INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring conducted on June 12, 2025 through June 13, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Aldie Counseling 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 the personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level per the facility ' s policy and procedures manual in two out of seven employee records reviewed. The facility ' s policy and procedures manual states that the annual individual training plan is due by July 31.
Employee # 3 was hired as a clinical supervisor on December 15, 2022 and was still in that position. The individual training plan in the personnel record was due by July 31, 2024; however, it wasn ' t documented September 25, 2024.
Employee # 4 was hired as a counselor on January 2, 2018 and is still in that position. The individual training plan in the personnel record was due by July 31, 2024; however, it was not documented until September 23, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with the clinical director. In addition, the requirement to have all training plans completed and signed by July 31st of each year was discussed at the June 18th staff meeting. The Clinical Director will ensure that the requirement is met, and will provide the staff person responsible for tracking completion with copies of all training plans. |
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 June 2024 through April 2025 fire drill logs, the facility failed to document the number of persons in the facility at the time of the drill during the June 2024, July 2024, August 2024, and September 2024 fire drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the matter with the Clinical Director and the employee responsible for conducting and documenting the fire drills. The deficiency was largely due to a change in staff. The employee conducting the fire drills has been trained on the proper completion of the forms. The CEO will verify compliance on a monthly basis. |
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 ten client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made to on a consent to release information form in one record reviewed.
Client # 1 was admitted to the outpatient level of care on October 7, 2024 and was active at the time of the inspection. The record contained three release of information forms signed by the client on October 3, 2024, during the intake process; however, the name of the person, agency or organization to whom the disclosure would be made was not documented on the forms.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the matter with the Clinical Director and the Assessment Supervisor in the Doylestown office. Staff were instructed that it is not permissible to have clients sign incomplete release of information forms. Staff have acknowledged the oversight and will provide clients with fully complete forms to sign. The Clinical Director will monitor compliance and review as part of chart audits along with the Assistant Clinical Director. The incomplete forms have been documented as void in the clinical record by the Assessment Supervisor. |
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 ten client records, the facility failed to ensure that consent to release information forms included the specific information to be disclosed in one record reviewed.
Client # 1 was admitted to the outpatient level of care on October 7, 2024 and was active at the time of the inspection. The record contained three release of information forms signed by the client on October 3, 2024, during the intake process; however, the specific information to be disclosed was not documented on the forms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the matter with the Clinical Director and the Assessment and Intake Supervisor in the Doylestown office. Staff were informed of the citation and the requirement to only present clients with fully complete forms to release information. The Clinical Director will provide oversight through ongoing supervision and will ensure compliance through regular chart audits in conjunction with the Assistant Clinical Director. The Assessment Supervisor has corrected the clinical record to document the incomplete ROI forms as void. |
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 ten client records, the facility failed to ensure that consent to release information forms included the purpose of disclosure in one record reviewed.
Client # 1 was admitted to the outpatient level of care on October 7, 2024 and was active at the time of the inspection. The record contained three release of information forms signed by the client on October 3, 2024, during the intake process; however, the purpose of the disclosure was not documented on the forms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the matter with the Clinical Director and the Assessment and Intake Supervisor in the Doylestown office. Staff were informed of the citation and the requirement to only present clients with fully complete forms to release information. The Clinical Director will provide oversight through ongoing supervision and will ensure compliance through regular chart audits in conjunction with the Assistant Clinical Director. The Assessment Supervisor has corrected the clinical record to mark the incomplete forms as void. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of eighteen weeks of narcotic treatment physician and physician assistant timesheets, the facility failed to provide at least one hour of narcotic treatment physician services a week on site for every ten patients in one week reviewed.
During the week of January 5, 2025 through January 11, 2025, the patient census was 275. The facility was required to provide at least 27.5 physician hours. There were only 24 hours documented.
This is a repeat citation from the June 7, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Aldie has submitted an Exception Request to DDAP regarding this deficiency. If approved the matter will be resolved. If rejected the CEO with either increase the hours of the Physician Assistant or pursue the services of a contracted physician to provided onsite coverage during the absence of the medical director due to vacation or other events. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of eighteen narcotic treatment physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census for one week reviewed. A narcotic treatment physician must provide one-third of the required hours, with a certified registered nurse practitioner or physician's assistant providing the remaining two-thirds of the required hours.
During the week of January 5, 2025 through January 11, 2025, the patient census was 275. The narcotic treatment physician was required to provide one-third of the 27.5 hours, which equals to 9 hours. The narcotic treatment physician provided 0 hours.
This is a repeat citation from the June 7, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Aldie has submitted an Exception Request to DDAP regarding this deficiency. If approved the matter will be resolved. If rejected the CEO will pursue the services of a contracted physician to provided onsite coverage during the absence of the medical director due to vacation or other events. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
During an observation of medication administration at 09:55 a.m. on June 13, 2025, the nurse in the second dosing window was observed to be preparing medications, instead of observing the patient when ingesting the agent.
This is a repeat citation from the June 7, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has discussed the citation with the Chief Nursing Officer and the Director of Nursing. Training and instruction was provided to the subject nurse on June 16, 2025. All indications are that the training was received and understood. The Chief Nursing Officer will reinforce compliance, and in conjunction with the Director of Nursing, will provide ongoing oversight. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within 30 days of admission, per the facility policy, in four of five applicable records reviewed.
Client # 1 was admitted on October 7, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by November 6, 2024; however, it was not completed until December 11, 2024.
Client # 4 was admitted on January 24, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by February 23, 2025; however, it was not completed until March 19, 2025.
Client # 9 was admitted on September 9, 2024 and was discharged on December 5, 2024. The individual treatment and rehabilitation plan was due to be completed by October 9, 2024; however, it was not completed prior to the date of discharge.
Client # 10 was admitted on September 16, 2024 and was discharged on March 18, 2025. The individual treatment and rehabilitation plan was completed on October 16, 2024; however, it was not completed until November 8, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with the Clinical Director, and discussed the issue with the full clinical staff at a meeting on June 18, 2025. The Clinical Director and Assistant Clinical Director will development a spreadsheet to use to track due dates of required documentation. The spreadsheet will be reviewed in regular clinical supervision to ensure compliance. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed within 48 hours of service, in three of ten records reviewed.
Client # 2 was admitted on September 13, 2013 and was active at the time of the inspection. The record contained a progress note for an individual session that occurred on April 30, 2025, that was not completed until May 6, 2025. Additionally, the record contained a progress note for an individual session that occurred on March 31, 2025, that was not completed until April 4, 2025.
Client # 5 was admitted on October 1, 2012 and was discharged on March 5, 2025. The record contained progress notes for individual sessions that occurred on October 30, 2024, November 3, 2024, December 2, 2024, and February 10, 2025, that were not completed until November 5, 2024, November 26, 2024, January 8, 2025, and March 5, 2025, respectively.
Client # 10 was admitted on September 16, 2024 and was discharged on March 18, 2025. The record contained a progress note for an individual session that occurred on October 29, 2024, that was not completed until November 10, 2024. Additionally, the record contained a progress note for an individual session that occurred on November 19, 2024, that was not completed until December 3, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with the Clinical Director, and discussed the issue with the full clinical staff at a meeting on June 18, 2025. The Clinical Director and Assistant Clinical Director will development a spreadsheet to use to track due dates of required documentation. The spreadsheet will be reviewed in regular clinical supervision to ensure compliance. |