INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on December 3, 2025 through December 4, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Narcotic Addict Rehabilitation Program of Thomas Jefferson University 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(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 annual training, during the facility's January 1, 2024 through December 31, 2024 training year, in one of seven applicable personnel records reviewed.
Employee # 10 was hired as a counselor on September 19, 2022. The personnel record documented 21.75 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A citation was issued on 12/15/2025 for a clinician's failure to complete the required 25 training hours within the reviewed year, in accordance with 704.11(f)(2). In response, the Thomas Jefferson University (TJU) NARP program implemented a monitoring schedule to ensure ongoing compliance with DDAP-required staff training.
This corrective action is designed to ensure that all employees complete required training within established timelines and that staff have consistent access to ongoing clinical and professional development opportunities.
Clinical Supervisors are responsible for closely monitoring staff compliance with DDAP training requirements and for providing staff with the most current training information, including available training dates published on the DBHIDS and DDAP websites.
Training compliance will be reviewed bi-annually through supervisory oversight and staff record audits. Any identified deficiencies will be addressed promptly through corrective action to ensure full compliance with regulatory requirements and prevent recurrence. |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment in one of three applicable patient records reviewed.
Patient # 3 was admitted on October 22, 2025 and was still active at the time of the inspection. At the time of the inspection, there was no face-to-face determination documented in the record prior to the patient's admission for maintenance treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A citation was issued on 12/15/2025 for failure to have face to face determination prior to the patient's admission in a client record in accordance with 715.9(a)(4). In response, the Thomas Jefferson University (TJU) NARP program developed and implemented a Plan of Correction to address the deficiency and prevent recurrence.
On 12/16/2025, the TJU NARP Executive Director and Clinical Supervisor implemented corrective measures. Effective immediately, all transfer admissions are required to complete the full admission intake process to ensure accurate and comprehensive documentation of a face-to-face determination prior to the patient's admission for maintenance treatment.
Previously, the admission process for transfer patients was expedited due to an increased volume of transfers from a local clinic that was closing. Moving forward, to correct this deficiency, all transfer patients will follow the standard admission process. This includes completion of a full intake assessment, biopsychosocial evaluation, and psychiatric evaluation upon admission. Adherence to this process will ensure that each patient obtains face-to-face determination that is accurately documented in the clinical record.
The patient has been scheduled for a psychiatric assessment on 1/9/2026. This evaluation will obtain and document face-to-face determination, thereby correcting the identified deficiency.
All patients previously admitted under the expedited transfer procedure have been reviewed and scheduled for a psychiatric assessment within the following 30 days. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of patient records, the facility failed to document the results of an initial intake physical examination in one of three applicable patient records reviewed.
Patient # 3 was admitted on October 22, 2025 and was still active at the time of the inspection. At the time of the inspection, there was no initial intake physical examination documented in the record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A citation was issued on 12/15/2025 for failure to obtain an initial intake physical examination in a client record in accordance with 715.9(a)(4). In response, the Thomas Jefferson University (TJU) NARP program developed and implemented a Plan of Correction to address the deficiency and prevent recurrence.
On 12/16/2025, the TJU NARP Executive Director and Clinical Supervisor implemented corrective measures. Effective immediately, all transfer admissions are required to complete the full admission intake process to ensure accurate and comprehensive documentation of an initial intake physical examination.
Previously, the admission process for transfer patients was expedited due to an increased volume of transfers from a local clinic that was closing. Moving forward, to correct this deficiency, all transfer patients will follow the standard admission process. This includes completion of a full intake assessment, biopsychosocial evaluation, and psychiatric evaluation upon admission. Adherence to this process will ensure that each patient's complete initial intake physical examination is accurately documented in the clinical record.
The patient has been scheduled for a psychiatric assessment on 1/9/2026. This evaluation will obtain and document the patient's initial intake physical examination, thereby correcting the identified deficiency.
All patients previously admitted under the expedited transfer procedure have been reviewed and scheduled for a psychiatric assessment within the following 30 days. |
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 a review of patient records, the facility failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and reviewed, dated, and signed by the medical director in one of one applicable patient records reviewed.
Patient # 7 was admitted on September 3, 2024 and was discharged on October 7, 2025. The annual evaluation of the patient's status was completed by the counselor on August 27, 2025; however, the evaluation was not reviewed, dated, and signed by the medical director.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A citation was issued on 12/15/2025 due to the annual clinical evaluation not being reviewed, dated, and signed by the Medical Director, in accordance with 715.23(c) (1?7). In response, the Thomas Jefferson University (TJU) NARP program developed and implemented a Plan of Correction to address the deficiency and prevent recurrence.
On 12/16/2025, the TJU NARP Executive Director and Clinical Supervisor implemented corrective measures. Effective immediately, all annual clinical evaluations completed by counselors will be routed to the Clinical Supervisor for initial review and approval. Upon approval, the Clinical Supervisor will forward the annual clinical evaluation to the Medical Director for review, signature, and dating.
This procedure has been implemented program-wide and will be monitored to ensure compliance with regulatory requirements and prevent future deficiencies. |
711.91(b)(3)(i) LICENSURE Medical History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admissions process, a medical history of the client in one of three client records reviewed.
Client # 3 was admitted on October 22, 2025 and was still active at the time of the inspection. There was no medical history documented in the client record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A citation was issued on 12/15/2025 for failure to document medical history in a client record, in accordance with 711.91(b)(3)(i). In response, the Thomas Jefferson University (TJU) NARP program developed and implemented a Plan of Correction to address the deficiency and prevent recurrence.
On 12/16/2025, the TJU NARP Executive Director and Clinical Supervisor implemented corrective measures. Effective immediately, all transfer admissions are required to complete the full admission intake process to ensure accurate and comprehensive documentation of current medical history.
Previously, the admission process for transfer patients was expedited due to an increased volume of transfers from a local clinic that was closing. Moving forward, to correct this deficiency, all transfer patients will follow the standard admission process. This includes completion of a full intake assessment, biopsychosocial evaluation, and psychiatric evaluation upon admission. Adherence to this process will ensure that each patient's complete medical history is accurately documented in the clinical record.
The patient has been scheduled for a psychiatric assessment on 1/9/2026. This evaluation will obtain and document the patient's medical history, thereby correcting the identified deficiency.
All patients previously admitted under the expedited transfer procedure have been reviewed and scheduled for a psychiatric assessment within the following 30 days. |
711.91(b)(3(ii) LICENSURE D & A History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake procedures, a drug or alcohol history of the client in one of three client records reviewed.
Client # 3 was admitted on October 22, 2025 and was still active at the time of the inspection. There was no drug or alcohol history documented in the client record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A citation was issued on 12/15/2025 for failure to document drug or alcohol history in a client record in accordance with 711.91(b)(3(ii). In response, the Thomas Jefferson University (TJU) NARP program developed and implemented a Plan of Correction to address the deficiency and prevent recurrence.
On 12/16/2025, the TJU NARP Executive Director and Clinical Supervisor implemented corrective measures. Effective immediately, all transfer admissions are required to complete the full admission intake process to ensure accurate and comprehensive documentation of drug and alcohol history.
Previously, the admission process for transfer patients was expedited due to an increased volume of transfers from a local clinic that was closing. Moving forward, to correct this deficiency, all transfer patients will follow the standard admission process. This includes completion of a full intake assessment, biopsychosocial evaluation, and psychiatric evaluation upon admission. Adherence to this process will ensure that each patient's complete drug and alcohol history is accurately documented in the clinical record.
The patient has been scheduled for a psychiatric assessment on 1/9/2026. This evaluation will obtain and document the patient's drug and alcohol history, thereby correcting the identified deficiency.
All patients previously admitted under the expedited transfer procedure have been reviewed and scheduled for a psychiatric assessment within the following 30 days. |
711.91(b)(3)(iii) LICENSURE Personal History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake procedures, a personal history of the client in one of three client records reviewed.
Client # 3 was admitted on October 22, 2025 and was still active at the time of the inspection. There was no personal history documented in the client record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A citation was issued on 12/15/2025 for failure to document personal history in a client record in accordance with 711.91(b)(3)(iii). In response, the Thomas Jefferson University (TJU) NARP program developed and implemented a Plan of Correction to address the deficiency and prevent recurrence.
On 12/16/2025, the TJU NARP Executive Director and Clinical Supervisor implemented corrective measures. Effective immediately, all transfer admissions are required to complete the full admission intake process to ensure accurate and comprehensive documentation of personal history.
Previously, the admission process for transfer patients was expedited due to an increased volume of transfers from a local clinic that was closing. Moving forward, to correct this deficiency, all transfer patients will follow the standard admission process. This includes completion of a full intake assessment, biopsychosocial evaluation, and psychiatric evaluation upon admission. Adherence to this process will ensure that each patient's complete personal history is accurately documented in the clinical record.
The patient has been scheduled for a psychiatric assessment on 1/9/2026. This evaluation will obtain and document the patient's personal history, thereby correcting the identified deficiency.
All patients previously admitted under the expedited transfer procedure have been reviewed and scheduled for a psychiatric assessment within the following 30 days. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake procedures, a psychosocial evaluation of the client in one of three client records reviewed.
Client # 3 was admitted on October 22, 2025 and was still active at the time of the inspection. There was no psychosocial evaluation of the client documented in the client record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A citation was issued on 12/15/2025 for failure to document psychosocial evaluation in a client record in accordance with 711.91(b)(6). In response, the Thomas Jefferson University (TJU) NARP program developed and implemented a Plan of Correction to address the deficiency and prevent recurrence.
On 12/16/2025, the TJU NARP Executive Director and Clinical Supervisor implemented corrective measures. Effective immediately, all transfer admissions are required to complete the full admission intake process to ensure accurate and comprehensive documentation of a psychosocial evaluation.
Previously, the admission process for transfer patients was expedited due to an increased volume of transfers from a local clinic that was closing. Moving forward, to correct this deficiency, all transfer patients will follow the standard admission process. This includes completion of a full intake assessment, biopsychosocial evaluation, and psychiatric evaluation upon admission. Adherence to this process will ensure that each patient's complete psychosocial evaluation is accurately documented in the clinical record.
The patient has been scheduled for a psychiatric assessment on 1/9/2026. This evaluation will obtain and document the patient's psychosocial evaluation, thereby correcting the identified deficiency.
All patients previously admitted under the expedited transfer procedure have been reviewed and scheduled for a psychiatric assessment within the following 30 days. |
711.93(c)(2)(iii) LICENSURE Purpose of Disclosure
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(iii) The purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on release of information forms in one of seven client records reviewed.
Client # 4 was admitted on February 3, 2025 and was discharged on October 6, 2025. There were release of information forms to external agencies signed and dated by the client on February 2, 2025, April 14, 2025, April 28, 2025 and May 12, 2025; however, each release of information form did not include documentation of the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A citation was issued on 12/15/2025 for releases of information failing to include documentation for the purpose of the disclosure, in accordance with 711.93(c)(2)(iii). In response, the Thomas Jefferson University (TJU) NARP program developed and implemented a Plan of Correction to address the deficiency and prevent recurrence.
To prevent this citation from recurring, the Executive Director made adjustments to the EHR on 12/11/2025 to ensure that all releases of information now include a the purpose of the disclosed information to each entity, in compliance with regulations.
Compliance will be monitored through monthly chart audits conducted by the Clinical Supervisors. The Executive Director will oversee compliance through additional chart audits and supervision meetings with the Clinical Supervisor. |