INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring inspection conducted on November 6, 2025 through November 7, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Healing Way 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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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on a release of information form in one of seven client records reviewed.
Client # 7 was admitted on August 19, 2025 and was active at the time of inspection. There was a release information form to the funding source signed and dated by the client on August 19, 2025; however, the specific information to be disclosed was not documented on the release form.
This is a repeat citation from the November 22, 2024 annual licensing renewal licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 11/19/2025 the ROI for Insurance form has been modified. The "information to be disclosed" section is now pre-filled so that the intake assessor does not have to select anything.
On 11/19/2025 our Chief Operating Officer held a staff meeting with all staff to review the modified form. During that staff meeting our Clinical Supervisors shared that they will now be conducting quality assurance chart reviews on a monthly basis of 5 charts per clinician, rather than quarterly reviews. The summary findings of the reviews will be discussed during monthly supervisory staff meetings.
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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 disclosure on a release information form in one of seven client records reviewed.
Client # 7 was admitted on August 19, 2025 and was active at the time of inspection. There was a release information form to the funding source signed and dated by the client on August 19, 2025; however, the purpose of the disclosure was not documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 11/19/2025 the ROI for Insurance form has been modified. The "purpose" section is now pre-filled so that the intake assessor does not have to select anything.
On 11/19/2025 our Chief Operating Officer held a staff meeting with all staff to review the modified form. During that staff meeting our Clinical Supervisors shared that they will now be conducting quality assurance chart reviews on a monthly basis of 5 charts per clinician, rather than quarterly reviews.
The summary findings of the reviews will be discussed during monthly supervisory staff meetings. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent to release information form was offered to the client in one of seven client records reviewed.
Client # 6 was admitted on June 17, 2025 and was active at the time of inspection. There was a release of information form to the funding source signed and dated by the client on June 17, 2025; however, there was no documentation in the record indicating a copy of the consent was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/19/2025 our Chief Operating Officer held a staff meeting with all staff to review the modified ROI for Insurance form.
During that staff meeting, COO also reviewed the policies and procedures of all consent forms and the importance of double checking our work.
Our Clinical Supervisors shared that they will now be conducting quality assurance chart reviews on a monthly basis of 5 charts per clinician, rather than quarterly reviews. The summary findings of the reviews will be discussed during monthly supervisory staff meetings.
During the meeting, staff was also reminded that three write ups for not following policies and procedures will result in termination of their employment. |
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 facility failed to maintain onsite a photograph of each patient, which includes the patient's name and birth date, in two of seven patient records reviewed.
Patient # 2 was admitted on May 16, 2024 and was discharged on October 15, 2025. There was no documentation of a photograph of the patient in the record during the patient ' s treatment episode.
Patient # 3 was admitted on August 22, 2016 and was a discharged on March 17, 2025. There was no documentation of a photograph of the patient in the record during the patient ' s treatment episode.
This is a repeat citation from the November 22, 2024 annual renewal licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/19/2025 our Chief Operating Officer held a staff meeting with all staff. All new clients will be required to have their photo taken for their chart during their intake appointment, as a secondary measure of having a photo ID in our system. The first measure is that all clients have their photo ID copied and scanned into their chart, which stays in effect as well.
During that staff meeting our Clinical Supervisors shared that they will now be conducting quality assurance chart reviews on a monthly basis of 5 charts per clinician, rather than quarterly reviews. The summary findings of the reviews will be discussed during monthly supervisory staff meetings. |
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.
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Observations
Based on the review of patient records, the facility failed to ensure the patient ' s counselor completed an annual evaluation of each patient ' s status, which is also to be reviewed, dated, and signed by the medical director, in one of four applicable patient records reviewed.
Patient # 3 was admitted on August 22, 2016 and was discharged on March 17, 2025. There was no recent annual evaluation documented in the record; nor was there any previous annual evaluations completed and documented in the record.
This is a repeat citation from the January 18, 2022, July 6, 2022, December 16, 2022, December 1, 2023, and November 22, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/19/2025 our Chief Operating Officer held a staff meeting with all staff to discuss and review policies and procedures and licensing regulations. During that staff meeting our Clinical Supervisors shared that they will now be conducting quality assurance chart reviews on a monthly basis of 5 charts per clinician, rather than quarterly reviews. The summary findings of the reviews will be discussed during monthly supervisory staff meetings. Staff was reminded that three write ups for not following policies and procedures will result in the termination of their employment. |
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:
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Observations
Based on a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client, per the facility ' s policy of within 30 days of admission, in one of two applicable client records reviewed.
Client # 6 was admitted on June 17, 2025 and was active at the time of the inspection. Per facility policy, the individual treatment and rehabilitation plan was due to be completed by July 17, 2025; however, the plan was not completed until August 28, 2025.
This is a repeat citation from the November 22, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/19/2025 our Chief Operating Officer held a staff meeting with all staff to discuss and review policies and procedures and licensing regulations. During that staff meeting our Clinical Supervisors shared that they will now be conducting quality assurance chart reviews on a monthly basis of 5 charts per clinician, rather than quarterly reviews. The summary findings of the reviews will be discussed during monthly supervisory staff meetings. Staff was reminded that three write ups for not following policies and procedures will result in the termination of their employment.
Furthermore, THW has signed a contract for a new EHR software which will go live on 2/23/2026. The new software automatically tracks treatment plan due dates, sends reminders to the clinician and clinician's supervisor, and does not let the clinician proceed forward in the chart without the treatment plan being completed. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of seven client records reviewed.
Client # 1 was admitted on February 16, 2023 and was discharged on August 21, 2025. A treatment plan update was completed on February 9, 2025 and the next update was due no later than April 9, 2025; however, the update was not completed until June 2, 2025.
Client # 2 was admitted on May 2, 2018 and was discharged on October 12, 2024. A treatment plan update was completed on May 12, 2025 and the next update was due no later than July 12, 2025; however, the update was not completed until August 12, 2025.
Client # 3 was admitted on August 22, 2016 and was discharged on March 17, 2025. A treatment plan update was completed on September 4, 2024, and the next update was due no later than November 4, 2024; however, the update was not completed until December 18, 2024.
This is a repeat citation from the December 1, 2023 and November 22, 2024 annual licensing renewal inspections.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On 11/19/2025 our Chief Operating Officer held a staff meeting with all staff to discuss and review policies and procedures and licensing regulations. During that staff meeting our Clinical Supervisors shared that they will now be conducting quality assurance chart reviews on a monthly basis of 5 charts per clinician, rather than quarterly reviews. The summary findings of the reviews will be discussed during monthly supervisory staff meetings. Staff was reminded that three write ups for not following policies and procedures will result in the termination of their employment.
Furthermore, THW has signed a contract for a new EHR software which will go live on 2/23/2026. The new software automatically tracks treatment plan due dates, sends reminders to the clinician and clinician's supervisor, and does not let the clinician proceed forward in the chart without the treatment plan being completed. |
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 a review of patient records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to ensure counselors completed an annual evaluation of the client ' s progress, which is to be signed by the medical director, was submitted and approved by the Department for the January 18, 2022, July 6, 2022, December 16, 2022, December 1, 2023, and November 22, 2024 licensing inspections. Failing to ensure annual evaluations were completed was again found to be a deficiency in the November 6, 2025 through November 7, 2025 annual licensing inspection.
A plan of correction for failing to ensure treatment plan updates were completed every 60 days was submitted and approved by the Department for the December 1, 2023 and November 22, 2024 licensing inspections. Failing to complete treatment plan updates within regulatory timeframes was again found to be a deficiency in the November 6, 2025 through November 7, 2025 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
THW has signed a contract for a new EHR software which will go live on 2/23/2026. The new software automatically tracks treatment plan due dates, sends reminders to the clinician and clinician's supervisor, and does not let the clinician proceed forward in the chart without the treatment plan being completed. It does the same function for any and all time sensitive encounters, including annual evaluations.
On 11/19/2025 our Chief Operating Officer held a staff meeting with all staff to discuss and review policies and procedures and licensing regulations. During that staff meeting our Clinical Supervisors shared that they will now be conducting quality assurance chart reviews on a monthly basis of 5 charts per clinician, rather than quarterly reviews. The summary findings of the reviews will be discussed during monthly supervisory staff meetings. Staff was reminded that three write ups for not following policies and procedures will result in the termination of their employment.
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