INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 4, 2025 through September 5, 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 DD/FIR was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 complete written fire drill record, which is to include the documentation of the amount of time it took for evacuation during a drill. At the time of the inspection, the fire drill logs for fire drills conducted in September 2024, October 2024, and November 2024 were all missing documentation of the amount of time it took to evacuate during the drill.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 of the drill, this will include the following: the date, time the amount of time it took for evacuation, the exit route used, the number of person in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detectors were operative.
a). Responsible Party:
Director of Safety and Security
b). Completion Date: 10/3/2025
The Senior Director of Operations will conduct a focus review of the fire drill logs cover sheets for three (3) months effective 10/32025 and "sign off" on the cover sheet ensuring that the cover sheet contains the date, time, the amount of time it took for evacuation, the exit route used, the number of person in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detectors were operative.
a). Responsible Party:
Senior Director of Operations
b). Completion Date: December 31, 2025
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in one of two applicable client records reviewed. The facility policy and procedure manual stated the emergency contact will be notified after a client is discharged from the facility against medical advice.Client #15 was admitted to the inpatient rehabilitation activity on July 24, 2025 and was discharged against medical advice on August 4, 2025. At the time of the inspection, there was no documentation in the record indicating the emergency contact was notified that the client was discharged against medical advice. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will provide and review the Emergency Contact Policy to respective staff during supervision and document accordingly.
a). Responsible Party:
Clinical Supervisor, Behavioral Specialists, and support staff (Community Recovery
Specialist, and Addiction Recovery Assistants)
b). Completion Date: 10/3/2025
Staff will document in the client's record attempt to notify emergency contact when a
client leaves the facility against medical advice.
a). Responsible Party:
Clinical Supervisor, Behavioral Specialists, and support staff (Community Recovery
Specialist, and Addiction Recovery Assistants)
b). Completion Date: 10/3/2025
Clinical Supervisor will conduct focus review of 90% or 5 charts of clients who leave the facility against medical advice during a 2-month period to ensure that the client emergency contact was notified.
a). Responsible Party:
Clinical Supervisor
b). Completion Date: 12/30/2025
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709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a recordkeeping system that allows for the identification of clients' admissions and discharges within a specific time.At the time of the inspection, facility staff were unable to efficiently produce a discharged client list for those clients who received medication-assisted treatment during their treatment episode at the facility. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Information Technology (IT) Department will create program specific report that will allow for the identification of clients' admissions and discharges within a specific time. The report for NTP clients will include information of clients' who received medication assisted treatment during their treatment episode.
a). Responsible Party:
Manager of Information Technology Department
b). Completion Date: October 30, 2025
The Senior Director of Operations will review and approve the report created by the IT Manager to ensure that it meets DDAP regulation 709.31 (b).
a). Responsible Party:
Senior Director of Operations
b). Completion Date: December 31, 2025
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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, as well as failing to ensure 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 five of six applicable patient records reviewed.Patient #1 was admitted on September 3, 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 the narcotic treatment physician. Patient #7 was admitted on September 2, 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 the narcotic treatment physician. Patient #16 was admitted on September 3, 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 the narcotic treatment physician. Patient #17 was admitted on September 1, 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 the narcotic treatment physician. Patient #18 was admitted on October 2, 2024 and was discharged on October 7, 2024. A certified registered nurse practitioner conducted the patient examination on October 2, 2024 and a narcotic treatment physician determined the initial dose and schedule on October 7, 2024; 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 order which will be signed by the narcotic treatment provider within 72 hours of verbal order.
a). Responsible Party:
CRNP and Physician
b). Completion Date: October 3, 2025
The narcotic treatment physician will consult with the provider (CRNP) who completed the history and physical prior to initiating an initial dose to confirm the client's clinical assessment and appropriateness for treatment.
a). Responsible Party:
CRNP and Narcotic Treatment Physician
b). Completion Date: October 3, 2025
Clinical Supervisor will conduct focus review of 90% or 10 charts of clients who are inducted during a 2-month period to ensure that the initial induction dose is prescribed by the narcotic treatment physician or that the CRNP contacted the narcotic treatment physician to review and consult with physician and obtain a verbal order
a). Responsible Party:
Clinical Supervisor
b). Completion Date: December 31, 2025
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