INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on February 17, 18, and 20, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, Inc. 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to collect feedback on completed trainings in four of five applicable records.
The facility policy and procedures state that feedback is to be collected for completed trainings, both internal and external.
The training year beginning January 1, 2025, through December 31, 2025, was reviewed.
Staff #1 was hired as project director on November 25, 2002, and still employed at the time of inspection.
Staff #3 was hired as counselor on August 2, 2023, and still employed at the time of inspection.
Staff #5 was hired as counselor on July 31, 2024, and still employed at the time of inspection.
Staff #6 was hired as counselor on August 22, 2024, and still employed at the time of inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The chart missing the information will be reviewed and the staff member will be provided with staff feedback forms. The staff member will also be instructed to complete a feedback form for all future trainings to be turned in to the project director. The project director is responsible to ensure implementation and monitoring of compliance with this regulation. |
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 employees received the minimum of at least 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment in one of seven records.
Staff #6 was hired as counselor on August 22, 2024, and still employed at the time of inspection. Staff #6 was due to have the communicable disease trainings no later than August 22, 2025. There was no documentation provided of the completion of the HIV/AIDS or TB/STD training as of the date of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director will meet with the clinical supervisor to review and discuss the staff training requirements. The clinical supervisor will be responsible to track all staff trainings and ensure that staff have completed the necessary trainings to comply with this regulation and ensure compliance in the future. |
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 have the counselor complete at least 25 clock hours of annual training in one of three applicable records.
Staff #6 was hired as counselor on August 22, 2024, and still employed at the time of inspection. Staff #6 documented 11 hours of training for the January 1, 2025- December 31, 2025 training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will meet with the clinical supervisor to review and discuss the staff training requirements. The clinical supervisor will be responsible to track all staff trainings and ensure that staff have completed the necessary trainings to comply with this regulation and ensure compliance in the future. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client which includes name of the person, agency, or organization to whom disclosure is made in one of seven records.
Client #1 was admitted on November 17, 2025, and discharged February 9, 2026. There was a release of information for an emergency contact signed November 17, 2025, that did not contain the name of the person, agency, or organization to whom disclosure is made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A staff meeting will be held to review releases of information and the legal requirements for the releases of information. Staff will be reminded that any release of information completed is required to be complete at the time of the patient's signature. Chart audits will be conducted to ensure future compliance with this regulation. The project director is responsible to ensure implementation and monitoring of compliance with this regulation. |
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 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 in one of two records.
Patient #1 was admitted on November 17, 2025, and discharged on February 9, 2026. There was no transfer paperwork sent at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director and the clinical supervisor will conduct a staff meeting to review and discuss the discharge policies and procedures. Particularly focusing on patient transfers. Discharge charts will be reviewed to ensure future compliance with this regulation. The project director is responsible to ensure implementation and monitoring of compliance with this regulation. |
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 facility failed to 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 in one of two applicable records.
Patient #1 was admitted on November 17, 2025, and discharged on February 9, 2026. A fax was sent to the transferring facility on November 17, 2025, and did not contain the date of the initial dose given to the patient.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director and the clinical supervisor will conduct a staff meeting to review and discuss the discharge policies and procedures. Particularly focusing on patient transfers. Discharge charts will be reviewed to ensure future compliance with this regulation. The project director is responsible to ensure implementation and monitoring of compliance with this regulation.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to include the results of an annual physical evaluation by the narcotic treatment physician in one of three applicable records.
Patient #7 was admitted on April 28, 2021, and discharged on August 7, 2025.
The annual physical evaluation was due no later than April 28, 2025; however, it was documented on May 19, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director and clinical supervisor will develop a tracking method to track all annual physicals for patients. Then a staff meeting will be held to remind staff of this regulation and review the tracking of patient's annual physicals to ensure that they are completed on or before the annual admission date. |
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 document follow-up information in two of three applicable records.
The facility's policy and procedures state follow-up contact is to be completed for all referred discharges within 7 days, and 90 days for all other discharges.
There was no follow-up information documented in client records #1 and #7.
Client #1 was admitted on November 17, 2025, and discharged (referred) on February 9, 2026.
Client #7 was admitted on April 28, 2021, and discharged (not referred) on August 7, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director and the clinical supervisor will conduct a staff meeting to review and discuss the discharge policies and procedures. Particularly focusing on patient transfers and 7 day follow up. Discharge charts will be reviewed to ensure future compliance with this regulation. The project director is responsible to ensure implementation and monitoring of compliance with this regulation.
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