This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on July 8, 2026 through July 9, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Dolminis 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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Observations
Based on a review of patient records, the program failed to document the results of annual physical examinations given by the narcotic treatment program, which included an annual reevaluation by the narcotic treatment physician in one out of four applicable records reviewed.
Patient #13 was admitted on December 10, 2018, and was discharged June 1, 2026. An annual physical exam was documented in the patient record on November 20, 2024, and the next annual physical exam was not documented in the patient record until January 12, 2026. There was no documentation of an annual physical exam for 2025.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Annual History and Physical (H&P) due dates will become a standard component of clinical treatment planning and weekly treatment team meetings. The Clinical Supervisor and/or Lead Counselor will review Annual H&P due dates with the clinical team during weekly treatment team meetings and identify patients whose Annual H&P is due within the next 90 days.
Counselors will be responsible for discussing the upcoming Annual H&P with the client during individual treatment sessions, assisting with scheduling as needed, and encouraging the client to attend the scheduled appointment. Counselors will document the discussion, appointment status, and any follow-up actions taken in the patient's progress note.
Clients who do not have an appointment scheduled or who miss a scheduled Annual H&P appointment will continue to be reviewed during weekly treatment team meetings until the Annual H&P has been completed. Medical staff will notify the client's counselor, Lead Counselor, Clinical Supervisor, and Executive Director of any missed Annual H&P appointment on the same business day to allow for prompt patient outreach and rescheduling.
The Clinical Supervisor and/or Lead Counselor will monitor timely completion of Annual |