INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on August 18, 2026 through August 19, 2026 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:
|
Plan of Correction
|
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a physical plant inspection, the facility failed to ensure all facility heaters were permanently mounted or installed.
At the time of the inspection, conducted on August 19, 2026, there was a portable space heater located in counselor office #224 and another portable space heater located in counselor office #230.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The portable space heaters identified in offices #224 and #230 were immediately removed from the facility. Staff were reminded that portable space heaters are prohibited and may not be brought into or used within the facility. Management will conduct a review of all offices and work areas to ensure that no additional portable heaters are present. This requirement will also be reinforced with staff during the next staff meeting and through written communication. Supervisory and management staff will monitor for continued compliance during routine environmental rounds. Any portable heater identified will be removed immediately and the staff will be counseled regarding the facility requirement.
Responsible Person: Executive Director and/or Office Manager |
715.9(a)(3) 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:
(3) Obtain a drug use history and current drug use status of the individual.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to obtain a drug use history and current drug use status of the individual prior to the administration of an agent in one of four applicable patient records reviewed.
Patient # 6 was admitted on November 26, 2025 and was discharged on June 2, 2026. The drug use history and current drug use status of the individual was to be completed prior to the patient's initial dose on November 26, 2025; however, the history and current status was not completed until December 12, 2025.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
All staff responsible for admission and intake process will be re-educated regarding the requirement that a patient's drug use history and current drug use status must be obtained and documented prior to the administration of the initial medication. The intake process will be reviewed to ensure that completion of the drug use history and current drug use status is verified before the patient proceeds to medication administration. The Director of the Behavioral Intake Unit will conduct routine audits of newly admitted patient records to confirm timely completion and documentation. Any deficiencies identified through monitoring will be addressed immediately with the responsible staff member and corrected as appropriate. Responsible Person: Director of Behavioral Intake Unit and Nurse Practitioner. |
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.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to secure a personal history from the patient within the first week of admission in two of four applicable patient records reviewed.
Patient # 6 was admitted on November 26, 2025 and was discharged on June 2, 2026. The personal history was to be completed within the first week of admission; however, the history was not completed until April 28, 2026.
Patient # 7 was admitted on January 23, 2026 and was discharged on July 1, 2026. The personal history was to be completed within the first week of admission; however, the history was not completed until February 12, 2026.
This is a repeat citation from the August 26, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective immediately, The Executive Director and Clinical Supervisors will ensure that personal history is completed and incorporated into the patient record within the first week of admission in accordance with the regulation. All clinical staff responsible for completing admission documentation will be re-educated regarding the regulatory requirement and the agency expectation that the personal history be completed within seven days of admission. To prevent recurrence, Clinical Supervisors will review all new admissions weekly to verify completion of the personal history within the required timeframe. Any outstanding documentation identified during the review will be addressed immediately with the assigned clinician. The Clinical Supervisors will conduct monthly audits of newly admitted patient records for a minimum of three months to ensure continued compliance. Audit findings will be reviewed by The Executive Director, and any deficiencies will result in immediate corrective action and additional staff education as indicated.
Responsible Persons: Clinical Supervisor and Executive Director |
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.
|
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 two applicable patient records reviewed.
Patient # 6 was admitted on November 26, 2025 and was discharged on June 2, 2026. There was documentation that a certified registered nurse practitioner conducted the patient examination on December 12, 2025; however, a different practitioner determined the initial dose and schedule of methadone on November 26, 2025 and there was no documentation in the record indicating a consultation occurred between the two practitioners prior to the initial dose and schedule.
Patient # 7 was admitted on January 23, 2026 and was discharged on July 1, 2026. There was documentation that a certified registered nurse practitioner conducted the patient examination on January 23, 2026; however, a different practitioner determined the initial dose and schedule of methadone on January 23, 2026; and there was no documentation in the record indicating a consultation occurred between the two practitioners prior to the initial dose and schedule.
This is a repeat citation from the August 26, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective immediately, when the practitioner determining the initial methadone dose and schedule is not the same practitioner who completed the patient examination, documented consultation between the two practitioners must occur prior to the initial dose and schedule being determined. The consultation will be documented in the patient's electronic medical record and will include the date of consultation and confirmation that the patient's examination findings and initial medication dosing plan were reviewed. All prescribing practitioners will be re-educated regarding the requirement of 715.15(b) and the facility's expectation for documentation of practitioner collaboration. To ensure ongoing compliance, the Lead Nurse Practitioner or designee will review 100% of new OTP admissions for 90 days to verify that the practitioner completing the examination and the practitioner establishing the initial dose are either the same practitioner or, when different, that the required consultation is documented prior to dosing. Any identified deficiencies will be corrected immediately and addressed directly with the responsible practitioner. Following the 90-day monitoring period, compliance will be incorporated into the facility's ongoing quarterly medical record review process.
Responsible Persons: Medical Director, Lead Nurse Practitioner, Executive Director. |
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.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to 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 in two of two applicable patient records reviewed.
Patient # 6 was admitted on November 26, 2025 and was transferred to another narcotic treatment program on June 2, 2026. The patient record did not document that the receiving narcotic treatment program was notified of the date of admission of the patient, medical and psychosocial summaries, and urinalysis reports or summary.
This is a repeat citation from the August 26, 2025 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective immediately, all patient transfers to another narcotic treatment program will include the required transfer information including the patient's admission date, medical and psychosocial summaries, current dose, urinalysis reports or summary, exception request, current status and written patient consent. A standardized transfer checklist will be developed and implemented for all OTP transfers to ensure all required documentation is included prior to transmission to the receiving program. Staff responsible for coordinating transfers will document in the electronic medical record the date of transfer information was sent and the receiving program to which it was provided.
Clinical staff will be re-educated regarding the requirements of 715.20(1) and the facility's transfer policy and procedure.
To ensure ongoing compliance, Clinical Supervisors will review 100% of OTP transfers for 90 days to verify that all required documents were transmitted and appropriately documented in the patient record. Any identified deficiencies will be corrected immediately and addressed with responsible staff member. Following the 90-day monitoring period, transfer documentation will be incorporated into the facility's ongoing quarterly record review process.
Responsible Persons: Clinical Supervisor, Executive Director
|
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.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to ensure each patient file included documentation of the results of an initial intake physical examination in one of four applicable patient records reviewed.
The facility's policy and procedure manual stated that for methadone administration, the program physician and/or medical director will complete the physical evaluation and then admits the participant.
Patient # 6 was admitted on November 26, 2025 and was discharged on June 2, 2026. The initial physical examination was not completed and documented until December 12, 2025.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility's policy and procedure regarding admission and physical examinations will be revised to accurately reflect current regulatory requirements including the required timeframe for completion of the initial physical examination. Medical staff will be educated on the revised policy and documentation expectations. Effective with new admissions, the medical team will ensure that the initial physical examination is completed and documented within the required regulatory time frame.
Monitoring: To ensure compliance, the NP or designee will conduct monthly audits of newly admitted patient records for three months to verify that initial physical examinations are completed and documented within the required timeframe. Audit findings will be reviewed by the Executive Director and PI Department. Any identified noncompliance will be addressed through immediate corrective action and additional education ad indicated.
Responsible Persons: Medical Director, Nurse Practitioner, Executive Director and Performance Improvement Personnel.
|
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.
|
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 was reviewed, dated, and signed by the medical director in three of three applicable patient records reviewed.
Patient # 1 was admitted on May 16, 2025 and was active at the time of inspection. The annual evaluation of the patient's status was completed by the counselor on May 20, 2026; however, the evaluation was not reviewed, dated, and signed by any facility medical practitioner.
Patient # 2 was admitted on April 15, 2022 and was active at the time of inspection. The annual evaluation of the patient's status was completed by the counselor on April 22, 2026; however, the evaluation was not reviewed, dated, and signed by any facility medical practitioner.
Patient # 3 was admitted on February 15, 2024 and was active at the time of inspection. The annual evaluation of the patient's status was completed by the counselor on March 6, 2026; however, the evaluation was not reviewed, dated, and signed by any facility medical practitioner.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective immediately, counselors will continue to complete annual evaluations based on the patient's admission date and in accordance with regulatory requirements. Upon completion, the annual evaluation will be forwarded to the Medical Director for review, date, and signature.
Clinical supervisors will provide education to counseling and timely completion of the annual evaluation. The Medical Director will be educated regarding the requirements to review, date and sign each completed evaluation.
Monitoring: Clinical Supervisors will monitor upcoming annual evaluation due dates through monthly chart reviews. Completed annual evaluations will be reviewed to verify that all required areas are addressed and that the Medical Director has reviewed, dated, and signed the evaluation. Compliance will be monitored monthly for three months. Any identified noncompliance will be addressed immediately with the responsible staff member.
Responsible Persons: Executive Director, Medical Director, Clinical Supervisors. |
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:
|
Observations
Based on a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client in four of four applicable client records reviewed.
The facility's policy and procedure manual stated that the comprehensive treatment plan will be completed within 7 days of the client's admission.
Client # 4 was admitted on November 21, 2025 and was discharged on July 29, 2026. The individual treatment and rehabilitation plan was due to be completed no later than November 28, 2025; however, the plan was not completed until December 18, 2025.
Client # 5 was admitted on January 5, 2026 and was discharged on July 29, 2026. The individual treatment and rehabilitation plan was due to be completed no later than January 12, 2026; however, the plan was not completed until April 9, 2026.
Client # 6 was admitted on November 26, 2025 and was discharged on June 2, 2026. The individual treatment and rehabilitation plan was due to be completed no later than December 3, 2025; however, the plan was not completed until April 28, 2026.
Client # 7 was admitted on January 23, 2026 and was discharged on July 1, 2026. The individual treatment and rehabilitation plan was due to be completed no later than January 30, 2026; however, the plan was not completed until May 7, 2026.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective immediately, the facility will ensure that an individual treatment and rehabilitation plan is developed with each client within seven (7) days of admission in accordance with facility policy.
Clinical supervisors will monitor newly admitted clients to ensure treatment plans are completed within the required timeframe. Counselors will be reminded of the requirement during clinical supervision and staff meetings, and supervisory oversight will include review of upcoming treatment plan due dates.
The clinical supervisor will conduct monthly monitoring of treatment plan compliance for a period of three (3) months. Any identified noncompliance will be addressed promptly with the responsible staff member through supervision and, when indicated, additional training or corrective action. The Executive Director will maintain oversight of the corrective action process to ensure ongoing compliance.
Responsible Persons: Executive Director and Clinical Supervisor |
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.
|
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 five of five applicable client records reviewed.
Client # 1 was admitted on May 16, 2025 and was active at the time of the inspection. A treatment plan update was completed on April 7, 2026 and the next update was due no later than June 7, 2026; however, the update was not completed until June 12, 2026.
Client # 2 was admitted on April 15, 2022 and was active at the time of the inspection. A treatment plan update was completed on November 24, 2025, and the next update was due no later than January 24, 2026; however, the update was not completed until February 5, 2026. Additionally, a treatment plan update was completed on April 8, 2026, and the next update was due no later than June 8, 2026; however, the update was not completed until June 29, 2026.
Client # 3 was admitted on February 15, 2024 and was active at the time of the inspection. A treatment plan update was completed on March 6, 2026, and the next update was due no later than May 6, 2026; however, the update was not completed until May 20, 2026.
Client # 4 was admitted on November 21, 2025 and was discharged on July 29, 2026. The individual treatment and rehabilitation plan was completed on December 18, 2025, and the first update was due no later than February 18, 2026; however, the update was not completed until February 27, 2026.
Client # 5 was admitted on January 5, 2026 and was discharged on July 29, 2026. The individual treatment and rehabilitation plan was completed on April 9, 2026, and the first update was due no later than June 9, 2026; however, the update was not completed until June 12, 2026.
This is a repeat citation from the August 26, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility will ensure that all treatment and rehabilitation plans are reviewed and updated at least every 60 days in accordance with the regulation.
Effective immediately, clinical staff will be responsible for monitoring treatment plan due dates and completing treatment plan updates within the required regulatory timeframe. Supervisory staff will reinforce the 60-day requirement with all applicable clinical staff and will monitor compliance through routine review of upcoming treatment plan due dates.
To prevent recurrence, supervisors will review treatment plan due dates during ongoing clinical supervision and will utilize the electronic health record and/or internal tracking systems to identify treatment plans approaching their due dates. Staff will be notified of upcoming treatment plan deadlines sufficiently in advance to allow completion within the required timeframe.
Clinical Supervisors will conduct monthly monitoring of treatment plan compliance. Any treatment plan identified as approaching its due date will be addressed with assigned clinician prior to expiration. Any identified noncompliance will result in immediate supervisory follow-up and corrective action, as appropriate.
The Executive Director will maintain oversight of the monitoring process to ensure continued compliance with the 60-day treatment plan review update and update requirement.
Responsible Persons: Clinical Supervisor and Executive Director |