INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 2, 2025 through October 3, 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 Family Healthcare, LLC 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure that two of two applicable employees received a minimum of six hours of HIV/AIDS and four hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.Employee # 10 has been in the position of counselor since April 3, 2024 and was due to have the communicable disease trainings, no later than April 3, 2025. There was no documentation that the employee received the communicable disease trainings as of the date of the onsite licensing inspection. Employee # 11 has been in the position of counselor since March 12, 2024 and was due to have the communicable disease trainings no later than March 12, 2025. There was no documentation that the employee received the communicable disease trainings as of the date of the onsite licensing inspection. The findings were reviewed with project staff during the licensing process.
|
Plan of Correction
All counselors were given a list of required trainings and how to register in DDAP TMS on 10/3/2025.
Beginning on 10/3/2025, ED and CS' will monitor completion monthly for all new teammates via a spreadsheet that lists all team members and when training is due by.
Employee 11 has completed HIV/AIDS training on 10/3/2025 and is on the waiting list for TB/STD training.
Employee 10 will complete HIV/AIDS training by 11/7/2025 and will register for TB/STD training by 10/31/2025. |
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.
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of eight client records reviewed.Client #1 was admitted on July 17, 2025 and was a current client at the time of the inspection. The facility failed to document a release of information for the funding source, and it was verified that billing had occurred.Client #6 was admitted on May 2, 2022 and was discharged on May 6, 2025. The client ' s insurance company changed on February 28, 2025, and facility failed to document a release of information for the new funding source, and it was verified that billing had occurred.This is a repeat citation from the November 3, 2023 and October 1, 2024 annual renewal licensing inspections.The findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Client #1 will sign consent on 11/10/2025.
CS' will train counselors and Center of Excellence staff on required intake documentation and Releases of Information by 10/27/2025.
ED and CS' will monitor completion through Intake Audits to be completed within 10-14 days of intake to ensure that all required documentation is complete. Any documentation that is outstanding will be completed within 48 hours at which time the ED and CS' will recheck for missed documentation. |
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.
|
Observations
Based on the review of client records, the project failed to offer a copy of release of information forms in two of eight records reviewed.Client #2 was admitted on June 25, 2025 and was a current client at the time of the inspection. There was no documentation that the client was offered a copy of the release of information form for a local hospital, that signed and dated by the client on August 28, 2025.Client #8 was admitted on January 30, 2025 and was a current client at the time of the inspection. There was no documentation that the client was offered a copy of the release of information form for governmental agency, that signed and dated by the client on January 30, 2025.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
CS' will train counselors and Center of Excellence staff on how to complete Releases of Information correctly by 10/27/2025.
ED and CS' will monitor will completion through Intake Audits to be completed within 10-14 days of intake to ensure that all required documentation is completed correctly. Any consent that is not completed correctly will be expired and redone within 48 hours at which time the ED and CS' will recheck for corrections. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
|
Observations
Based on a review of patient records, the program failed to verify a patient's identity, which included the name, address, date of birth, emergency contact and other identifying information prior to the administration of an agent in one of nine patient records reviewed.Patient #8 was admitted on January 30, 2025 and was a current patient at the time of the inspection. There was no documentation of the patient ' s emergency contact prior to the administration of an agent.These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
Patient #8 signed Emergency Contact ROI on 10/9/2025.
CS' will train counselors and Center of Excellence staff on required intake documentation and Releases of Information by 10/27/2025.
ED and CS' will monitor completion through Intake Audits to be completed within 10-14 days of intake to ensure that all required documentation is complete. Missing Releases for Emergency Contact that are outstanding will be completed within 48 hours at which time the ED and CS' will recheck for missed documentation. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
|
Observations
Based on a review of patient records, the program failed to review the dosage levels at least twice a year, with each review occurring at least two months apart, to determine a patient's therapeutic dosage in one of five applicable patient records reviewed.Patient #8 was admitted on January 30, 2025 and was a current patient at the time of the inspection. A semi-annual dosage review was not documented in the patient record at the time of the inspection.These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
All teammates will be trained on documentation timeframes on 10/28/2025.
CS' created scheduled events for all dose reviews so that every patient has an alert that the dose review is due. ED and Nursing will review upcoming required dose reviews one week prior to the beginning of the month to plan with patients. |
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.
|
Observations
Based on the review of patient records, the program failed to transfer the patient file that included admission date, urinalysis reports or summary, exception requests and current status of the patient in one applicable patient records reviewed.Patient #7 was admitted on June 8, 2022 and transferred to another program on August 29, 2025. There was no documentation that the facility transferred the patient ' s files to the receiving program.These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
Counselors will be trained in documentation requirements on 10/28/2025.
CS' will review all transfers prior to discharge to ensure that the transfer out checklist has been completed, a copy of what was sent to the receiving provider has been uploaded into the chart and the counselor's note indicates who transfer was coordinated with so follow up can occur. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
|
Observations
Based on a review of patient records, the program failed to document the results of annual physical examinations given by the narcotic treatment program, which included an annual reevaluation by the narcotic treatment physician in four of five applicable records reviewed.Patient #3 was admitted on May 15, 2020 and was a current patient at the time of the inspection. The only annual physical exam documented in the patient record was for a physical exam that occurred on October 1, 2025. Patient #4 was admitted on February 4, 2021 and was a current patient at the time of the inspection. The only annual physical exam documented in the patient record was for a physical exam that occurred on October 1, 2025. Patient #6 was admitted on May 2, 2022 and was discharged on May 6, 2025. An annual physical exam was not documented in the patient record at the time of the inspection. Patient #7 was admitted on June 8, 2022 and was discharged on August 29, 2025. An annual physical exam was not documented in the patient record at the time of the inspection. This is a repeat citation from the October 1, 2024 annual renewal licensing inspections.These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
All teammates will be trained on documentation timeframes on 10/28/2025.
CS' created scheduled events for all annual physicals so that every patient has an alert that the physical is due. ED and Nursing will review upcoming annual physicals one week prior to the beginning of the month to plan with patients. |
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.
|
Observations
The program failed to document an annual evaluation of each patient's status that was completed by the patient's counselor and was reviewed, dated and signed by the medical director in four of five applicable patient records reviewed.Patient #3 was admitted on May 15, 2020 and was a current patient at the time of the inspection. An annual evaluation was documented in the record on May 15, 2024, and the next annual evaluation was due no later than May 15, 2025; however, there was no documentation in the patient record of an annual evaluation until September 29, 2025.Patient #5 was admitted on April 23, 2024 and was discharged on August 6, 2025. An annual evaluation was not documented in the record at the time of the inspection.Patient #6 was admitted on May 2, 2022 and was discharged on May 6, 2025. An annual evaluation was not documented in the record at the time of the inspection.Patient #7 was admitted on June 8, 2022 and was discharged on August 29, 2025. An annual evaluation was documented in the record on July 19, 2025; however, it was not signed by the medical director until September 18, 2025This is a repeat citation from the September 20, 2024, and November 6, 2023, annual licensing renewal inspections.This is a repeat citation from the October 1, 2024, annual renewal licensing inspections.These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
All teammates will be trained on documentation timeframes on 10/28/2025.
CS' created scheduled events for all annual clinical evaluations so that every patient has an alert that the evaluation is due. Counselors will review upcoming annual clinical evaluations one week prior to the beginning of the month to plan with patients. |
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.
|
Observations
Based on the review of outpatient client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in four of eight records reviewed. Client #3 was admitted on May 15, 2020 and was a current client at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on December 6, 2024, with the next update due no later than February 6, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until March 8, 2025. Additionally, the next treatment and rehabilitation plan update was due no later than May 8, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until May 29, 2025. Client #4 was admitted on February 4, 2021 and was a current client at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on December 6, 2024, with the next update due no later than February 6, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until February 28, 2025. Additionally, the next treatment and rehabilitation plan update was due no later than April 28, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until May 2, 2025. Client #6 was admitted on May 2, 2022 and was discharged on May 6, 2025. An updated treatment and rehabilitation plan was documented in the record on December 5, 2024, with the next update due no later than February 5, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until March 25, 2025. Client #7 was admitted on June 8, 2022 and was discharged on August 29, 2025. An updated treatment and rehabilitation plan was documented in the record on December 5, 2024, with the next update due no later than February 5, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until March 25, 2025. This is a repeat citation from the October 1, 2024 annual renewal licensing inspections.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
All counselors were retrained on documentation timeframes by ED and CS on 10/7/2025.
All counselors receive a list of treatment plans coming due every Monday, which began on 10/6/2025. Counselors will begin treatment plans at least 14 days prior to the current treatment plan expiring to ensure that all signatures are obtained by the expiration date. CS' will review to ensure treatment plans has been completed daily and review items due in weekly individual supervisions. |
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.
|
Observations
Based on a review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in three of eight records reviewed.Client #2 was admitted on June 25, 2025 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on July 15, 2025, indicated that the client was to receive two counseling sessions per month; however, there was only one counseling session documented for the months of July 2025 and August 2025.Client #3 was admitted on May 15, 2020 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan update, documented in the client record on October 1, 2024, indicated that the client was to receive two counseling sessions per month; however, there were no counseling sessions documented for the months of November 2024 and January 2025. Additionally, A comprehensive treatment and rehabilitation plan update, documented in the client record on March 8, 2025, indicated that the client was to receive one counseling session per month; however, there was no counseling session documented for the month of August 2025Client #8 was admitted on January 30, 2025 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on March 27, 2025, indicated that the client was to receive two counseling sessions per month; however, there was only one counseling session documented for the months of April 2025, June 2024 and August 2025.This is a repeat citation from the October 1, 2024 annual renewal licensing inspections.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Counselors received training on Prescription of Time on 10/9/2025 and Patient Engagement on 10/22/2025.
ED and CS' will monitor counseling requirements weekly in individual supervision, provide direct observation in individual and group settings to provide feedback on potential increased engagement beginning 10/27/2025. Counselors will document all rescheduled and missed sessions beginning 10/27/2025. Counselors, CS', and ED will complete documentation on the barriers to completing prescribed time monthly. |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes entered every 90 days and then yearly after the first year, per the facility's policy, in four of eight records reviewed.Client #2 was admitted on June 25, 2025 and was a current client at the time of the inspection. A case consultation note was not documented in the record within 90 days of the date of service, per the facility's policy. Client #3 was admitted on May 15, 2020 and was a current client at the time of the inspection. A yearly case consultation note was documented in the client record on March 11, 2024, and the next case consultation was due no later than March 11, 2025, per the facility ' s policy; however, there was no case consultation note documented in the client record until July 28, 2025. Client #6 was admitted on May 2, 2022 and was discharged on May 6, 2025. A yearly case consultation note was documented in the client record on February 21, 2024, and the next case consultation was due no later than February 21, 2025, per the facility ' s policy; however, there was no case consultation note documented in the client record at the time of the inspection.Client #8 was admitted on January 30, 2025 and was a current client at the time of the inspection. A 90-day case consultation note was to be documented in the client record by March 30, 2025, per the facility ' s policy; however, there was no case consultation note documented in the client record until May 22, 2025. Additionally, the next case consultation note was to be documented in the client record by August 22, 2025; however, there was no case consultation note documented in the client record until September 11, 2025.This is a repeat citation from the November 3, 2023, and October 1, 2024, annual renewal licensing inspections.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Counselors will receive updated training on charting timeframes on 10/28/2025.
CS' created scheduled events for all case consultations so that every patient has an alert that the consultation is due. Counselors will review their upcoming required consultations one week prior to the beginning of the month to plan with patients. |
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.
|
Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information entered within 7 days, 30 days and 60 days of the client's discharge, per the facility's policy, in three out of four applicable records reviewed.Client #5 was admitted on April 23, 2024 and was discharged on August 6, 2025. There was no 7-day, or 30-day follow-up contact information documented in the client record at the time of the inspection.Client #6 was admitted on May 2, 2022 and was discharged on May 6, 2025. There was no 7-day, 30-day or 90-day follow-up contact information documented in the client record at the time of the inspection.Client #7 was admitted on June 8, 2022 and was discharged on August 29, 2025. There was no 7-day, or 30-day follow-up contact information documented in the client record at the time of the inspection.This is a repeat citation from the November 3, 2023 and October 1, 2024 annual renewal licensing inspections.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Counselors will receive updated training on follow up calls on 10/28/2025.
CS' will provide a list of required follow up calls for the following week every Friday beginning 10/24/2025. CS' will audit charts every Friday to ensure follow up calls were completed. |
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.
|
Observations
Based on a review of patient records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for documenting case consultation notes was submitted and approved by the Department for the November 3, 2023, and October 1, 2024, annual licensing inspections. Missing or late treatment case consultation notes were again found to be a deficiency in the October 2, 2025 through October 3, 2025, licensing inspection. A plan of correction for documenting follow-up information was submitted and approved by the Department for the November 3, 2023, and October 1, 2024, annual licensing inspections. Documenting follow-up information was again found to be a deficiency in the October 2, 2025 through October 3, 2025, licensing inspection.A plan of correction for documenting annual physical examination was submitted and approved by the Department for the November 3, 2023, and October 1, 2024, annual licensing inspections. Completing annual physical examinations were again found to be a deficiency in the October 2, 2025 through October 3, 2025, licensing inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Once POC is approved, Quality Improvement Director, Executive Director, Clinical Supervisors, and Nursing Supervisor will monitor the approved plan actions by completing the following:
QI Director will complete 3 chart audits per quarter to ensure that all areas of the chart are being documented according to the POC. Lansdowne ED, CS', and NS will review QI's audits quarterly with QI. CS' will complete 4 chart audits per month, each, to ensure that all clinical items in the chart are being documented per the POC. NS will review nursing and medical documentation weekly to ensure the POC is being followed. ED will monitor the POC with the CS' and NS in biweekly meetings to address any barriers to following the POC and strategies to ensure all POC items are followed. |