will be documented in the clients chart.
If an emergency transfer has to occur that would necessitate admission to Family Center from another methadone provider of a patient with already established methadone regimen, the staff at Family Center will ensure there is current physical evaluation on file prior to admission.
As a measure of QI/Compliance, the Clinical Program Director will conduct quarterly chart audits through 2026 to assess for compliance with the agency's stated plans of correction.
The findings from the audit will be documented, reviewed, and, if necessary, addressed, with appropriate department leads and supervisors, including the medical director.
In addition, the Navigation Team is only scheduling new patient admissions for days when the medical doctor is available to do the physical examination.
Physical examinations for the charts reviewed during the audit will be completed by May 1, 2026 |
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 one applicable patient records reviewed. Patient # 1 was admitted on November 30, 2022 and was still active at the time of the inspection. The annual evaluation of the patient's status was completed by the counselor on December 6, 2025; however, there was no documentation indicating the evaluation was reviewed, dated, and signed by the medical director. This is a repeat citation from the December 13, 2023 and December 18, 2024 annual licensing renewal inspections. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
he annual evaluation signature process will be revised to make it mandatory for the medical director to sign the annual evaluation before the clinical supervisor can sign the form.
The clinical supervisor will get alerts throughout the ECR system indicating the their signature is required on the form. The clinical supervisor will only be able to sign the form if the medical director signed the form. If the medical director's signature is missing, the clinical director will request that the medical director signs the form. The program director will also be notified of the request and will follow up with the medical director to ensure the annual evaluation form is signed.
The deficiency for patient #1 will be corrected by 04/01/2026. |
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 unusual incident report logs and patient records, the narcotic treatment program failed to file a written unusual incident report with the Department within 48 hours following unusual incidents, which includes death or serious injury due to trauma, suicide, medication error or unusual circumstances and a complaint of patient physical abuse.At the time of the inspection, there was documentation indicating the facility was notified of the off-site death of a patient on August 5, 2025; however, there was no documentation that the incident was reported to the Department.This is a repeat citation from the December 18, 2024 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program director will add each reportable incident to the schedule of tasks to be completed within the required timeline of the incident. The schedule will trigger a reminder ensuring the incident report is submitted on time.
Clinical Program Director will keep the running list of reportable unusual incidents and will cross check the incident reporting database to ensure compliance with incident reporting requirements.
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711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) 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 a review of client records, the facility failed to ensure individual treatment and rehabilitation plans were completed and developed with the client and per facility policy in two of three applicable client records reviewed. The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within 30 days of admission. Client # 2 was admitted on September 16, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by October 16, 2025; however, the plan was not completed at the time of the inspection. Client # 3 was admitted on September 15, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by October 15, 2025; however, the plan was not completed until November 3, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will review the requirements for treatment plan development and updates with the counseling team during their group supervision by March, 2026. The review will include the process for documenting via document disclaimers the reason for treatment plan not being able to be developed within the required timeline (for example, the client missed scheduled sessions; client was hospitalized, etc). It is best practice and in alignment with patient driven care to develop treatment plans together with the client, and therefore treatment plans will be developed with the client's input. In instances when the client refuses to participate in treatment plan, such refusal will be documented on the treatment plan template in the client's chart.
The treatment plan for client # 2 was completed on 01/14/2026.
The Clinical Supervisor will conduct random selection audits on a quarterly basis through December 2026 to ensure the deficiency does not recur. Findings of the audit will be reviewed with counselors and program director. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of four applicable client records reviewed. Client # 1 was admitted on November 30, 2022 and was still active at the time of the inspection. A treatment plan update was completed on September 29, 2025 and the next update was due no later than November 29, 2025; however, the update was completed on December 4, 2025. Client # 6 was admitted on February 22, 2023 and was discharged on August 19, 2025. A treatment plan update was completed on January 28, 2025 and the next update was due no later than March 28, 2025; however, the update was completed on April 18, 2025. Client # 7 was admitted on May 30, 2016 and was discharged on August 5, 2025. A treatment plan update was completed on December 24, 2024 and the next update was due no later than February 24, 2025; however, the update was completed on March 3, 2025. Additionally, the next treatment plan update was due no later than May 3, 2025; however, the update was completed on May 16, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will review the requirements for treatment plan updates with the counseling team during their group supervision by March, 2026 to emphasize that the updates need to be completed every 60 days. The group supervision note will include the process for documenting instances when the client did not participate in the treatment plan update.While it is best practice to include the client the treatment plan update, in instances when the client is unavailable the update will still be completed by the counselor, and the client will review and sign the treatment plan update when they meet with the therapist . If the client refuses to sign the treatment plan updates, the counselor will note the refusal on the treatment plan update form. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in one of two applicable client records reviewed.Client # 6 was admitted on February 22, 2023 and was discharged on August 19, 2025. There was no documentation of follow-up information in the record at the time of the inspection.This is a repeat citation from the December 18, 2024 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 track all discharges and will run a report on a bi-weekly basis for discharged charts and identify any charts missing a discharge follow up, and inform the staff responsible for completing 30 day discharge follow-ups of the need to complete the follow up and document it.
Running reports bi-weekly will allow for timely identification of missing follow-ups and timely documentation of the follow -up attempts. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in three of seven client records reviewed. Client # 1 was admitted on November 30, 2022 and was still active at the time of the inspection. There was a release of information form to the funding source signed by the client on November 30, 2022 and expired on November 30, 2023. There was evidence of disclosures to the funding source after November 30, 2023; however, there was no consent to release information form signed by the client documented in the record prior to any disclosures after November 30, 2023. Client # 6 was admitted on February 22, 2023 and was discharged on August 19, 2025. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.Client # 7 was admitted on May 30, 2016 and was discharged on August 5, 2025. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor and the care coordination manager will complete a refresher training on confidentiality of client records with the counseling team and the patient navigation team. The training will include the process for obtaining a written consent from the client prior to releasing any protected information to external sources.
The refresher training will be documented in each team's supervision note. The refresher training will be completed by March, 2026.
The deficiency in client record (client #1) was corrected on 12/11/2025. The new release of information was signed and it is set to expire upon discharge from Family Center.
Clinical supervisor will conduct random audit of charts to specifically focus on compliance with confidentiality laws. The audit will be conducted on a quarterly basis through December, 2026. |
711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(ii) The specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on release of information forms in two of seven client records reviewed.Client # 2 was admitted on September 16, 2025 and was still active at the time of the inspection. The release of information form to a funding source was signed by the client on September 16, 2025; however, there was no specific information to be disclosed documented on the release form. Client # 4 was admitted on November 25, 2025 and was still active at the time of the inspection. The release of information form to a funding source was signed by the client on November, 2025; however, there was no specific information to be disclosed documented on the release form.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor and the clinical care coordinator will complete a refresher training confidentiality of client records with the counseling and navigation team by March, 2026. The training will include the process for completing the written release of information form and will cover all aspects including the specific information to be released.
The training will be documented in each team's supervision note.
Both deficiencies in clients' records for client #2 and #4 will be corrected by 03/01/2026.
Clinical supervisor already conducted a random chart audit and will continue with quarterly audits through December 2026 to monitor compliance with the requirement. |
711.93(c)(2)(iii) LICENSURE Purpose of Disclosure
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(iii) The purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on release of information forms in three of seven client records reviewed.Client # 2 was admitted on September 16, 2025 and was still active at the time of the inspection. A release of information form to a government agency was signed by the client on September 16, 2025; however, the there was no purpose of disclosure documented on the release form. Client # 3 was admitted on September 15, 2025 and was still active at the time of the inspection. The release of information form to a government agency was signed by the client on September 15, 2025; however, the there was no purpose of disclosure documented on the release form.Client # 4 was admitted on November 25, 2025 and was still active at the time of the inspection. The release of information form to a government agency was signed by the client on November, 2025; however, the there was no purpose of disclosure documented on the release form.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor and the clinical care coordinator will complete a refresher training confidentiality of client records with the counseling and navigation team by March, 2026. The training will include the process for completing the written release of information form and will cover all aspects including the purpose of the disclosure.
The training will be documented in each team's supervision note.
Deficiencies noted for client #2 and client #4 will be corrected by 03/01/2026
Clinical supervisor already conducted a random chart audit focusing and will continue with quarterly audits through December 2026 to monitor compliance with the regulation. |
711.96(a) LICENSURE Written Termination Notice
711.96. Notification of termination.
(a) The project director 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 a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, which is to also include the reason for termination, in one of one applicable client record reviewed.Client # 6 was admitted on February 22, 2023 and was administratively discharged on August 19, 2025. There was no documentation in the record indicating the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program director will update the discharge policy to outline specific steps staff needs to take for each type of discharge (e.g., administrative discharge, involuntary discharge, treatment completion, etc). The new discharge policy will also include a clearer process for informing clients about the discharge/transfer decisions. The policy will then be reviewed with direct care staff and their supervisors by March, 2026.
The clinical supervisor will review the revised discharge policy and the process counselors need to follow in a group supervision by April 2026. Group supervision will provide space for counselors to brainstorm on unique circumstances and will provide an opportunity for more in-depth understanding of the discharge process. This review will be documented in the counselor's group supervision note.
The clinical supervisor will conduct quarterly audits through December 2026 to review all administrative discharges/transfers and check compliance with the discharge policy specifically focusing on issuance of the termination letter. all findings will be reviewed with the clinical program director. |