INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone buprenorphine monitoring inspection conducted on December 4, 2025 through December 5, 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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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director completed at least 12 clock hours of training annually, during the facility's January 1, 2024 through December 31, 2024 training year, in one of one applicable personnel record reviewed.
Employee # 1 was hired as the project director on July 1, 2013. The personnel record documented zero hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On December 9, 2025, NET received a copy of Employee #1/CEO transcript, totaling 14.5 training hours.
Moving forward, NET leadership will submit a request to waive the CEO's 12 required training hours. Program Director will submit This request by April 15, 2026.
If the exception is not granted by the Department, VP of Addiction Services will monitor the completion of annual trainings prior to the yearly deadline of December 31st, 2026 to ensure all 12 hours of training is completed before the date. |
705.29 (2) (iv) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
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Observations
Based on a physical plant inspection, the facility failed to secure all hazardous and poisonous substances and materials with safety latches or locks within the child care room of the facility.
During the inspection, which was conducted on December 5, 2025, there was hand sanitizer and bleach left unsecured on the top of a cabinet in the child care room.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On December 5, 2025, the Program Direct had removed the hand sanitizer and bleach bottle that was left unsecured on the top of the cabinet in the childcare room. Facilities maintenance staff will continue to monitor the grounds to ensure the facility is free from all hazardous and poisonous substances and materials with safety latches or locks to protect the health and safety of our clients and their children. Childcare staff has been retrained on December 8, 2025, on safety protocols regarding hazardous and poisonous substances in the playroom. Playroom staff supervisor will conduct daily safety inspections in the playroom to ensure the space is free of all hazardous and poisonous materials. |
715.9(a)(3) 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:
(3) Obtain a drug use history and current drug use status of the individual.
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Observations
Based on a review of patient records, the facility failed to obtain a drug use history and current drug use status of the individual, prior to the administration of a maintenance agent, in one of three applicable patient records reviewed.
Patient # 7 was admitted on January 9, 2025 and was active at the time of the inspection. There was no documentation in the record of a drug use history and current drug use status prior to administration of the first dose on January 9, 2025. The drug use history and current drug use status documentation was completed by the clinician on January 27, 2025 and was reviewed and completed by the physician on August 19, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On December 22, 2025, NET updated the Bridge Screening Assessment to include the following questions: Drug use history, Current drug use status, psychiatric history and medical and medication history.
The Medical Director is actively working in collaboration with the QA team to revise the physical assessment into a concise yet comprehensive format to ensure same-day completion and signature prior to patient dosing. This will be completed and implemented by February 2, 2026. Effective Immediately, Program Manager will ensure all physicals are completed and including a doctor's signature prior to the patient's first dose being administered.
Patient #7 documentation was signed by the medical director on August 19, 2025.
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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 have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug prior to the administration of a maintenance agent in one of three applicable patient records reviewed.
Patient # 7 was admitted on January 9, 2025 and was active at the time of the inspection. There was no documentation in the record of an initial face-to-face meeting with the physician prior to the first dose on January 9, 2025. The face-to-face documentation was completed by the physician on August 19, 2025.
This is a repeat citation from the December 18, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director is actively working in collaboration with the QA team to revise the physical assessment into a concise yet comprehensive format to ensure same-day completion and signature prior to patient dosing. This will include the medical director's determination of the individual's dependence upon a narcotic drug. This will be completed and implemented by February 2, 2026. Effective Immediately, Program Manager will ensure all physicals are completed and including a doctor's signature prior to the patient's first dose being administered.
Patient #7 documentation was signed by the medical director on August 19, 2025.
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715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
Based on a review of patient records, the narcotic treatment program failed to complete a personal history from the patient, within the first week of admission, in one of three applicable patient records reviewed.
Patient # 7 was admitted on January 9, 2025 and was active at the time of the inspection. The documentation of the patient's personal history was not completed by the clinician until January 27, 2025.
This is a repeat citation from the December 18, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On December 22, 2025, NET updated the Bridge Screening Assessment to include the following questions: Client's personal information, Drug use history, Current drug use status, psychiatric history and medical and medication history.
This form will be completed during the intake assessment portion prior to meeting with the physician to complete the physical assessment.
Patient #7 documentation was signed by the medical director on August 19, 2025.
The Medical Director is actively working in collaboration with the QA team to revise the physical assessment into a concise yet comprehensive format to ensure same-day completion and signature prior to patient dosing. This will include the personal history of the patient. This will be completed and implemented by February 2, 2026. Effective Immediately, Program Manager will ensure all physicals are completed and including a doctor's signature prior to the patient's first dose being administered.
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715.10(a)(2) LICENSURE Pregnant patients
(a) A narcotic treatment program may place a pregnant patient, regardless of age, who has had a documented narcotic dependency in the past and who may return to narcotic dependency, on a comprehensive maintenance regime.
(2) Evidence of all findings and the criteria used to determine the findings shall be recorded in the patient's record by the admitting narcotic treatment physician before the initial dose is administered to the patient.
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Observations
Based on a review of patient records, the narcotic treatment physician failed to record evidence of all findings and the criteria used to determine the findings in the patient record, before the initial dose is administered for pregnant patients, in one of one applicable patient reviewed.
Patient # 7 was admitted on January 9, 2025 and was active at the time of the inspection. The initial dose was given to the patient on January 9, 2025; however, the documentation was not completed by the physician until August 19, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director is actively working in collaboration with the QA team to revise the physical assessment into a concise yet comprehensive format to ensure same-day completion and signature prior to patient dosing. This will include documenting additional findings for pregnant patient's and creating a maintenance regiment prior to their initial dose being administered. This will be completed and implemented by February 2, 2026. Effective Immediately, Program Manager will ensure all physicals are completed and including a doctor's signature prior to the patient's first dose being administered.
Patient #7 documentation was signed by the medical director on August 19, 2025.
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715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of patient records, the facility failed to physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and 709.28 (relating to confidentiality), in one of seven patient records reviewed.
Patient # 5 was admitted on September 8, 2025 and was active at the time of inspection. At the time of the inspection, there was another patient's transfer packet information included in this patient's record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the QA department will review all documentation that are scanned into patient charts to ensure all documents are filed in the designated patient charts to ensure confidentiality in accordance with 42 CRF 2.22 and 709.28.
QA department supervisor will audit patient charts weekly to monitor the documents that are scanned into patient's charts by February 2, 2026.
Patient #5 the documents removed from their record on December 8, 2025.
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715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure patient files, including admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, were transferred to the receiving narcotic treatment program in one of one applicable patient records reviewed.
Patient # 3 was admitted on July 20, 2017 and was transferred to another narcotic treatment program on May 20, 2025. There was no documentation in the record indicating the receiving narcotic treatment program was notified of the date of admission of the patient, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient.
This is a repeat citation from the December 18, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the QA department will ensure the following are added to the patient's chart at the time of transfer: the date of admission of the patient, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient.
QA department supervisor will create a transfer document tracker to maintain and review during weekly supervisions. This will include date of transfer packets being sent and received and any missing documents that are needed to complete a transfer. The tracker will include a space to indicate the date documents were uploaded to the patient's chart. This will be effective February 2, 2026.
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715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of patient records, the narcotic treatment program failed to include documentation of the results of an initial intake physical examination in the patient file, per the facility policy and procedure manual, in one of three applicable patient records reviewed.
The facility policy and procedure manual stated the initial physical examination is to be completed by the physician upon admission.
Patient # 7 was admitted on January 9, 2025 and was active at the time of the inspection. The initial intake physical examination was not completed by the physician until August 19, 2025.
This is a repeat citation from the December 18, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director is actively working in collaboration with the QA team to revise the physical assessment into a concise yet comprehensive format to ensure same-day completion and signature. This will be completed and implemented by February 2, 2026. Effective Immediately, Program Manager will ensure all physicals are completed and including a doctor's signature.
Effective immediately, senior program director will ensure the medical director is re-trained on the intake process and the DDAP regulations to ensure all documentation completed and signed on the date of intake.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in the record, an annual evaluation of each patient's status completed by the patient's counselor and reviewed, dated, and signed by the medical director in three of four applicable patient records reviewed.
Patient # 1 was admitted on May 5, 2022 and was discharged on October 19, 2025. The annual clinical evaluation was signed by the counselor on August 15, 2025, but the evaluation was not signed by the medical director at the time of the inspection.
Patient # 3 was admitted on July 20, 2017 and was discharged on May 20, 2025. The annual clinical evaluation was signed by the counselor on April 1, 2025, but the evaluation was not signed by the medical director at the time of the inspection.
Patient # 6 was admitted on September 7, 2021 and was active at the time of inspection. The most recent clinical evaluation, in the record, was completed by the counselor on September 5, 2024. There was no documentation of an updated, annual clinical evaluation in the patient record as of the date of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor and Program manager will continue to audit the caseload reports weekly to review the annuals that are due for each patient in that current month. The QA team will continue sending the caseloads reports on a weekly basis and will highlight the annuals that are due that month. The clinical supervisor and program manager will audit the completed annuals on a weekly basis and ensure that all annuals are completed for that month. The QA supervisor will monitor compliance and work with the clinical supervisor and program manager to inform on any non-compliance with timely completion.
Effective February 2, 2026, QA supervisor will send a weekly report that will include the list of completed Annual Clinical Evaluations for the medical director to review and sign.
Patient #1 has been discharged as of 10/19/2025, therefore the medical director cannot provide a signature.
Patient #3 has been discharged as of 5/20/2025, therefore the medical director cannot provide a signature.
Patient #6 annual clinical evaluation was completed and signed on 12/31/2025.
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709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to ensure individual treatment and rehabilitation plans were developed with the client in three of three applicable client records reviewed.
The facility policy and procedure manual stated the individual treatment plans were to be completed with the client within 30 days of admission.
Client # 4 was admitted on July 28, 2025 and was active at the time of inspection. The individual treatment plan was signed by the clinician on August 8, 2025, but there was no documentation in the record indicating the plan was completed with the client.
Client # 5 was admitted on September 8, 2025 and was active at the time of inspection. The individual treatment plan was signed by the clinician on October 3, 2025, but there was no documentation in the record indicating the plan was completed with the client as it was signed by the client on October 13, 2025.
Client # 7 was admitted on January 9, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed by the clinician and the client no later than February 9, 2025; however, the treatment plan was completed on February 19, 2025
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The QA department will continue to send weekly reports to all clinical staff and supervisors, which includes each patient, and their initial treatment plan due dates.
The leadership team will continue to monitor and retrain the clinical staff on completing initial treatment plans correctly and within the required times.
This will begin February 2, 2026 and will occur during bi-weekly supervisions and weekly clinical staff meetings.
Effective January 5, 2026, staff will undergo retraining on the treatment plan process to reinforce patient participation in treatment plan development and proper signature collection.
Patient #4 has been hospitalized since 11/12/2025, treatment plan has not been signed by the patient.
Patient #5 treatment plan could not be corrected as the treatment plan was already signed by the patient on October 13, 2025.
Patient #7 treatment plan was completed and signed on February 19, 2025.
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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 three of six applicable client records reviewed.
Client # 1 was admitted on May 5, 2022 and was discharged on October 19, 2025. A treatment plan update was completed on July 31, 2025 and the next update was due no later than October 1, 2025; however, the update was not completed prior to discharge.
Client # 3 was admitted on July 20, 2017 and was discharged on May 20, 2025. A treatment plan update was completed on September 11, 2024 and the next update was due no later than November 11, 2024; however, the update was not completed until February 5, 2025.
Client # 4 was admitted on July 28, 2025 and was active at the time of inspection. The individual treatment plan was completed on August 8, 2025 and the next update was due no later than October 8, 2025; however, the update was not completed until October 24, 2025.
This is a repeat citation from the January 11, 2023, January 9, 2024 and December 18, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The QA department will continue to send weekly reports to all clinical staff and supervisors, which includes each patient, and their treatment plan update due dates.
The leadership team will continue to monitor and retrain the clinical staff on completing treatment plan updates correctly and within the required times.
This will begin February 2, 2026 and will occur during bi-weekly supervisions and weekly clinical staff meetings.
Patient #1 was discharged on 10/19/2025, therefore a treatment plan update cannot be completed at this time.
Patient #3 was deceased on 5/20/2025, therefore a treatment plan update cannot be completed at this time.
Patient #4 treatment plan was completed on 10/24/2025. Patient has been suspended since 11/12/2025, therefore, a treatment plan could not be completed.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include the documentation of a discharge summary, in one of three applicable client records reviewed.
Client # 1 was admitted on May 5, 2022 and was discharged on October 19, 2025. There was no discharge summary documented in the record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 discharge summary will be completed by 1/2/2026.
At the time of discharge, the leadership team will be made aware of the discharges and reason for their discharge. The counselor of the discharged patient will be informed that their patient has been discharged and the reason. The clinical supervisor and program manager will inform each counselor to complete the discharge form group within 5 business days. The QA team will assist with monitoring the completion of discharges using their tracking system. The QA supervisor will inform the clinical supervisor and program manager of any discharges that have not yet been completed.
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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 maintain a complete client record, which is to include the documentation of follow-up information, in two of two applicable client records reviewed.
Client # 1 was admitted on May 5, 2022 and was discharged on October 19, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client # 3 was admitted on July 20, 2017 and was discharged on May 20, 2025. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program manager and senior program director met with the QA department on 12/29/2025 to implement a process for discharge follow-up letters. Effective February 2, 2026, The QA department will ensure all discharge follow-up letters are mailed to discharged patient's address on file on a weekly basis.
All discharged patients will receive a follow-up letter regarding their discharge within 7 days after discharge summary is completed.
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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 complete treatment plan updates within the regulatory timeframe was submitted and approved by the Department for the January 11, 2023, January 9, 2024, and December 18, 2024 annual licensing inspections. Failing to complete treatment plan updates within the regulatory timeframe was again found to be a deficiency in the December 4, 2025 through December 5, 2025 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The leadership team will continue to monitor compliance and provide ongoing training and retraining to clinical staff regarding the timely and accurate completion of treatment plan updates in accordance with regulatory requirements.
Clinical Supervisors will review counselor caseloads and treatment plan due dates during bi-weekly supervision sessions and will provide clear direction and deadlines for upcoming treatment plan updates. Treatment plan status will also be reviewed during weekly clinical staff meetings.
The clinical team will continue to receive a weekly caseload report which will include the treatment plan due dates for each of their patients. Counselors will continue completing treatment plan updates every 45 days to prevent late or missed updates. If treatment plan deadlines are consistently missed, the affected staff will be subject to increased monitoring and provided with more frequent reminders of due dates until sustained compliance is demonstrated.
This Plan of Correction will be implemented effective February 2, 2026.
Senior management will meet quarterly to review this Plan of Correction, monitor implementation, and ensure ongoing compliance. Any identified deficiencies will be addressed promptly through additional supervision, training, or corrective action.
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