INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on May 12, 2026 through May 13, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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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 the review of the fire drill log from July 2025 through April 2026, the facility failed to maintain written fire drill records that indicated whether the fire alarm or smoke detector was operative during each unannounced monthly drill.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CEO has reviewed the deficiency with the administrative staff responsible for conducting monthly fire drills. A section will be added to the fire drill form indicating if the fire alarm and smoke detector are operative. These systems will be tested as part of the monthly fire drills by the administrative assistant to the CEO. The fire drill logs will be marked accordingly. The CEO will ensure compliance during regular supervision which will include a review of the fire drill log. |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of fourteen records reviewed.
Client #12 was admitted on December 16, 2016, and was discharged March 25, 2026. The facility failed to obtain a release of information for the funding source, and it was verified that billing had occurred.
Client #14 was admitted on October 25, 2010, and was discharged on February 27, 2026. The facility failed to obtain a release of information for the funding source, and it was verified that billing had occurred.
This is a repeat citation for the June 14, 2024, and June 6, 2025, annual licensing inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CEO has discussed the deficiency with the Clinical Director, who in turn has addressed the matter with the clinical staff in group supervision. Instruction was provided in group supervision on how to properly complete a release of information. The Clinical Director and Assistant Clinical Director will address the issue further during individual supervision. Ongoing compliance will be monitored during regular chart audits. |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosures will be made to in two of fourteen records reviewed.
Client #3 was admitted on November 2, 2025, and was discharged on November 10, 2025. A release of information form signed by the client on November 2, 2025, did not specify the name of the person, agency or organization to whom disclosure is to be made.
Client #13 was admitted on November 12, 2025, and was active at the time of the inspection. A release of information form signed by the client on November 17, 2025, did not specify the name of the person, agency or organization to whom disclosure is to be made.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CEO has discussed the deficiency with the Clinical Director, who in turn has addressed the matter with the clinical staff in group supervision. Instruction was provided in group supervision on how to properly complete a release of information. The importance of ensuring that all required information is included, prior to obtaining the client signature was stressed. The Clinical Director and Assistant Clinical Director will address the issue further during individual supervision. Ongoing compliance will be monitored during regular chart audits. |
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
The program failed to maintain a photo of each patient, which included the patient ' s name and birth date that was updated every three years, in two of seven patient records reviewed.
Patient #11 was admitted on May 9, 2024, and was active at the time of the inspection. The photograph of the patient that was maintained in the patient record by the program was more than three years old.
Patient #13 was admitted on November 12, 2025, and was active at the time of the inspection. The photograph of the patient that was maintained in the patient record by the program was more than three years old.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The CEO has discussed the dificiency with the Chief Nursing Officer and the Clinical Director. A process has begun of taking new photographs of each patient. The Chief Nursing Officer is managing the process and ensuring completion. The CEO is monitoring progress during regular supervision. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The project failed to ensure that the intake procedures included the documentation of a psychosocial evaluation in one of three applicable client records reviewed.
Client #13 was admitted on November 12, 2025, and was active at the time of the inspection. A psychosocial evaluation was not documented in the client record during the intake process.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CEO has reviewed the dificiency with the Clinical Director and Assessment and intake Supervisor. The importance of having a psychosocial evaluation has part of the clinical record was stressed. The Assessment Supervisor will ensure that a psychosocial evaluation is completed for all individuals starting treatment at Aldie. For individuals transferring from another facility the evaluation will be obtained from the transferring facility, and if one is not available the Assessment Supervisor will complete it and incorporate the document in the record. Compliance will be ensured through regular supervision and chart audits. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information entered within 7 days of the client's discharge, per the facility's policy, in two out of four applicable records reviewed.
Client #10 was admitted on December 4, 2012, and was discharged on February 6, 2026. There was no 7-day follow-up contact information documented in the client record at the time of the inspection.
Client #14 was admitted on October 25, 2010, and was discharged on February 27, 2026. There was no 7-day follow-up contact information documented in the client record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Aldie disputes this finding as the policy since July 2024 states that follow-up should occur within 90 days. However, responsibility is acknowledged that the current policy must not have been properly communicated to DDAP.
Notwithstanding the above information, the CEO has reviewed the matter with the Clinical Director, who has addressed the matter with all clinical staff in group supervision. Clinical staff will continue to track patient discharge and initiate follow up communication to comply with agency policy. The Clinical Director will ensure compliance in supervision and as part of chart audits. |
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 client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record was submitted and approved by the Department for the June 14, 2024, and June 6, 2025, annual licensing inspections. Completing annual physical examinations were again found to be a deficiency in the May 12, 2026 through May 13, 2026, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Aldie has diligently executed previous plans of correction. However, the full scope of these efforts has not yet been realized. Additional focus and oversight will be brought to the deficiency of obtaining informed and voluntary consent forms. Training has been provided to all clinical staff and compliance will be monitored during supervision and as part of regular chart audits. The CEO will also enforce the importance of compliance at monthly staff meetings. |