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 10, 2025 through December 11, 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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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 complete an informed and voluntary consent to release information form prior to the disclosure of information in the client record in one of fourteen client records reviewed.
Client # 14 was admitted on November 7, 2025 and was discharged on November 7, 2025. The client was referred to and transported to another treatment provider; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure to the other treatment provider.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior Director will provide training to the support staff regarding the use of the Release of Information form on 1/29/2026. The training will include how and why the program must obtain a written informed and voluntary consent from the client for the disclosure of information prior to the
disclosure of information. The Records Management Supervisor will monitor charts for compliance. The Senior Director will follow up during individual supervision as needed.
The program will be in compliance on 1/29/2026.
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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 narcotic treatment program 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 # 4 was admitted on September 17, 2025 and was discharged on October 6, 2025. The initial face-to-face meeting was completed and documented on September 23, 2025; however, the patient's first dose of medication was given on September 17, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will provide training to the medical providers and nursing staff regarding the policy that a narcotic treatment physician must 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, and that 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 prior to the administration of a maintenance agent. Training will be provided individually and will be completed by 1/22/2026. The Records Management Supervisor will monitor charts for compliance.
The program will be in compliance on 1/22/2026.
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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.
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to maintain a complete client record on an individual, which is to include the documentation of case consultation notes, per facility policy, in three of six applicable client records reviewed.
The facility policy and procedure stated case consultations will be completed every fifteen days.
Client # 1 was admitted on November 17, 2025 and was active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 2 was admitted on November 18, 2025 and was active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 5 was admitted on November 11, 2025 and was discharged on November 29, 2025. There were no case consultation notes documented in the record prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/5/2026, the Program Director provided the counselors with training regarding the timing of and writing of case consultations. The program will address the deficiency by designating a day of the week for all due case consultations to be completed in morning team meeting by counselors. The Program Director and The Medical Records Supervisor will monitor charts for compliance and follow up with counselors during supervision and prior to case consult due date .
The program will be in compliance on 1/20/2026.
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709.53(a)(10) LICENSURE Discharge Summary
709.53. 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 two of four applicable client records reviewed.
Client # 5 was admitted on November 11, 2025 and was discharged on November 29, 2025. There was no discharge summary documented in the record at the time of the inspection.
Client # 6 was admitted on September 29, 2025 and was discharged on October 9, 2025. There was no discharge summary 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 Director will provide the counselors with training regarding the timing of and writing of discharge summaries. The Medical Records Supervisor will monitor charts for compliance and follow up with counselors during supervision.
The program will be in compliance on 1/20/2026.
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