INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 10-11, 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, LLC 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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709.23 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
The Project Director will review and ensure policies are updated and issue a signed attestation to that effect by January 15, 2027. |
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 10-16, 2026, the patient census was 284. The facility was required to provide at least 28.4 physician hours. There were 10.38 physician hours documented. During the week of June 14-20, 2026, the patient census was 284. The facility was required to provide at least 28.4 physician hours. There were 26.49 physician hours documented.This finding was reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 23, 2025, September 20, 2024, November 6, 2023, and May 23, 2023 annual licensing inspections.
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Plan of Correction
Executive Director will develop a physician and certified registered nurse practitioner schedule that will ensure that facility is providing 1 hour per every 10 clients of physician time per week. This will be monitored via weekly timesheets. During holiday or vacations adjustments to the schedule will occur to ensure medical professional availability remains in compliance with regulation. |
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 the review of patient records, the facility failed to document an annual clinical evaluation within the regulatory timeframe in one out of four applicable records reviewed.Client #7 was admitted on February 16, 2024 and discharged on July 7, 2026. The annual clinical evaluation was due no later than February 16, 2026; however, it was completed on May 6, 2026. These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the September 23, 2025, September 20, 2024, November 6, 2023, May 23, 2023, and June 9, 2022 annual licensing inspections.
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Plan of Correction
Clinical Supervisor provided training to staff on timely completion of annual evaluations on 9/23/2026. Clinical Supervisor will review again no later than 10/26/2026. Staff will be advised annual clinical evaluations will be completed no later than the patients annual review date. Executive Director and Clinical Supervisor will monitor via internal documentation reports and chart audits to ensure staff are completing upcoming annual evaluations and provide counselors with reports of upcoming due dates. |
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 two out of four applicable records.Client #2 was admitted on March 31, 2026 and discharged on June 25, 2026.Client #4 was admitted on March 16, 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
Clinical Supervisor provided training to staff on timely completion of intake documents on 9/23/2026. Clinical Supervisor will review again no later than 10/26/2026. Staff will be advised intake biopsychosocial will be completed no later than the patients third day in treatment. Executive Director and Clinical Supervisor will monitor to ensure staff are completing intake documentation on time. Clinical Supervisor to monitor by completing intake chart audit within 7 days of intake. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in five out of eight applicable records reviewed.Client #1 was admitted on February 17, 2017 and discharged on August 3, 2026. Treatment plans dated January 6, 2026 and March 4, 2026 indicated individual therapy twice a month. There was only one session documented in January, February and March 2026. Client #2 was admitted on March 31, 2026 and discharged on June 25, 2026. Treatment plans dated April 10, 2026 and May 22, 2026 indicated individual therapy one-time a month. There were no documented sessions in May 2026. Client #3 was admitted on April 6, 2026 and discharged on June 29, 2026. A treatment plan dated April 29, 2026 indicated 2.5 hours of therapy per month. In May 2026, there was a one-hour session on May 12, 2026 and a missed scheduled one-hour session on May 6, 2026. There were no more documented sessions in May 2026. Client #4 was admitted on March 16, 2026 and was still active at the time of the inspection. A treatment plan dated April 17, 2026 indicated 2.5 hours of therapy per month. A treatment plan dated June 11, 2026 indicated 1.5 hours of therapy per month. In May 2026, there was one hour of therapy documented. In June 2026, there was forty-five minutes of therapy documented.Client #5 was admitted on December 1, 2021 and was still active at the time of the inspection. Treatment plans dated March 13, 2026 and May 6, 2026 indicated two hours of therapy per month. In May 2026, there was forty-five minutes of therapy documented. In June 2026, there was 30 minutes of therapy documented and a missed scheduled on hour session. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor provided training to staff on providing treatment services per the patients treatment plan on 9/23/2026. Clinical Supervisor will review again no later than 10/26/2026. Staff will be advised that the treatment plan indicates the prescribed amount of counseling per patient. Patients should be scheduled for their full amount of counseling and systems in place to ensure they are meeting these requirements. Executive Director and Clinical Supervisor will monitor with internal scheduling reports, chart audits, and documentation reviews to ensure patients scheduled and are receiving the appropriate amount of counseling per their treatment plan. |
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 annual clinical evaluations were submitted and approved by the Department for the September 23, 2025, September 20, 2024, November 6, 2023, May 23, 2023, and June 9, 2022 annual licensing inspections. Annual clinical evaluations were again found to be a deficiency in the September 11, 2026 licensing inspection.A plan of correction for physician hours were submitted and approved by the Department for the September 23, 2025, September 20, 2024, November 6, 2023, and May 23, 2023 annual licensing inspections. Physician hours were again found to be a deficiency in the September 11, 2026 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will ensure that plan of correction is executed by all facility staff to ensure that all regulations and agency policies are being met and that plan of correction was enacted. This will be completed through consistent training reviews, intake and discharge chart audits, documentation reviews, work schedule reviews, calendar reminders and consistent follow up during staff supervision. |