INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on June 10-11, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Directions Healthcare, LLC 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that one employee received the minimum of at least 6 hours of HIV/AIDS training within the first year of employment in one of three applicable records.
Staff #10 was hired as a counselor on August 21, 2023 and still employed. Staff #10 was due to have the communicable disease trainings no later than August 21, 2024 but did not complete until January 21, 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On all new hires a HIV/AIDS/communicable disease training requirement box on the front page of their personnel file if they had previous or need. This is effective starting 6/18/2025 for all new hires. The project director will ensure that all therapists' have within one year of hire and that all others have within 2 years of hire. |
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 facility failed to document transfer of patient files to the patient's new treatment facility in one out of two applicable records.
Patient #4 was admitted on June 3, 2024 and transferred to another facility on April 23, 2025. At the time of the inspection, there was no documentation that the facility transferred the required patient files.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director will develop a discharge/ transfer checklist and be responsible for ensuring that all discharge records are transferred to the patient's new treatment center. All staff will be trained on how to complete the checklist in the 6/24/2025 staff meeting. The checklist will be signed off by either the Clinical Director and or lead counselors. The clinical supervisor shall monitor this by random chart review. |