INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and monitoring inspection conducted on September 3-4, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Northeast Family Health Care LLL, dba Lansdowne Treatment Services 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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee within the regulatory timeframe, appropriate to that employee's skill level in one out of ten employee records reviewed. Employee #9 was hired on February 2, 2026, as a counselor and was still in the position as of the date of the inspection. The plan is dated March 11, 2026.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Training plans will be completed within seven days of new hires first day. It is part of the onboarding checking list and will be completed by the new hire's supervisor.
Executive Director will review all onboarding documents are completed on time. Executive Director will sign off when new hire completes onboarding training.
Clinical Supervisor will be trained on how to sign off and review onboarding documents and training for new hires on 10/02/26. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.Employee #11 was hired as support staff on December 13, 2022, and was due to have the communicable disease trainings no later than December 13, 2024. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.This finding was reviewed with facility staff during the licensing inspection. This is a repeat citation from the October 3, 2025 annual licensing inspection.
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Plan of Correction
Employee #11 is scheduled to completed training on 12/3/2026.
All staff are provided a training plan including required DDAP trainings that must be completed within 1 year of hire.
Executive Director and Clinical Supervisor will monitor to ensure all staff complete DDAP trainings within 1 year of hire. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1. Employee #3 was promoted to Clinical Supervisor on July 6, 2025 and was still acting in that position. Employee #3 was reported to have 25 hours per week devoted to their 34 clients on their caseload.The staff Full Time Equivalent (FTE) is determined by dividing the total number of hours the staff devotes to their clients by facility ' s work week. Then, in order to obtain the staff ' s ratio, the total number of clients on the staff ' s caseload is divided by the FTE.The FTE staff ' s caseload calculation is as follows: 25/40 = .625 (FTE); 34/.625= 54.4, which equals to a client/staff ratio of 54:1.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review caseload size and units prescribed during supervision to ensure compliance.
Executive Director and Clinical Supervisor will monitor to ensure caseloads are in ratio. |
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on a physical plant inspection, the facility failed to store all trash in noncombustible, covered containers that prevent the penetration of insects and rodents. The dumpster was observed to be open with trash protruding over the top of the dumpster.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Lids on dumpsters will be closed at all times.
Facility staff will be trained that lids on dumpsters must be closed at all times on 9/30/26.
Executive Director will monitor that lids are closed daily. |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The dosing restroom was observed to be unclean at the time of the inspection.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client bathroom is added to the cleaning schedule for the contracted housekeepers that come daily.
Executive Director will monitor to ensure that bathroom is cleaned daily along with all other cleaning completed by the contracted housekeepers. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits are unobstructed. The emergency side door had a removable flood barrier device on the floor in front of the door sill creating a tripping hazard. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Obstruction was removed on the day of the audit and disposed of. A sandbag was on the inside of the door to prevent water from coming in. There is a water grate outside the door and will be monitored to make sure it is clear for water to drain so water does not come in the building.
Executive Director will monitor that there is no obstacles to evacuation routes in the facility daily. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment. Employee #2 was hired on April 27, 2026 as the Facility Director and was still in the position as of the date of the inspection. The training was completed on September 2, 2026.Employee #9 was hired on February 2, 2026 as a counselor and was still in the position as of the date of the inspection. The training was completed on September 2, 2026. Employee #10 was hired on August 17, 2026 as a counselor and was still in the position as of the date of the inspection. The training was completed on September 2, 2026.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Training plans will be completed within seven days of new hires first day. It is part of the onboarding checking list and will be completed by the new hire's supervisor.
Executive Director will review all onboarding documents are completed on time. Executive Director will sign off when new hire completes onboarding training.
Clinical Supervisor will be trained on how to sign off and review onboarding documents and training for new hires on 9/30/26.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from October 2025 - August 2026, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the months of October 2025, March 2026, and May 2026.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Fire drills will be completed monthly. New Executive Director is trained on the completion of monthly safety drills.
Executive Director will facilitate and document monthly fire inspections. Quality director monitoring completion of safety drills. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies. Employee #2 was hired on April 27, 2026 as the Facility Director and was still in the position as of the date of the inspection. There was no documentation of the training being completed as of the date of the inspection.Employee #9 was hired on February 2, 2026 as a counselor and was still in the position as of the date of the inspection. There was no documentation of the training being completed as of the date of the inspection.Employee #10 was hired on August 17, 2026 as a counselor and was still in the position as of the date of the inspection. The training was completed on September 2, 2026.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Training plans will be completed within seven days of new hires first day. It is part of the onboarding checking list and will be completed by the new hire's supervisor.
Employee 9 and 10 will complete training by 10/02/2026
Executive Director will review all onboarding documents are completed on time. Executive Director will sign off when new hire completes onboarding training.
Clinical Supervisor will be trained on how to sign off and review onboarding documents and training for new hires on 9/30/26. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative documents, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.The last documented sign-off from the project director was dated January 15, 2025, and the next one was due no later than January 15, 2026; however, the documentation provided was dated August 11, 2026, and signed by the compliance specialist.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will review annual policies and sign off each year.
The Project Director will review and ensure policies are updated and issue a signed attestation to that effect by January 15, 2027. |
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 out of five applicable records reviewed. There was no consent to release information forms for a funding source. Facility staff confirmed billing had occurred.Client #2 was admitted on March 12, 2026 and was still active at the time of the inspection.These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the October 3, 2025, October 1, 2024, November 3, 2023, and September 1, 2023 annual licensing inspections.
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Plan of Correction
ROI will be completed upon intake or as needed prior to reaching out to any person or agency to ensure that it is documented in writing and signed by the client. Clinical Supervisor will complete a training on documenting ROI on 10/01/2026.
Clinical Supervisor and Quality will review releases completed are properly filled out during chart audits. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which include specific information to be disclosed in two out of five applicable records reviewed.Client #1 was admitted on November 28, 2025 and discharged on July 8, 2026. A consent form dated November 28, 2026 to a funder had "other" checked for information to be disclosed without specifying what additional information was permitted to be released.Client #2 was admitted on March 12, 2026 and was still active at the time of the inspection. A consent form dated March 12, 2026 to a funder did not indicate specific information to be disclosed. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
ROI will be completed upon intake or as needed prior to reaching out to any person or agency to ensure that it is documented in writing and signed by the client. Clinical Supervisor will complete a training on documenting ROI on 10/01/2026.
Clinical Supervisor and Quality will review releases completed are properly filled out during chart audits. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in one out of five applicable client records reviewed. Client #1 was admitted on November 28, 2025 and discharged on July 8, 2026. Three release of information forms for a funding source, government agency and hospital dated November 28, 2025 did not have documentation that the client was offered a copy of the consent form. This finding was reviewed with the facility staff during the licensing process. This is a repeat citation from the October 3, 2025 annual licensing inspection.
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Plan of Correction
ROI will be completed upon intake or as needed prior to reaching out to any person or agency to ensure that it is documented in writing and signed by the client. Counselor will check box if the client received a cop of the ROI or not. Clinical Supervisor will complete a training on documenting ROI on 10/01/2026.
Clinical Supervisor and Quality will review releases completed are properly filled out during chart audits. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients. During the week of May 17-23, 2026, the patient census was 350. The facility was required to provide at least 35 physician hours. There were 29 physician hours documented. During the week of July 12-18, 2026, the patient census was 355. The facility was required to provide at least 35.5 physician hours. There were 29 physician hours documented.During the week of July 19-25, 2026, the patient census was 349. The facility was required to provide at least 34.9 physician hours. There were 29 physician hours documented.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Following identification of the deficiency, facility leadership reviewed the active patient census and required physician staffing hours to determine the number of onsite physician hours necessary to maintain regulatory compliance.
Effective 9/23/26 , the facility adjusted the medical staffing schedule to ensure that required narcotic treatment physician services are provided based upon the program's current patient census. Medical provider schedules were revised as necessary to provide sufficient coverage and maintain compliance.
To prevent recurrence, the Executive Director will review the OTP census and required physician hours weekly and compare the required hours against the actual documented provider hours. Any identified or anticipated staffing shortfall will be immediately escalated to Regional Leadership so that additional qualified medical coverage can be scheduled. |
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
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in three out of three applicable records. Client #1 was admitted on November 28, 2025 and discharged on July 8, 2026.Client #2 was admitted on March 12, 2026 and was still active at the time of the inspection.Client #3 was admitted on July 7, 2026 and was still active at the time of the inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Quality Director trained Clinical Supervisor on the intake checklist on 09/15/26 to ensure all required assessments and forms are completed upon admission. Clinical Supervisor will complete training on Biopsychosocials on 09/24/26.
Clinical Supervisor will audit all intakes 10-14 days after admission to ensure all assessments and documents are completed. |
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 document treatment plan updates within the regulatory timeframe in two out of six applicable records reviewed.Client #1 was admitted on November 28, 2025 and discharged on July 8, 2026. A treatment plan update was completed on January 27, 2026 and the next update was due no later than March 27, 2026; however, the next update was completed on April 1, 2026.Client #4 was admitted on August 11, 2025 and was still active at the time of the inspection. A treatment plan update was completed on May 20, 2026 and the next update was due no later than July 20, 2026; however, the next update was completed on July 29, 2026.These findings were reviewed with facility staff during the next licensing inspection. This is a repeat citation from the October 3, 2025, October 1, 2024, November 3, 2023, and September 1, 2023 annual licensing inspections.
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Plan of Correction
Treatment plans are to be completed every 60 days. Clinical Supervisor will complete training on Treatment Plans on 10/01/26.
Executive Director and Clinical Supervisor will be monitoring the treatment plan dashboard in Powertools to ensure timely completion of treatment plan updates. |
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, the facility failed to provide a complete client record, which is to include follow-up information in two out of three discharged records reviewed. The facility's policy and procedures manual states follow-ups are to be completed at 7-day, 30-day and 60-days post discharge.Client #1 was admitted on November 28, 2025 and discharged on July 8, 2026. Client #5 was admitted on March 11, 2024 and discharged on June 4, 2026.These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the October 3, 2025, October 1, 2024, November 3, 2023, and September 1, 2023 annual licensing inspections.
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Plan of Correction
Clinical Supervisor will review the 7 day, 30 day and 60 day follow up call in our discharge process policy with all counselors.
Executive director and Clinical supervisor will review supervisee's schedulers on a weekly basis to ensure completion of any discharge follow up calls. |
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 staff training records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for obtaining a consent form prior to release of information were submitted and approved by the Department for the October 3, 2025, October 1, 2024, November 3, 2023, and September 1, 2023 annual licensing inspections. Releases of information was again found to be a deficiency in the September 4, 2026 licensing inspection.A plan of correction for treatment plan updates were submitted and approved by the Department for the October 3, 2025, October 1, 2024, November 3, 2023, and September 1, 2023 annual licensing inspections. Treatment plan updates was again found to be a deficiency in the September 4, 2026 licensing inspection.A plan of correction for follow-up information were submitted and approved by the Department for the October 3, 2025, October 1, 2024, November 3, 2023, and September 1, 2023 annual licensing inspections. Follow-up information was again found to be a deficiency in the September 4, 2026 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
New Executive Director will follow up on all past plans of corrective action
Executive Director will monitor all plans of corrections to ensure actions steps are followed and completed. |