INITIAL COMMENTS
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This report is a result of an on-site licensure renewal, methadone monitoring inspection and complaint investigation conducted on July 7-9, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Progressive Medical Specialists, 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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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 a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one of seven records.
Client #7 was admitted on October 11, 2024, and discharged on February 21, 2025. There was no consent to release information form for the funding source in client #7 ' s record. Facility staff confirmed billing had occurred.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Comprehensive Chart Review ? Completed 8/4/2025
Upon being notified of the missing consent, the Project Director instructed front office staff to conduct a full review of each client's chart. This review focused on verifying that valid, signed releases of information were on file for both billing and emergency contacts. The review was completed in full as of August 4, 2025.
Reinforcement of Admission Chart Audit Procedures ? Implemented 7/10/2025
On July 10, 2025, Clinical Supervisors were reminded of the established procedures for auditing the charts of newly admitted patients. This includes a detailed review of the chart before a patient is assigned to a primary counselor?specifically ensuring that all required releases of information are completed, signed, and valid.
Newly admitted patients are assigned to a primary counselor within 24?48 hours of admission, which allows for any missing or incomplete documents to be identified and corrected promptly.
Quarterly Chart Audit Process Enhanced ? Implemented 7/10/2025
Also on July 10, 2025, staff responsible for conducting quarterly chart audits reviewed the audit protocol to emphasize the importance of verifying all releases of information during each audit cycle. This reinforcement ensures continued compliance and documentation accuracy over time.
The reinforcement of these chart audit procedures will help prevent missing or expired releases of information in the future. Compliance will be monitored on a continuous basis through regular audits and oversight by supervisory staff.
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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records and incident reports, the facility failed to inform the Department of an unusual incident within the required three business days.
The facility was informed of the death of a client on December 17, 2024, and an incident report was due to be filed no later than December 20, 2024; however, it was filed December 30, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Corrective Action Taken:
As of April 7, 2025, the Project Director provided formal training to Clinical Supervisor on the proper procedures for completing and submitting unusual incident reports. This training was initiated in response to an increase in the number of reportable incidents and the need to ensure timely and accurate submission.
Ongoing Compliance Strategy:
With both the Project Director and the Clinical Supervisor now trained and authorized to complete unusual incident reports, the responsibility is shared between two qualified individuals. This redundancy ensures reports can be submitted without delay, even if one staff member is unavailable.
Monitoring of Unusual Incident Reports
Electronic Submission and Tracking
All unusual incident reports will be submitted to DDAP through the designated software messaging system.
A tracking process, maintained in Microsoft OneDrive, will be used to document each submission.
Daily Review
PD and/or Clinical Supervisor will review the tracking log daily to confirm that each submitted report has been accepted by DDAP.
Filing in Patient Record
Once acceptance is verified, the unusual incident report will be printed and filed in the patient's electronic software chart.
This procedure ensures timely submission, verification, and accurate recordkeeping of all unusual incident reports in compliance with DDAP requirements.
This corrective action is expected to prevent recurrence of the issue. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records and incident reports, the facility failed to inform the Department of an unusual incident within the required three business days.
Client #7 was admitted on October 11, 2024, and discharged on February 21, 2025.
An incident note in client #7 ' s record indicates an ambulance was called and came to the facility on January 14, 2025. An unusual incident report was due to be filed by January 17, 2025; however, there was no unusual incident report filed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Corrective Action Taken:
As of April 7, 2025, the Project Director provided formal training to Clinical Supervisor on the proper procedures for completing and submitting unusual incident reports. This training was initiated in response to an increase in the number of reportable incidents and the need to ensure timely and accurate submission.
Ongoing Compliance Strategy:
With both the Project Director and the Clinical Supervisor now trained and authorized to complete unusual incident reports, the responsibility is shared between two qualified individuals. This redundancy ensures reports can be submitted without delay, even if one staff member is unavailable.
Monitoring of Unusual Incident Reports
Electronic Submission and Tracking
All unusual incident reports will be submitted to DDAP through the designated software messaging system.
A tracking process, maintained in Microsoft OneDrive, will be used to document each submission.
Daily Review
PD and/or Clinical Supervisor will review the tracking log daily to confirm that each submitted report has been accepted by DDAP.
Once acceptance is verified, the unusual incident report will be printed and filed in the patient's electronic software chart.
This procedure ensures timely submission, verification, and accurate recordkeeping of all unusual incident reports in compliance with DDAP requirements.
This corrective action is expected to prevent recurrence of the issue.
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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 a review of medical staff coverage, the facility failed to ensure one-third of all required narcotic treatment physician time was provided by a narcotic treatment physician for one of sixteen weeks.
Physician service hours were reviewed from February 2, 2025, through May 31, 2025. During the week of May 25, 2025, through May 31, 2025, the facility's census was 257 patients. The facility was required to provide 25.7 hours of onsite physician services. One-third of 25.7 is 8.56. The narcotic treatment physician hours should have been 8.56 hours; However, the physician hours totaled 6.5 hours.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
On July 24, 2025, the Project Director and Medical Director reviewed medical coverage requirements and identified the shortfall. All medical staff were informed of compliance expectations based on census. The facility already reviews and verifies scheduled physician hours weekly to ensure regulatory minimums are met but preventive measures have been revised
Preventive Measures:
As of August 4, 2025, all medical staff agreed:
that in any week where required physician hours are at risk of not being met, additional coverage will be scheduled for Saturday.
Contingency coverage plans will be activated in advance of any short work week (e.g., due to holidays or closures).
Expected Outcome:
This plan ensures that required narcotic treatment physician hours are consistently met or exceeded. These changes are intended to prevent recurrence of this deficiency
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