INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring conducted on July 28, 2025 through July 29, 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 Treatment Services 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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705.28 (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 a review of the facility's January 2025 through July 2025 fire drill records, the facility failed to maintain a complete written fire drill record, which is to include the documentation of which exit route is used.
The record for the fire drill conducted on July 2, 2025 was missing which exit route was used during the fire drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 09/05/2025, the Program Director will remind staff who conduct the monthly fire drill to document the specific exit used during the fire drill. Staff will also be reminded that when an instruction to use the "nearest exit" is issued, the staff member will document all exits used by staff members. Ongoing compliance will be the responsibility of the Facility Manager through random review of the fire drill documentation logs. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document the verification that an individual had reached 18 years of age, prior to the administration of a narcotic agent in one of thirteen patient records reviewed.
Patient #4 was admitted on October 2, 2024 and was active at the time of the inspection. There was no documentation indicating and verifying the age of the patient prior to the patient ' s first dose on October 3, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/25/2025, the Program Director reminded Intake staff that a copy of the client document providing proof of identity, age and address, will be scanned and entered in the medical record prior to the administration of the first dose of medication. The Nursing Director will be responsible for ensuring ongoing compliance with the regulation by verifying that a copy of the proof of the client's identity, age and address, has been entered in the EMR prior to the administration of the first dose. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document the verification of an individual ' s identity, which is to include their name, address, and date of birth, emergency contact, and other identifying data, prior to the administration of a narcotic agent in one of thirteen patient records reviewed.
Patient #4 was admitted on October 2, 2024 and was discharged on March 22, 2025. There was no documentation indicating and verifying the age of the patient prior to the patient ' s first dose on October 3, 2024.
Patient #13 was admitted on April 29, 2025 and was discharged on May 29, 2025. There was no verification of the patient ' s emergency contact documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/05/2025, the Clinical Supervisor will remind Intake staff to scan and enter a copy of the proof of identity provided by the client into the EMR. The Clinical Supervisor reminded staff that identity cards must include a photograph, name, date of birth and current address. The Nursing Director will notify medical staff that proof of identity provided by the client must be verified in the EMR prior to the administration of the first dose of medication. Ongoing compliance with the regulation will be the responsibility of the QA Manager through regular review of Intake documentation. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of patient records, the narcotic treatment program failed to maintain onsite a photograph of the patient, which is to be 3 years old or less and also include the patient ' s name and birth date in one of thirteen patient records reviewed.
Patient #4 was admitted on October 2, 2024 and was discharged on March 22, 2025. There was no copy of a photograph with the patient name and birth date in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/08/2025 the QA Manager will create a tracking list in the EMR to alert dispensing staff before the patients' ID photographs are due to expire. The Nursing Director will advise nursing staff to update the client's photograph in the EMR to ensure that no client ID photograph is more than three years old. Monitoring ongoing compliance with the regulation will be the responsibility of the QA Manager during regularly scheduled audit of the clinical records.
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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 document the transfer of patient files, which are to include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of patient, to the receiving narcotic treatment program in one of one applicable patient record reviewed.
Patient #11 was admitted on September 19, 2023 and was transferred to another narcotic treatment program on March 25, 2025. There was no documentation in the record indicating any of the patient files were transferred to the receiving narcotic treatment program.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 09/08/2025, the Clinical Supervisor will remind clinical staff to scan a copy of the Transfer Document Check List sent to the receiving program into the EMR after the Transfer documentation has been sent to the receiving program. The checklist will include the following: admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, current status of the patient, and a copy of the patient's written consent. Ongoing compliance with the regulation will be the responsibility of the QA Manager and/or the Clinical Supervisor through review of the records of all clients transferred out of the program.
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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 narcotic treatment program failed to ensure each patient file included the completion and documentation of the results of all annual physical examinations given by the narcotic treatment program, which is to include an annual reevaluation by the narcotic treatment physician, in one of six applicable patient records reviewed.
Patient # 6 was admitted on September 25, 2023 and was discharged on February 8, 2025. There was no annual physical examination completed and documented for the 2024 year at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 09/08/2025, The Program Director will revise the agency policy to state that Annual Physical Examinations are due within 30 days of the anniversary date of the client's admission to the program. The QA Manager will create a tracking system for the due dates of the client annual physicals in the dispensing messaging system that will remind clients of the upcoming physical. Ongoing compliance with the regulation will be the responsibility of the QA Manager through review of the medical records to ensure that Annual Physical examinations have been completed in accordance with the policy timeframe.
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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 review and update treatment and rehabilitation plans at least every 60 days in seven of twelve applicable client records reviewed.
Client #3 was admitted on January 5, 2023 and was still active at the time of the inspection. A treatment plan update was completed on June 27, 2024 and the next update was due no later than August 27, 2024; however, the update was completed on August 30, 2024. Additionally, a treatment plan update was completed on January 21, 2025 and the next update was due no later than March 21, 2022; however, the update was completed on March 27, 2025.
Client #4 was admitted on October 2, 2024 and was discharged on March 22, 2025. A treatment plan update was completed on November 6, 2024 and the next update was due no later than January 6, 2025; however, the update was completed on January 31, 2025.
Client #5 was admitted on January 10, 2018 and was discharged on May 27, 2025. A treatment plan update was completed on June 4, 2024 and the next update was due no later than August 4, 2024; however, the update was completed on August 20, 2024. Additionally, a treatment plan update was completed on August 20, 2024 and the next update was due no later than October20, 2024; however, the update was completed on October 29, 2024.
Client #6 was admitted on September 25, 2023 and was discharged on February 8, 2025. A treatment plan update was completed on July 30, 2024 and the next update was due no later than September 30, 2024; however, the update was completed on October 29, 2024.
Client #10 was admitted on April 1, 2025 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on May 1, 2025 and the first update was due no later than July 1, 2025; however, the update was completed on July 16, 2025.
Client #11 was admitted on September 19, 2023 and was discharged on March 25, 2025. A treatment plan update was completed on November 5, 2024 and the next update was due no later than January 5, 2025; however, the update was completed on January 12, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning on 9/08/2025, the QA Manager will post a Treatment Plan Review and Update tracking list in the EMR. The Program Director will meet with the clinicians to notify them that Treatment Plan Reviews must be completed every 60 days. Clinicians will be advised to complete the Review and Update of the Treatment Plans no later than every 60 days without the clients who are unwilling or unable to attend an appointment on the scheduled due date. The Treatment Plan Reviews and Updates will be reviewed and signed by the client when the client is present. Ongoing compliance with the regulation will be the responsibility of the QA Manager through regular record review.
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