INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Northeast Treatment Centers, 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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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on the physical plant inspection, the facility failed to ensure fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company with the date of the inspection being indicated on the fire extinguisher or inspection tag.
At the time of the inspection, there were a total of seven fire extinguishers located throughout the facility. Six of the fire extinguishers were last inspected in May 2024 and one fire extinguisher was last inspected in June 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All fire extinguishers will be checked twice yearly while completing the emergency facility checklist. The results will be reported to the VP of Integrated Care and the Health and Safety Committee. All fire extinguishers will be checked twice yearly by the site director and operations director and the results will be recorded on the facility checklist health and safety form. The site director and operations director will work with the building manager to ensure that they arrange that the fire department inspect, recharge and update the inspection tag yearly. All fire extinguishers have been charges and the tag has been updated. |
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 document the specific information to be released on consent to release information forms in four of five applicable client records reviewed.
Client #1 was admitted on April 23, 2025 and was active at the time of the inspection. There was a release of information form to a transportation agency signed and dated by the client on April 23, 2025; however, there was no specific information to be disclosed documented on the release form.
Client #2 was admitted on June 4, 2025 and was active at the time of the inspection. There was a release of information form to a transportation agency signed and dated by the client on June 4, 2025; however, there was no specific information to be disclosed documented on the release form.
Client #4 was admitted on July 10, 2025 and was discharged on November 24, 2025. There was a release of information form to a transportation agency signed and dated by the client on July 10, 2025; however, there was no specific information to be disclosed documented on the release form.
Client #5 was admitted on April 29, 2025 and was discharged on September 28, 2025. There was a release of information form to a transportation agency signed and dated by the client on April 29, 2025; however, there was no specific information to be disclosed documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All care coordination and clinical staff were re-trained on how to appropriately complete releases of information forms on 1/8/26 during the staff meeting. The site director and clinical supervisor reviewed the importance of documenting the specific information to be released to a transportation agency as well as to all other entities. The clinical supervisor and/or director will review all Releases of Information that are completed. The director will report her findings to the VP of Integrated Care in weekly supervision. Releases of Information will be reviewed in an ongoing basis by the director in staff meetings. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on individual treatment and rehabilitation plans in four of five applicable client records reviewed.
Client #1 was admitted on April 23, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 29, 2025; however, the plan did not include the frequency of treatment and rehabilitation services being provided to the client.
Client #2 was admitted on June 4, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 20, 2025; however, the plan did not include the frequency of treatment and rehabilitation services being provided to the client.
Client #3 was admitted on May 28, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 7, 2025; however, the plan did not include the frequency of treatment and rehabilitation services being provided to the client.
Client #4 was admitted on July 10, 2025 and was discharged on November 24, 2025. The individual treatment and rehabilitation plan was completed on September 12, 2025; however, the plan did not include the frequency of treatment and rehabilitation services being provided to the client.
This is a repeat citation from the January 22, 2024, and December 12, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff were re-trained on 1/8/26 on how to document the type and frequency of treatment and rehabilitation services on individual treatment plans. The director reviewed the importance of thorough documentation and making the frequency as specific as possible. Treatment plans will be reviewed on a weekly basis by the clinical supervisor and/or site director. All treatment plans will be tracked through the caseload report. The site director will report her findings to the VP of integrated care in weekly supervision. Treatment planning will be an ongoing agenda item in the staff meetings lead by the director and clinical supervisor. |
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 client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to document the type and frequency of treatment and rehabilitation services on treatment plans were submitted and approved by the Department for the January 22, 2024, and December 12, 2024 annual licensing inspections. Failing to document the type and frequency of treatment and rehabilitation services on treatment plans was again found to be a deficiency in the December 15, 2025 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor and program director completed a re-training for staff on 1/8/26 during the staff meeting. The re-training focused on the importance of documenting the type and frequency documented in a treatment plan. The clinical supervisor and director will review all treatment plans on a weekly basis to ensure that the type and frequency are clearly documented in the treatment plan. This will be documented in the case load report. The site directors will share her findings with the VP of Integrated Care on a weekly basis in supervision. Treatment planning will also be an ongoing topic for counselors in the bi-weekly staff meetings. |