INITIAL COMMENTS
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This report is a result of an on-site plan of correction follow-up inspection conducted on September 17, 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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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for the completion of an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities, for the project's fiscal year ending June 2023. This is a repeat citation from January 8, 2025 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The organization has completed the financial audit with a licensed and independent CPA firm.
A standardized audit compliance calendar/tracker will be developed and maintained by the Finance Department to ensure future audits are initiated and completed on schedule. The agency's Director of Compliance and program director will monitor said tracker. Agency will be in compliance 10/6/2025 |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on release of information consent forms in two of fourteen client records reviewed. Client #2 was admitted to the inpatient non-hospital activity on March 5, 2025 and was discharged on April 4, 2025. There were release of information forms to a funding source, a treatment provider, a pharmacy, an emergency contact, and two government agencies that were all signed and dated by the client on March 5, 2025; however, there was no purpose of the disclosures documented on any of the release forms.Client #8 was admitted to the intake, evaluation and referral activity on March 6, 2025 and was discharged on March 6, 2025. A release of information form to a funding source was signed and dated by the client on March 6, 2025; however, there was no purpose of the disclosure documented on the release form.This is a repeat citation from January 18, 2024 and January 8, 2025 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/30/2025, the Release of Information form had a section titled "The Purpose of the Disclosure" added to it. The Program Director provided staff with training on 2/12/2025 regarding the need to include the Purpose of Disclosure on all releases of information. This section was not added to all versions of the Release of Information form. The absence of the section was discovered, and all versions of the Release of Information form were updated on 3/24/2025. The update included "Section 4: What is the purpose of releasing this information" with the prompt "The purpose of this disclosure is specifically for:" This question is a mandatory field. The form cannot be completed without the staff member entering a reason from a checkbox list. The Program Director will provide oversight through supervision and chart reviews.
The program will be in compliance on 10/13/2025. |
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.
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Observations
Based on a review of client records, the facility failed to document if a copy of a client consent to release information form was offered to the client in one of fourteen client records reviewed.Client #2 was admitted to the inpatient non-hospital activity on March 5, 2025 and was discharged on April 4, 2025. A release of information form to a funding source was signed and dated by the client on March 5, 2025; however, there was no documentation in the record indicating that a copy of the consent form was offered to the client. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/6/2025, the Release of Information form had the question "A copy of the ROI was offered to the client:" with the choices Accepted or Declined added to it. The question is a mandatory field. The form cannot be completed without the staff member entering an answer. Staff received training from the Program Director on 3/12/2025. The Program Director will provide oversight through supervision and chart reviews.
The program will be in compliance on 10/13/2025. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 develop an individual comprehensive treatment and rehabilitation plan with the client in three of four applicable client records reviewed. Client #1 was admitted to the inpatient non-hospital activity on March 6, 2025 and was discharged on April 3, 2025. There was no documentation, in the record, of an individual treatment and rehabilitation plan at the time of the inspection.Client #2 was admitted to the inpatient non-hospital activity on March 5, 2025 and was discharged on April 4, 2025. There was no documentation, in the record, of an individual treatment and rehabilitation plan at the time of the inspection.Client #5 was admitted to the inpatient non-hospital activity on May 12, 2025 and was discharged on June 10, 2025. There was no documentation, in the record, of an individual treatment and rehabilitation plan at the time of the inspection.This is a repeat citation from January 18, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will provide education to all counseling staff on 10/17/2025 on the timing and completion of treatment plan updates. The Quality Assurance Team provides the Counselors with a list of upcoming treatment plan updates on a weekly basis. The Program Director will monitor the electronic record for compliance and will continue to address treatment plan updates during biweekly supervision with the counselors.
The facility will be in compliance as of 10/24/2025. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of patient records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in three of seven client records reviewed.Client #2 was admitted to the inpatient non-hospital activity on March 5, 2025 and was discharged on April 4, 2025. There was no documentation, in the record, of follow-up information at the time of the inspection. Client #5 was admitted to the inpatient non-hospital activity on May 12, 2025 and was discharged on June 10, 2025. There was no documentation, in the record, of follow-up information at the time of the inspection.Client #6 was admitted to the inpatient non-hospital activity on June 30, 2025 and was discharged on July 31, 2025. There was no documentation, in the record, of follow-up information at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Weekly Documentation Due List was emailed to the counselors on 10/14/2025 by the Program Director. The Program Director will provide training regarding the policy, implementation of the policy, and documentation of the follow-up during individual supervision. The Program Director will monitor discharge charts for compliance with the policy. |
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 ensuring the documentation of the purpose of a disclosure on consent forms was submitted and approved by the Department for the January 18, 2024 and January 9, 2025 annual licensing inspections. Failing to document the purpose of the disclosure on consent forms was again found to be a deficiency at the September 17, 2025 plan of correction follow-up inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/30/2025, the Release of Information form had a section titled "The Purpose of the Disclosure" added to it. The Program Director provided staff with training on 2/12/2025 regarding the need to include the Purpose of Disclosure on all releases of information. This section was not added to all versions of the Release of Information form. The absence of the section was discovered, and all versions of the Release of Information form were updated on 3/24/2025. The update included "Section 4: What is the purpose of releasing this information" with the prompt "The purpose of this disclosure is specifically for:" This question is a mandatory field. The form cannot be completed without the staff member entering a reason from a checkbox list. The Program Director will provide oversight through supervision and chart reviews. The Program Director and Director of Information Services will be responsible for monitoring and implementing the plan of corrections and modifications.
The program will be in compliance on 10/13/2025. |