INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on July 16, 2025 through July 17, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Addiction Medicine and Health Advocate, 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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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 personnel records, the facility failed to ensure each employee had a written individual training plan, with input from both the employee and the supervisor, in ten of twelve personnel records reviewed.
Employee #1 was hired as the project director on April 18, 1988. The individual training plan was signed by employee on January 3, 2025; however, there was no documentation verifying the plan was completed with input from the supervisor.
Employee #2 was hired as the facility director on September 16, 2024. The individual training plan was signed by employee on January 3, 2025; however, there was no documentation verifying the plan was completed with input from the supervisor.
Employee #3 was hired as the clinical supervisor on October 9, 2023. The individual training plan was signed by employee on January 3, 2025; however, there was no documentation verifying the plan was completed with input from the supervisor.
Employee #4 was hired as a counselor on March 21, 2021. The individual training plan was signed by employee on December 31, 2024; however, there was no documentation verifying the plan was completed with input from the supervisor.
Employee #5 was hired as a counselor on September 7, 1999. The individual training plan was signed by employee on January 24, 2025; however, there was no documentation verifying the plan was completed with input from the supervisor.
Employee #6 was hired as a counselor on April 23, 2012. The individual training plan was signed by employee on January 23, 2025; however, there was no documentation verifying the plan was completed with input from the supervisor.
Employee #7 was hired as a counselor on May 31, 2023. The individual training plan was signed by employee on January 3, 2025; however, there was no documentation verifying it was completed with input from the supervisor.
Employee #8 was hired as a counselor on June 19, 2023. The individual training plan was signed by employee on January 23, 2025; however, there was no documentation verifying the plan was completed with input from the supervisor.
Employee #11 was hired as a counselor on March 24, 2025. The individual training plan was signed by employee on March 24, 2025; however, there was no documentation verifying the plan was completed with input from the supervisor.
Employee #12 was hired as a counselor on April 7, 2025. The individual training plan was signed by employee on April 7, 2025; however, there was no documentation verifying the plan was completed with input from the supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Support Staff member oversees trainings for the staff. As individual training plans are due to be developed, she will remind both clinical and supervisory staff of the requirement to complete training plans in collaboration, as well as signing plans right after completion. Clinical Support Staff will review all employee training files to ensure full compliance and report any issues to Program Director. |
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 document in the patient's record the determination of current dependency, prior to the administration of a narcotic agent, in three of three applicable patient records reviewed.
Patient # 2 was admitted on December 19, 2024 and was still active at the time of the inspection. The patient received their first dose of methadone on December 23, 2024; however, the current opiate narcotic dependency was not documented in the patient record until December 27, 2024.
Patient # 3 was admitted on February 18, 2025 and was still active at the time of the inspection. The patient received their first dose of methadone on February 18, 2025; however, the current opiate narcotic dependency was not documented in the patient record until February 19, 2025.
Patient # 6 was admitted on August 20, 2024 and was discharged on December 16, 2024. The patient received their first dose of methadone on August 22, 2024; however, the current opiate narcotic dependency was not documented in the patient record until August 23, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director discussed this finding with both the Medical Director and Narcotic Treatment Physician. The physicians have been reminded to complete and sign the required Physician's Documentation of Opiate Dependence form and Intake Physical Form on the day of intake, prior to the patient's first dose of methadone. Intake Coordinator will check newly admitted patient charts prior to them receiving their first dose to ensure documentation is signed. Program Director will also monitor this via quality record management and discuss in our Quality Assurance committee meetings. The Medical Director will be responsible for oversight. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document the results of an annual physical examination given by the narcotic treatment program, which is to include an annual reevaluation by the narcotic treatment physician, in one of four applicable patient records reviewed.
Patient #7 was admitted on June 6, 2014 and was discharged on December 9, 2024. The last physical examination documented in the record was dated on July 10, 2023. There was no annual physical examination completed during the 2024 treatment year.
This is a repeat citation from the July 8, 2024 through July 9, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A more robust tracking system will be developed by Clinical Program Manager and Clinical Support staff member to track patients that are due for annual physical exams. Clinical Support Staff will schedule patients ahead of their due date to allow for timely completion. She will inform the Clinical Program Manager and Program Director if any patient is not in compliance by their due date so this can be addressed with patient and their counselor in a timely fashion. The Clinical Program Manager will be responsible for oversight of this process and informing Program Director if further steps are required. |
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 sixty days in six of seven applicable client records reviewed.
Client # 1 was admitted on June 22, 2017 and was still active at the time of the inspection. A treatment plan update was completed on May 7, 2025 and the next update was due no later than July 7, 2025; however, the update was not completed until July 15, 2025.
Client # 2 was admitted on December 19, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 23, 2025 and the first update was due no later than March 23, 2025; however, the update was not completed until May 12, 2025.
Client # 3 was admitted on February 18, 2025 and was still active at the time of the inspection. A treatment plan update was completed on April 7, 2025 and the next update was due no later than June 7, 2025; however, the update was not completed until July 1, 2025.
Client # 4 was admitted on October 29, 2014 and was discharged on November 5, 2024. A treatment plan update was completed on August 26, 2024 and the next update was due no later than October 26, 2024; however, the update was not completed prior to discharge.
Client # 5 was admitted on August 23, 2018 and was discharged on July 12, 2025. A treatment plan update was completed on January 21, 2025 and the next update was due no later than March 21, 2025; however, the update was not completed until April 15, 2025.
Client # 7 was admitted on June 6, 2014 and was discharged on December 9, 2024. A treatment plan update was completed on September 27, 2024 and the next update was due no later than November 27, 2024; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed this finding during staff meeting on 7/24/25. Clinical staff was re-trained on timely completion of treatment plans, emphasizing importance of signing the document on the day it was completed. We will monitor treatment plan completion as part of Quality Assurance committee's Quality Record Management activities and discuss findings in our bi-monthly meetings. Clinical Supervisors will also review compliance during individual supervision with clinical staff. The clinical Program Manager will be responsible for oversight of these activities.
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