INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 25, 2025 through August 26, 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 Behavioral Wellness Center at Girard Goldman Clinic 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure clinical supervisors, who have not functioned for 2 years as a supervisor in the provision of clinical services, completed a Department-approved core curriculum in clinical supervision in one of three applicable personnel records reviewed.
Employee #3 was hired as a clinical supervisor on October 7, 2024 and did not have documented clinical supervision experience prior to being hired. There was no documentation, in the personnel record, indicating the employee completed a Department-approved clinical supervision core curriculum at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will ensure that all clinical supervisors will complete the department approved core curriculum in clinical supervision within 90 days of hire. The Executive Director will audit all new hire clinical supervisor HR files for compliance sixty days after the new hires start of employment. The clinical supervisor will complete the required hours of training by September 30, 2025, and the Executive Director will ensure the trainings are completed as required. |
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 2024 through December 2024 training year in one of ten applicable personnel records reviewed.
Employee #18 was hired as a counselor on May 8, 2023. The personnel record documented 7 hours of annual training during the review period.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will submit a waiver for any employee who fails to complete the required 25 hours of trainings due to FMLA. Clinical supervisors will review and track employee trainings quarterly to ensure they are on track for completing required hours of training. |
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 review of the August 2024 through July 2025 fire drill logs, the facility failed to maintain a written fire drill record, which is to include the documentation of the exit route used and the amount of time it took for evacuation.
At the time of the inspection, the fire drill logs for the fire drills conducted in December 2024, March 2025, and June 2025 were missing documentation of the amount of time it took to evacuate, and which exit route was used during the drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill logs will include a
cover sheet detailing the findings to include the following:
Exact time of evacuation.
Exit route used.
Number of persons.
Fire alarm or smoke detector operative or inoperative. The director of safety and security will be completing the logs which will be reviewed by the Sr. Manager of Operations. The director of safety and the executive director will ensure that the corrective action plan is implemented by September 25, 2025.
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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 a review of client records, the facility failed to obtain written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven applicable client records reviewed.
Client #4 was admitted on January 5, 2021 and was discharged on June 9, 2025. The release of information form to the funding source expired in 2023. There was documentation of disclosures to the funding source between the time the consent form expired and the client was discharged; however, there was no new consent to release information form signed by the client documented in the record prior to any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors will provide reeducation to clinical staff on written informed and voluntary consent for disclosure of information. Clinical Supervisors will audit 10% of admission charts for period of 3 months to ensure compliance. The corrective action will be completed by September 25, 2025, and The Executive Director will follow up with the clinical supervisors to ensure the training occurred by the aforementioned date. |
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 an administrative review, the narcotic treatment program failed to ensure the time provided by a physician assistant or a certified registered practitioner did not exceed two-thirds of the required narcotic treatment physician onsite time.
During the week of July 13, 2025, the patient census was 693. The total onsite narcotic treatment physician time was at least 69.3 hours, which means the physicians were required to provide at least 23 hours; however, there was documentation that the physicians completed 10 hours onsite and the remaining hours were completed by a physician assistant or certified registered nurse practitioner.
During the week of July 20, 2025, the patient census was 685. The total onsite narcotic treatment physician time was at least 68.5 hours, which means the physicians were required to provide at least 23 hours; however, there was documentation that the physicians completed 10 hours onsite and the remaining hours were completed by a physician assistant or certified registered nurse practitioner.
During the week of July 27, 2025, the patient census was 677. The total onsite narcotic treatment physician time was at least 67.7 hours, which means the physicians were required to provide at least 22 hours; however, there was documentation that the physicians completed 10 hours onsite and the remaining hours were completed by a physician assistant or certified registered nurse practitioner.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Goldman Clinic will schedule the narcotic treatment physician to be on site 25 hours weekly. Adjustments and increases in physician hours will occur as the census increases. The Executive Director will monitor the census and physician hours to ensure compliance. Monitoring of census will occur daily by the Executive Director. This adjustment in physician schedule was made on September 1, 2025. |
715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
Based on a review of patient records, the narcotic treatment program failed to obtain a personal history from the patient within the first week of admission in two of four applicable patient records reviewed.
Patient #2 was admitted to on May 7, 2025 and was active at the time of the inspection. The personal history was due to be completed by May 14, 2025; however, the complete personal history was documented in the record on May 20, 2025.
Patient #3 was admitted to on June 10, 2025 and was active at the time of the inspection. The personal history was due to be completed by June 17, 2025; however, the complete personal history was not documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy was revised to note that the biopsychosocial history must be completed within seven days of admission. All Goldman staff were notified of the policy change effective September 5, 2025. The clinical supervisors will audit 10% of new admission charts for three months to ensure that the biopsychosocial history is completed per regulation. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document informed and voluntary consent in the patient record prior to the administration of an agent in one of four applicable patient records reviewed.
Patient #6 was admitted on February 5, 2025 and was discharged on July 18, 2025. There was no documentation of informed and voluntary consent in the record prior to the administration of a narcotic agent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director will provide reeducation to providers to document informed and voluntary consent in the participants record prior to the administration of a narcotic agent. Clinical Supervisors will audit 10% of admission charts for a period of three months to ensure compliance. The executive director will ensure the corrective action is implemented by September 25, 2025. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility failed to ensure the narcotic treatment physician determined the proper dosage level for a patient and if the narcotic treatment physician determining the initial dose was not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient's initial dose and schedule in two of four applicable patient records reviewed.
Patient #1 was admitted on January 24, 2025 and was active at the time of the inspection. The initial medication dose was determined and ordered by a certified registered nurse practitioner, not a narcotic treatment physician.
Patient #6 was admitted on February 5, 2025 and was discharged on July 18, 2025. A certified registered nurse practitioner conducted the patient examination on February 5, 2025. A narcotic treatment physician determined the initial dose and schedule on February 5, 2025; however, there was no consultation between the certified registered nurse practitioner and physician documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The initial induction dose will be prescribed by the narcotic treatment physician. If the narcotic treatment physician is not initiating the initial dose the CRNP will contact the narcotic treatment physician to review and consult with physician and if appropriate obtain a verbal telephone order which will be signed off on by the narcotic treatment provider within 72 hours of verbal order.
The prescribing physician will consult with the provider/physician who completed the history and physical prior to initiating an initial dose to confirm the patient's clinical assessment and appropriateness for treatment.
The medical director will ensure the corrective action plan is implemented on or before September 25, 2025 |
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 a review of patient records, the narcotic treatment program failed to transfer patient files, which is to include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, to the receiving narcotic treatment program in one of one applicable patient records reviewed.
Patient #7 was admitted on May 24, 2024 and was transferred out on December 17, 2024. There was no documentation in the record indicating the receiving narcotic treatment program was transferred the required patient files.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors will provide reeducation on patient transfers. The policy on patient transfers will be redistributed to the clinical staff for review and reeducation. Clinical supervisors will review all patient transfers for a period of three months to ensure compliance. The executive director will ensure that the clinical supervisors have reeducation by September 25, 2025. |
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 narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in three of five applicable patient records reviewed.
Patient #3 was admitted on June 10, 2025 and was active at the time of the inspection. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient #6 was admitted on February 5, 2025 and was discharged on July 18, 2025. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient #7 was admitted on May 24, 2024 and was discharged on December 17, 2024. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors will review and reeducate admissions coordinators on transfer policy and procedures. The clinical supervisor in behavioral intake will review all patients being transferred to Goldman Clinic to ensure that the transferring narcotic treatment program are notified of admission, admission date and date of initial dose. All transferred charts will be audited for three months to ensure compliance. The executive director will ensure the corrective action is implemented by September 25, 2025. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) 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 seven applicable client records reviewed.
Client #1 was admitted on January 14, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 4, 2025, and the first update was due no later than April 5, 2025; however, the update was completed on April 29, 2025.
Client #3 was admitted on June 10, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 10, 2025, and the first update was due no later than August 10, 2025; however, the update was not completed at the time of the inspection.
Client #7 was admitted on May 24, 2024 and was discharged on December 17, 2024. A treatment plan update was completed on August 21, 2024 and the next update was due no later than October 21, 2024; however, the update was completed on November 25, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors will reeducate counselors on documentation timelines for treatment plans to be submitted every 60 days according to policy and regulations. Clinical Supervisors will audit 20% of each counselor's caseload to ensure compliance. Charts will be audited for three months. The executive director will ensure corrective action is implemented by September 25, 2025. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) 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 documentation of follow-up information, in two of three applicable client records reviewed.
Client #6 was admitted February 5, 2025 and was discharged on July 18, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client #7 was admitted May 24, 2024 and was discharged on December 17, 2024. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Post discharge follow-up responsibilities have been reassigned to the case managers. The case managers will reach out to the participant 7 days after discharge and 30 days after discharge per policy. The policy was reviewed with the case managers on September 10th along with training. The Clinical Supervisors will audit 20% of discharged charts for three months to ensure compliance. The executive director implemented the corrective action plan on September 10, 2025, and will continue to monitor for compliance. |