INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on August 10, 2026 through August 12, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Kirkbride Center 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure a written individual training plan was developed for each employee, with the plan being appropriate to that employee's skill level and developed annually with input from both the employee and the supervisor, in six of twenty-two applicable personnel records reviewed.
Employee # 9 was hired as a counselor on June 19, 2022. There was no current individual training plan documented in the personnel record at the time of the inspection. The most recent training plan documented in the personnel record was completed on October 3, 2025; however, that training plan was for the July 1, 2025 through June 30, 2026 facility training year.
Employee # 10 was hired as a counselor on July 19, 2005. There was no current individual training plan documented in the personnel record at the time of the inspection. The most recent training plan documented in the personnel record was completed on October 3, 2025; however, that training plan was for the July 1, 2025 through June 30, 2026 facility training year.
Employee # 12 was hired as a counselor on October 17, 2022. There was no current individual training plan documented in the personnel record at the time of the inspection. The most recent training plan documented in the personnel record was completed on October 3, 2025; however, that training plan was for the July 1, 2025 through June 30, 2026 facility training year.
Employee # 15 was hired as a counselor on October 9, 2023. There was no current individual training plan documented in the personnel record at the time of the inspection. The most recent training plan documented in the personnel record was completed on December 9, 2025; however, that training plan was for the July 1, 2025 through June 30, 2026 facility training year.
Employee # 17 was hired as a counselor on May 28, 2024. There was no current individual training plan documented in the personnel record at the time of the inspection. The most recent training plan documented in the personnel record was completed on October 3, 2025; however, that training plan was for the July 1, 2025 through June 30, 2026 facility training year.
Employee # 22 was hired as a counselor on October 23, 2026. There was no current individual training plan documented in the personnel record at the time of the inspection. The most recent training plan documented in the personnel record was completed on October 10, 2025; however, that training plan was for the July 1, 2025 through June 30, 2026 facility training year.
This is a repeat citation from the September 12, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR Director (or designee) is responsible for ongoing monitoring of completed staff training plans by the required date. Upon review of our processes we discovered duplication in training content across three documents in the HR files, and typos in training year dates that went unnoticed on our forms and were not updated to reflect the correct training year. For this and other process-related reasons, we have removed the redundancies and all dates must be entered manually. We have also updated our policy to change from a fiscal to a calendar training year. We believe this to be a cleaner and more user-friendly process for both our managers and auditors to ensure that training plans are completed in a timely manner. Managers have been informed of the new process and educated on the requirement to complete the upcoming training plans for their respective staff before the end of the calendar year for the next training year. Moving forward, all training plans for 2027 will be completed by December 31st of 2026, inclusive of those for staff #'s (9, 10, 12, 15, 17 and 22). The HR Director (or designee) will monitor for ongoing compliance and report any variances to the department head for resolution. |
704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of personnel records, the facility failed to ensure each annual, written individual training plan was based upon the employee's previous education, experience, current job functions, and performance in six of sixteen applicable personnel records reviewed.
Employee # 1 was hired as the project director and facility director on January 28, 2023. The individual training plan, completed on June 6, 2026, was not based on the employee's previous education, experience, current job functions and performance as it was identical to the training plans for the clinical supervisors and newly hired counselors.
Employee # 2 was hired as a clinical supervisor on September 27, 2021. The individual training plan, completed on June 9, 2026, was not based on the employee's previous education, experience, current job functions and performance as it was identical to the training plans for the project director/facility director, other clinical supervisors and newly hired counselors.
Employee # 3 was hired as a clinical supervisor on November 6, 2013. The individual training plan, completed on June 11, 2026, was not based on the employee's previous education, experience, current job functions and performance as it was identical to the training plans for the project director/facility director, other clinical supervisors and newly hired counselors.
Employee # 4 was hired as a clinical supervisor on November 1, 2021. The individual training plan, completed on June 29, 2026, was not based on the employee's previous education, experience, current job functions and performance as it was identical to the training plans for the project director/facility director, other clinical supervisors and newly hired counselors.
Employee # 6 was hired as a counselor on September 3, 2025. The individual training plan, completed on June 8, 2026, was not based on the employee's previous education, experience, current job functions and performance as it was identical to the training plans for the project director/facility director, clinical supervisors and the other newly hired counselor.
Employee # 7 was hired as a counselor on March 3, 2026. The individual training plan, completed on June 9, 2026, was not based on the employee's previous education, experience, current job functions and performance as it was identical to the training plans for the project director/facility director, clinical supervisors and the other newly hired counselor.
This is a repeat citation from the August 29, 2024 and September 12, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director is responsible for the staff development program. In October of 2025 we updated the documentation to remove the default language and clarify that all staff's training plans were completed based on their previous education, experience, current job function and job performance. However, upon review of staff training plan documents we noted that some older documents were still in use and, based on the June dates listed for employees (#1, 2, 3, 4, 6 and 7), that it was actually our Annual Training Fair documentation that caused the citation, as it included a "training plan" section which contained some duplication of training plan portions while not encapsulating all of the required elements. In consultation with the HR Director and other members of leadership, the redundant areas of the HR staff documents have been removed to avoid future duplication of efforts and eliminate any confusion. We have also updated our policy from a fiscal to a calendar training year, and have educated managers on the correct training plan form to use and to document the use of employee's previous education, experience, current job functions and performance to ensure individualization of training plans. Moving forward, all individualized training plans for the new training year - 2027 - will be completed by December 31st of 2026, inclusive of those for staff #'s (1, 2, 3, 4, 6 and 7). The HR Director (or designee) will also monitor the training plans submitted for employee's HR files before filing to ensure that the correct form is in use and is reflective of individualized content. Any variances will be reported to the Project Director for follow-up and resolution with appropriate staff. |
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 and the Staffing Requirements Facility Summary Report, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframes in five of five applicable personnel records reviewed.
Employee # 23 was hired as a behavioral health technician on May 22, 2023 and was due to have the HIV/AIDS training no later than May 22, 2025; however, the HIV/AIDS training was not completed as of the date of the inspection.
Employee # 24 was hired as a behavioral health technician on April 23, 2013 and was due to have the TB/STD training no later than April 23, 2015; however, the TB/STD training was completed on July 31, 2026.
Employee # 25 was hired as an admissions coordinator on October 10, 2022 and was due to have the HIV/AIDS and TB/STD trainings no later than October 10, 2024; however, both trainings were completed on August 8, 2026.
Employee # 26 was hired as an admissions coordinator on July 20, 2007 and was due to have the HIV/AIDS and TB/STD trainings no later than July 20, 2009; however, the trainings were not completed as of the date of the inspection.
Employee # 27 was hired as an admissions coordinator on May 13, 2023 and was due to have the HIV/AIDS and TB/STD trainings no later than May 13, 2025; however, both trainings were completed on August 7, 2026.
This is a repeat citation from the September 8, 2023, August 29, 2024, and September 12, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR Director (or designee) is responsible for monitoring and ensuring staff completion of the required communicable disease trainings within the regulatory timeframes. Since the last POC we have been meeting the required trainings for HIV/AIDS and TB/STD by revising our orientation schedule for all new hires in order to include the requisite trainings for (HIV/AIDS and TB/STD) using the state's online training portal or state-approved curriculums as part of their onboarding process. The cited employees (#24, 25, and 27) were already past their required timeframes from date of hire since before the previous September 2025 survey and POC, but were subsequently identified through internal audits during follow-up review of staff files and received the required trainings using the state's curriculum; documentation of completion was noted as present by the surveyors during the visit. Of the two remaining cited employees, #23 has completed their training with the approved curriculum and documentation placed in their file, and employee #26 is no longer an active employee and is thus moot. Ongoing requirements for completion upon new hire since the September 2025 POC have not shown further deficiencies. However, to further ensure compliance moving forward and avoid a repetition of this citation, all completed mandatory HIV/AIDS and TB/STD certificates received for new hires will be sent monthly to the Executive and Compliance Directors by the HR Director (or designee) for additional oversight. Should any variances be identified, they will be reported to the relevant department head for follow-up remediation and will be required to complete the mandatory training(s) within 90 days or by their due date (whichever comes first) or be taken off the schedule as a disciplinary action. |
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 ensure each counselor completed at least 25 clock hours of training annually, during the facility's July 1, 2025 through June 30, 2026 training year, in four of fifteen applicable personnel records reviewed.
Employee # 16 was hired as a counselor on August 24, 2021. The personnel record documented 20.5 hours of training received during the training year reviewed.
Employee # 18 was hired as a counselor on January 1, 2024. The personnel record documented 22 hours of training received during the training year reviewed.
Employee # 21 was hired as a counselor on May 23, 2022. The personnel record documented 23 hours of training received during the training year reviewed.
Employee # 22 was hired as a counselor on October 23, 2023. The personnel record documented 20 hours of training received during the training year reviewed.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR Director (or designee) is responsible for monitoring and ongoing compliance with mandatory training hours and due dates for relevant employees. Moving forward as of 8/24/26, our HR employee files are being digitized to be more clearly organized and maintained to ensure proper documentation is present and easily monitored for completion, including training certificates. We have also moved our training year to coincide with the calendar (rather than fiscal) year and updated the policy to reflect that change. Ongoing progress towards training requirements will be shared monthly with department managers for follow-up with their staff as the training calendar year progresses in order to ensure that managers stay aware of and involved in their staff's ongoing development and training. Any variances will be reported monthly to the management team for review in our compliance/rehab dashboard meeting. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide a wall mirror and either individual paper towels or a mechanical dryer in each bathroom.
At the time of the inspection, conducted on August 11, 2026 between 10 a.m. and 12 p.m., the bathroom located in room 310 did not have a wall mirror and the bathroom located in room 510 did not have any individual paper towels or a mechanical dryer installed.
This is a repeat citation from the September 12, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All areas cited during the survey in rooms 310 and 510 were addressed same or next day by environmental services and engineering staff. The Environmental Service Managers are responsible for ensuring their staff provide daily cleaning and replenishment of paper towels on patient units which is an ongoing daily process. On the day of the walk-through cleaning staff were on the unit to conduct their daily process but had not yet gotten to room 510 - once they did the paper towels were replaced within the hour. The Property Manager is responsible for any work orders submitted for the engineering department and this is also an ongoing daily process. The mirror in room 310 was replaced by engineering staff the following day on 8/12/26. Monitoring of completion is conducted by the EOC Coordinator and any variances identified are reported to the Property Manager and/or Service Master Manager for remediation and to Kirkbride senior leadership [President/CEO and Board Directors] for monitoring of vendor performance. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
At the time of the inspection, conducted on August 11, 2026 between 10 a.m. and 12 p.m., the shower pans/floors in the bathrooms located in rooms 305, 330, 417, and 530 had what appeared to be mold and mildew, as well as dirt, grime, and soap scum. Additionally, the men's urinal located in bathroom N0-058 was not functioning properly.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All areas cited during the survey in rooms 305, 330, 417, 530 and 058 were addressed by environmental services or engineering staff as of 9/3/26. The Environmental Service Managers are responsible for ensuring their staff provide daily cleaning on patient units which is an ongoing daily process - and while cleaning was conducted of the areas observed in rooms 305, 330, 417 and 530, upon closer inspection the presence of mold/mildew was not confirmed and appeared to be soap scum. The Property Manager is responsible for any work orders submitted for the engineering department and this is also an ongoing daily process. Per his report the urinal in room 058 had not been reported yet as a work order to his department for resolution as it was unoccupied and was repaired same day as the walkthrough on 8/11/26. Monitoring of completion is conducted by the EOC Coordinator and any variances identified are reported to the Property Manager and/or Service Master Manager for remediation. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to keep frozen food at or below 0 degrees Fahrenheit.
At the time of the inspection, conducted on August 11, 2026 between 10 a.m. and 12 p.m., the thermometer inside the freezer had a reading of 23 degrees Fahrenheit.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Property Manager is responsible for any work orders submitted for the engineering department and this is also an ongoing daily process. Per his report the freezer in the cafeteria had not been reported yet as a work order to his department for resolution. Vendor was out to diagnose and fix the identified problem which was a faulty fan, as well as replacement of the door gasket seals. Subsequent temperature readings since the repair are now showing 0F. Monitoring of completion is conducted by the EOC Coordinator and any variances identified are reported to the Property Manager and/or Service Master Manager for remediation. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
As of the date of the inspection, there was no financial audit completed for the project's fiscal year ending on June 30, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Governing Board is responsible for the ongoing fiscal management of the project. As such, a timely annual fiscal audit for the previous year was scheduled by the previous CFO with an independent certified public accountant (CPA) firm, but they have yet to conclude and deliver the completed audit letter due in part to the untimely loss of our previous CFO. Because Pennsylvania regulation requires an independent audit, we cannot self-certify or complete this requirement without the firm's final sign-off. The CPA firm has assured us they will deliver the completed audit letter as soon as they are able. To ensure compliance moving forward, our new CFO will schedule the next CPA audit ASAP for the next fiscal year under review and manage the feed of data to the auditor and conduct any research and response to queries in a timely fashion. The CFO (with the Board's approval) will also dictate strict deadline requirements to the CPA by which the final letter must be received following completion of the audit to maintain compliance moving forward and will notify the Board in writing of any progress or delays for possible follow-up remediation with the CPA should it be required. Additionally, to show compliance and transparency, the previous year's tax returns were submitted during the pre-submission period of the survey before 7/15/26, but in retrospect an exception request should have been submitted for approval at that time in accordance with regulatory requirements. An exception request was submitted on 8/14/26 to the licensure division of DDAP and a letter dated 8/21/26 was received from them on 8/26/26 approving a 3-month extension for its completion which will be made available for review upon its receipt. While this is the first time this deficiency has occurred for the organization, should this issue reoccur in the future an exception request will also be submitted by the Executive Director (or designee) at least 30 days prior to the survey date to comply with regulatory requirements. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of twenty-seven client records reviewed.
Client # 25 was admitted to the inpatient non-hospital activity April 18, 2026 and was discharged on July 6, 2026. There was documentation of a follow-up note on July 27, 2026 where the counselor discussed the status of the client with another current client of the facility; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure of information.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All therapists are responsible for obtaining and maintaining appropriate releases of information in their patient records. The therapist responsible in this case was met with by their Clinical Manager on 8/11/24 when this finding was initially reported. The therapist stated that they had not sought this information out from the other party and that it had been volunteered, but was still re-educated regarding their responsibility with obtaining voluntary consent prior to any release of information to a third party. The Compliance Analyst will conduct monthly validation audits to monitor adherence with this regulation and any variances identified will be brought to the attention of the Program Director and Clinical Manager for remediation. |
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 document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in two of twenty-seven client records reviewed.
Client # 15 was admitted to the outpatient activity on June 16, 2026 and was active at the time of the inspection. A release of information form for an emergency contact was signed by the client on June 16, 2026; however, there was no name of the person, agency or organization to whom the disclosure was to be made documented on the release form.
Client # 16 was admitted to the outpatient activity on March 18, 2026 and was active at the time of the inspection. There were release of information forms for adult probation agency and another outpatient provider that were signed by the client on March 18, 2026; however, there was no name of the person, agency, or organization to whom the disclosures were to be made to documented on either release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors are responsible for fully and accurately completing release of information forms including documenting the name of the person, agency or organization to whom the disclosure is being made. The counselor responsible in these 2 cases in outpatient was met with by their Clinical Supervisor and re-educated regarding this regulation and the two clients (#15 and #16) were met with by the counselor to ensure that any new releases obtained were complete in their entirety. The Compliance Analyst will conduct random monthly validation audits to monitor adherence with this regulation and any variances identified will be brought to the attention of the Program Director and Clinical Supervisor for remediation, and findings discussed monthly in our compliance/rehab dashboard meeting. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the release on release of information forms in two of twenty-seven client records reviewed.
Client # 26 was admitted to the inpatient non-hospital detoxification activity on January 13, 2026 and was discharged on January 18, 2026. A release of information form for a funding source was signed by the client on January 13, 2026; however, there was no purpose for the disclosure documented on the release form.
Client # 27 was admitted to the inpatient non-hospital activity on January 18, 2026 and was discharged on January 28, 2026. A release of information form for a funding source was signed by the client on January 13, 2026; however, there was no purpose for the disclosure documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All Admission staff are responsible for complete and accurate consents to release information in their patient records. The consent form that was cited is the "payer's" form and has the items under the Purpose section already pre-typed with an "other" option checkbox also listed under them where, if there was an additional purpose needed, it would need to be specified. Upon review of the form in client #27's file, we realized that our EHR vendor had by default "pre-checked" the checkbox for "other" under the Purpose section unnecessarily and staff were not "de-selecting" it. No other purpose actually needed documenting, but because the default option had it pre-checked the section appeared deficient as staff were not specifying the purpose after it. We cannot retrospectively rectify this in the patient record from January, but our EHR vendor was notified that we want that checkbox "un-checked" by default to avoid future confusion and the edit to the document was made by them on 9/2/26. The Compliance Analyst will conduct monthly validation audits to monitor adherence with this regulation and any variances identified will be brought to the attention of the Admissions Director for remediation. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of two applicable client records reviewed.
Client # 27 was admitted to the inpatient non-hospital activity on January 18, 2026 and was involuntarily terminated on January 28, 2026. There was no documentation, in the record, indicating the client received written notice of their involuntary termination from the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director (or designee) is responsible for written notification to the client of a decision to involuntarily terminate them. The documentation did indicate the patient having been met with to review the decision to terminate and the patient's decision to appeal; however, it was not clearly documented that this was communicated in writing. This cannot be corrected retroactively with the patient, but to rectify this moving forward we have asked our EHR vendor on 9/1/26 to add to our non-routine document a section that indicates that the client was notified in writing of the decision in the case of an involuntary termination and evidenced by staff and patient signature. The Compliance Analyst will review any such cases that occur monthly (if any) to ensure compliance. |
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 provide documentation indicating that verification of the individual's identity, including name, address, date of birth, emergency contact and other identifying data prior to administration of an agent and shall screen each individual to determine eligibility for admission in two of ten applicable patient records reviewed.
Patient # 16 was admitted to the outpatient activity on March 18, 2026 and was active at the time of the inspection. The narcotic treatment program failed to provide verification of the individual's identity to determine eligibility for admission, prior to the administration of an agent.
Patient # 20 was admitted to the outpatient activity on January 30, 2026 and was discharged on April 8, 2026. The narcotic treatment program failed to provide verification of the individual's identity to determine eligibility for admission, prior to the administration of an agent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Admissions Manager (or designee) is responsible for verifying individuals' identity either through collection of PA driver's or non-driver's license and/or through the Electronic Verification System (EVS) at time of admission to determine their eligibility for admission and prior to administration of an agent. Both patients #16 and 20 have had their identities verified through the EVS system and documentation placed in their records. Moving forward, any new admissions to the Outpatient program will have a copy of their EVS and/or driver's/non-driver's license placed in the patient record by the Admissions Manager (or designee) which will be verified by the Dosing Nurse prior to any administration of an agent. A validation audit will also occur monthly on any new Outpatient admissions by the Compliance Analyst to ensure ongoing compliance. |
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 each patient, which is to include the patient's name and date of birth and shall be updated every 3 years in three of fifteen patient records reviewed.
Patient # 17 was admitted to the outpatient activity on June 22, 2022 and was active at the time of the inspection. The narcotic treatment program failed to provide documentation indicating the onsite photograph in the record was updated within 3 years.
Patient # 18 was admitted to the outpatient activity on June 8, 2022 and was active at the time of the inspection. The narcotic treatment program failed to provide documentation indicating the onsite photograph in the record was updated within 3 years.
Patient # 22 was admitted to the outpatient activity on December 2, 2022 and was active at the time of the inspection. The narcotic treatment program failed to provide documentation indicating the onsite photograph in the record was updated within 3 years.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Dosing Nurse is responsible for maintaining updates to the patients' photographs in the records every 3 years. We have obtained a camera for the Outpatient program that prints the date on the photo for evidentiary purposes and have a placed one in each record. Moving forward, the Dosing Nurse will monitor the 3-year due dates for each patient's photo and will update it in the patient record at the appropriate time in 2029 for those patients who are still active in the program at that time. Any new admissions will also get fresh, date-stamped photos at time of admission and once yearly checks will occur by the DON (or designee) to maintain compliance moving forward. |
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 to a receiving narcotic treatment program, with the records including urinalysis reports or summary, in one of one applicable patient record reviewed.
Patient # 25 was admitted to the inpatient non-hospital activity on April 18, 2026 and was transferred to another treatment provider on July 6, 2026. There was no documentation of the patient ' s urinalysis reports or summary being transferred to the receiving treatment provider.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Health Information Care Coordinator (or designee) is responsible for transmitting patient files to a receiving narcotic treatment program (NTP), inclusive of urinalysis reports or summary. This has been done routinely for all cases unless the patient is returning to an open clinic. The Care Coordinator has since been educated by the Clinical Manager on 8/17/26 to include urinalysis results in all transfer packets sent to other NTPs. The Compliance Analyst will conduct random monthly audits to monitor adherence with this regulation and any variances identified will be brought to the attention of the Clinical Manager for remediation. |
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 narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of two applicable patient records reviewed.
Patient # 24 was transferred in and admitted to the inpatient non-hospital detoxification activity on April 13, 2026 and was discharged on April 18, 2026. There was documentation that the transferring narcotic treatment program was notified of the date of the patient's admission on April 14, 2026; however, the facility documented that the date of the initial dose was on January 14, 2026, which was prior to the patient's admission.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Health Information Care Coordinator (or designee) is responsible for transmitting patient files to a receiving narcotic treatment program, inclusive of the date of admission and date of the initial dose. Upon review of the patient record it did appear that that Coordinator made a typographical error on the form and entered the incorrect date. She was educated by the Compliance Director of the error which was rectified in the patient record and the receiving facility notified. The Compliance Analyst will conduct random monthly audits to monitor accuracy of the date of the initial dose and any variances identified will be brought to the attention of the Clinical Manager for remediation. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client in three of nine applicable client records reviewed.
The facility's policy and procedure manual stated comprehensive treatment plans will be completed within 72 hours of admission.
Client # 10 was admitted to the inpatient non-hospital activity on May 7, 2026 and was discharged on May 14, 2026. The individual treatment and rehabilitation was due to be completed no later than May 10, 2026; however, the plan was not completed until May 11, 2026.
Client # 14 was admitted to the inpatient non-hospital activity on July 17, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation was due to be completed no later than July 20, 2026; however, the plan was not completed until July 22, 2026.
Client # 27 was admitted to the inpatient non-hospital activity on January 18, 2026 and discharged on January 28, 2026. The individual treatment and rehabilitation was due to be completed no later than January 21, 2026; however, the plan was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All therapists are responsible for completing treatment plan documentation within the appropriate timelines as dictated in our policies. We should note that upon review of the record for client #10 we did see a note from the therapist on 5/8/26 indicating their attempt to meet with the client to complete the treatment plan, but being unable to do so due to the patient's health at the time. This is in compliance with our policy guidelines for appropriate documentation should a treatment plan be unable to be completed within the appropriate timeframe. Regardless, as these findings are in closed records they cannot be rectified. However, the therapists for client #10 and 14 were notified of the citations by their respective clinical managers on 9/2/26 and provided re-education on our policy timelines for completion of the treatment plans. The Compliance Analyst will conduct monthly validation audits to monitor adherence with this regulation and any variances identified will be brought to the attention of the Program Director and Clinical Manager(s) for remediation. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include the documentation of case consultation notes, in seven of seven applicable client records reviewed.
Client # 16 was admitted to the outpatient activity on March 18, 2026 and was active at the time the inspection. There was no documentation of case consultation notes in the record at the time of the inspection.
Client # 17 was admitted to the outpatient activity on June 22, 2022 and was active at the time the inspection. There was no documentation of case consultation notes in the record at the time of the inspection.
Client # 18 was admitted to the outpatient activity on June 8, 2022 and was active at the time the inspection. There was no documentation of case consultation notes in the record at the time of the inspection.
Client # 19 was admitted to the outpatient activity on January 24, 2023 and was active at the time the inspection. There was no documentation of case consultation notes in the record at the time of the inspection.
Client # 21 was admitted to the outpatient activity on October 3, 2025 and was discharged on March 20, 2026. There was no documentation of case consultation notes in the record at the time of the inspection.
Client # 22 was admitted to the outpatient activity on December 2, 2022 and was discharged on July 28, 2026. There was no documentation of case consultation notes in the record at the time of the inspection.
Client # 23 was admitted to the outpatient activity on August 6, 2024 and was discharged on May 26, 2026. There was no documentation of case consultation notes 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 therapist is responsible for maintaining a complete client record including case consultation notes and was educated on the policy requirements along with other members of the treatment team. The notes for clients #16, 17, 18, and 19 have been completed; clients # 21, 22, and 23 are closed cases so cannot be rectified. Moving forward, the Compliance Analyst will conduct monthly audits to ensure that ongoing compliance with the due dates for case consultation notes are completed in compliance with our internal policy. Any variances will be reported to the Program Director for follow-up and remediation with staff. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on an administrative review, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for failing to ensure all staff received communicable disease trainings within the regulatory timeframe for their position were submitted and approved by the Department for the September 8, 2023, August 29, 2024, and September 12, 2025 annual licensing renewal inspections. Failing to ensure all staff received communicable disease trainings within the regulatory timeframe for their position was again found to be a deficiency in the August 10, 2026 through August 12, 2026 annual licensing inspection.
Plans of correction for failing to ensure each annual, written individual training plan was based upon the employee's previous education, experience, current job functions, and performance were submitted and approved by the Department for the August 29, 2024 and September 12, 2025 annual licensing renewal inspections. Failing to ensure all staff received communicable disease trainings within the regulatory timeframe for their position was again found to be a deficiency in the August 10, 2026 through August 12, 2026 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director (ED) is responsible for ensuring ongoing compliance and follow-through of all POCs and will review ongoing progress of each POC item until successful completion is achieved in an effort to prevent any future repeat citations. This will be evidenced through monthly review of QA data during compliance/rehab and leadership meetings, as well as quarterly retrospective reviews. No POC item will be marked as "resolved" internally, until the ED has signed off on the item. In addition, sixty days prior to the facility's anticipated annual licensing window, the ED will lead a mock audit of the previous year's citations to proactively identify and fix any operational drift before DDAP surveyors arrive. With regard to the specific repeat citation for the mandatory trainings, we feel it important to note that the 5 employees cited were from time periods that preceded last year's September 2025 survey and POC (for example, employee #26 was hired in 2007). These older staff files reflect our more recent efforts to show due diligence and identify and resolve past deficiencies. Ongoing requirements for completion upon new hire since the September 2025 POC have not shown further deficiencies as supported by the survey results that found no deficiencies post that date, and we hope that the licensing body recognizes that important distinction. However, to further ensure compliance moving forward and avoid a repetition of this particular citation, all completed mandatory HIV/AIDS and TB/STD certificates for all active employees, as well as new hires, will be sent to the Executive and Compliance Directors by the HR Director (or designee) for additional oversight. Should any variances be identified, they will be reported to the relevant department head for follow-up remediation and will be required to complete the mandatory training(s) within 90 days or by their due date (whichever comes first) or be taken off the schedule as a disciplinary action. |