INITIAL COMMENTS
|
This report is the result of an on-site licensure renewal and methadone monitoring inspection conducted on September 22. 2025 through September 23, 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. 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
|
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 one of eight client records reviewed.Client #3 was admitted on July 26, 2024 and was discharged on June 27, 2025. The facility failed to document a release of information for the funding source, and it was verified that billing had occurred. This is a repeat citation from the September 20, 2024 annual licensing renewal inspection.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Clinical Supervisor will ensure that all staff are educated on 10/22/2025 maintaining proper releases of information for funding sources. Clinical Supervisor will review ROI's during intake chart audits to confirm that they are properly documented and for identified current funder. Executive Director will develop process with front desk staff to ensure that clinical staff are being notified when persons served provide updated insurance cards. Clinical Supervisor will perform chart audit within 7 days of intake date for all new patients. Executive Director will review and confirm ROI in place during quarterly billing audits. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
|
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 that included the specific information to be disclosed in one of eight client records reviewed.Client #8 was admitted on June 13, 2025 and was active at the time of the inspection. A release of information form for a government agency, signed by the client on June 13, 2025, did not specify the specific information to be disclosed.This is a repeat citation from the September 20, 2024 annual licensing renewal inspection.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Supervisor will ensure that staff are reviewing ROI's for completion before presenting to persons served for signature. Review of ROI completion will take place on 10/15/2025. Any information to be disclosed will be documented and checked off on the ROI before signatures are obtained. Clinical Supervisor will perform intake chart audit within 7 days of intake date. Client #8 will have an updated release completed. |
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 the release of information form in one of eight client records reviewed.Client #8 was admitted on June 13, 2025 and was active at the time of the inspection. There was no documentation that the client was offered a copy of the release of information form for the funding source; signed and dated by the client on June 13, 2025.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Clinical Supervisor will ensure that all staff are retrained on 10/15/2025 on the completion of releases of information. Staff will document on the release that the patient was offered a copy, and indicate if they accepted or declined the copy. Client #8 will have an updated release presented and offered a copy. |
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
|
Observations
Based on the review of sixteen narcotic treatment physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census for one week reviewed. A narcotic treatment physician must provide one-third of the required hours, with a certified registered nurse practitioner or physician's assistant providing the remaining two-thirds of the required hours. During the week of June 8, 2025 through June 14, 2025, the patient census was 283. The narcotic treatment physician was required to provide one-third of the 28.3 hours, which equals to 9.4 hours. The narcotic treatment physician only provided 8 hours. This is a repeat citation from the September 20, 2024 and November 6, 2023 annual licensing renewal inspections.These findings were reviewed with project staff during the licensing process.
|
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. |
715.9(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 facility 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 June 13, 2025 and was active at the time of the inspection. There was no documentation that the patient ' s emergency contact was verified prior to the administration of an agent. These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Clinical Supervisor will ensure that all staff are retrained by 10/15/2025 on the completion of releases of information. Staff will ensure that if a patient is identifying an emergency contact, there is a corresponding release documented in the chart. If patient is declining to identify an emergency contact that will be documented on the ROI as DECLINED, and noted in the EHR. Client #8 will have an updated release presented. |
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 facility failed to transfer the patient file that included admission date, urinalysis reports or summary, exception requests and current status of the patient in one of two applicable patient records reviewed.Patient #2 was admitted on July 8, 2024 and transferred to another facility on December 4, 2024 before being readmitted on May 9, 2025. There was no documentation that the facility transferred the patient ' s files during the December 4, 2024 transfer.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Clinical Supervisor will retrain staff by 10/22/2025 on transfer in and out protocols. Clinical Supervisor will ensure that staff is providing receiving facility with adequate transfer documentation per policy and regulation, and that all documents sent are uploaded to EHR with confirmation of receipt. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
|
Observations
Based on a review of patient records, the facility failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in one applicable patient records reviewed.Patient #2 was admitted on May 9, 2025, and was discharged on August 22, 2025. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Clinical Supervisor will retrain staff by 10/22/2025 in transfer in and out protocols. All staff will ensure that patients being received from another project will have a transfer acknowledgement sent to sending project to include intake date, and first dose on the day of intake. Clinical Supervisor will ensure transfer acknowledgement has been received via intake chart audit. |
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 facility 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 three applicable patient records reviewed.Patient #4 was admitted on March 24, 2016, and was discharged on July 7, 2025. An annual evaluation was documented in the record on May 21, 2024, and the next annual evaluation was due no later than May 21, 2025; however, there was no documentation in the patient record of an annual evaluation at the time of the inspection.Patent #6 was admitted on December 30, 2016, and was active at the time of the inspection. An annual evaluation was documented in the record on March 9, 2023, and the next two annual evaluations were due no later than March 9, 2024, and March 9, 2025; however, the next annual evaluation was not documented in the patient record until August 20, 2025.Patent #7 was admitted on January 8, 2020, and was active at the time of the inspection. An annual evaluation was documented in the record on January 30, 2023, and the next two annual evaluations were due no later than January 30, 2024, and January 30, 2025; however, the next annual evaluation was not documented in the patient record until July 24, 2025.This is a repeat citation from the September 20, 2024 and November 6, 2023 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Supervisor provided training to staff on timely completion of annual evaluations on September 17, 2025. Clinical Supervisor will review again on 10/15/2025. 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 to ensure staff are completing upcoming annual evaluations and provide counselors with reports of upcoming due dates. |
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 three of seven applicable records reviewed. Client #3 was admitted on July 26, 2024, and was discharged on June 27, 2025. An updated treatment and rehabilitation plan was documented in the record on November 19, 2024, with the next update due no later than January 19, 2025; however, there was no updated treatment and rehabilitation plans documented in the client record until February 13, 2025. Additionally, the next treatment and rehabilitation plan update was due no later than April 13, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until May 6, 2025. Client #4 was admitted on March 24, 2016, and was discharged on July 7, 2025. An updated comprehensive treatment and rehabilitation plan was documented in the record on November 21, 2024, with the updated treatment and rehabilitation plans due no later than January 21, 2025; however, there were no updated treatment and rehabilitation plans documented in the client record until February 11, 2025. Additionally, the next treatment and rehabilitation plan update was due no later than April 11, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until April 30, 2025. Client #5 was admitted on May 3, 2022, and was discharged on December 6, 2024. An updated treatment and rehabilitation plan was documented in the record on June 26, 2024, with the next updates due no later than August 26, 2024 and October 26, 2024; however, there were no treatment and rehabilitation plan updates documented in the client record prior to the client ' s discharge. This is a repeat citation from the September 20, 2024 and November 6, 2023 annual licensing renewal inspections.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
QI Regional Director provided staff with treatment plan training on April 23, 2025. Clinical Supervisor retrained all staff on treatment plan requirements on September 17, 2025. Clinical Supervisor will address treatment upcoming plan updates in weekly individual supervision. Counselors implemented calendar event reminders to ensure that treatment plan updates are created, completed and signed prior to the expiration date of current treatment plan. Clinical supervisor will monitor through EHR reports and Tableau Dashboards. |
709.93(a)(5) 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:
(5) Progress 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 progress notes entered within twenty-four hours of the date of service, per the facility's policy, in three of eight records reviewed. Client #1 was admitted on June 16, 2025 and was discharged August 22, 2025. The record contained a progress note for an individual counseling session occurring on July 16, 2025, that was not documented in the record until July 21, 2025. Client #3 was admitted on June 26, 2024, and was discharged on May 6, 2025. The record contained progress notes for individual counseling sessions occurring on October 1, 2024; October 15, 2024, October 22, 2024, December 10, 2024, December 16, 2024, December 31, 2024, and February 4, 2025, that were not documented in the record until October 8, 2024, October 21, 2024, October 29, 2024, January 6, 2025, and February 10, 2025, respectively. Client #4 was admitted on March 24, 2016, and was discharged on July 7, 2025. The record contained progress notes for an individual counseling session occurring on October 3, 2024, that was not documented in the record until October 8, 2024. Additionally, the progress note for a session occurring on April 30, 2025, was incomplete. These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Clinical supervisor will ensure that all documentation is completed and signed within 24 hours of service being provided, including staff signature, per policy. Clinical Supervisor will review in supervision on 10/22/2025. Clinical supervisor will monitor counselor daily activities to ensure progress notes are being completed within the timeframe provided. |
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 in the client ' s first year of services and then yearly thereafter, per the facility's policy, in three of seven applicable records reviewed.Client #2 was admitted on May 9, 2025, and was discharged on August 22, 2025. 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 July 26, 2024, and was discharged on June 27, 2025. A case consultation note was not documented in the record within 90 days of the date of service, per the facility's policy.Client #6 was admitted on December 30, 2016, and was active at the time of the inspection. A case consultation note was documented on January 31, 2024, and the next case consultation note was to be documented by January 31, 2025, per the facility ' s policies and procedure; however, there was no case consultation note documented at the time of the inspection.This is a repeat citation from the September 20, 2024 and November 6, 2023 annual licensing renewal inspections.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Executive Director, Clinical Supervisor will provide retraining to clinical staff on 10/15/2025. Counselors will implement calendar reminders and will review each patient and document case consultations every 90 days within the patients first year, and annually or as needed for every year the patient participates in treatment. Clinical supervisor will monitor via EHR reports and chart audits. |
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 seven days of the client ' s discharge, per the facility ' s policy, in four of four applicable records reviewed.Client #1 was admitted on June 16, 2025 and was discharged August 22, 2025. Follow-up information was not documented in the client record at the time of the inspection. Client #3 was admitted on July 26, 2024, and was discharged on June 27, 2025. Follow-up information was not documented in the client record at the time of the inspection. Client #4 was admitted on March 24, 2016, and was discharged on July 7, 2025. Follow-up information was not documented in the client record at the time of the inspection. Client #5 was admitted on May 3, 2022, and was discharged on December 6, 2024. Follow-up information was not documented in the client record at the time of the inspection. This is a repeat citation from the September 20, 2024 and November 6, 2023 annual licensing renewal inspections.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Executive Director will provide additional training to clinical staff on 10/15/2025. Clinical Supervisor will conduct discharge chart audits. Counselors will ensure that patients discharged from the program are contacted for follow up every 7, 30 and 60 days per agency policy, and that documentation of follow up is completed. Counselors will implement EMR calendar events to track when discharge follow up is required per 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.
|
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 completing treatment plan updates was submitted and approved by the Department for the November 6, 2023, and September 20, 2024 annual licensing inspections. Completing annual clinical evaluations was again found to be a deficiency in the September 22, 2025 through September 23, 2025, licensing inspection. A plan of correction for documenting case consultation notes was submitted and approved by the Department for the November 6, 2023, and September 20, 2024 annual licensing inspections. Completing annual clinical evaluations was again found to be a deficiency in the September 22, 2025 through September 23, 2025, licensing inspection. A plan of correction for documenting follow-up information was submitted and approved by the Department for the November 6, 2023, and September 20, 2024 annual licensing inspections. Completing annual clinical evaluations was again found to be a deficiency in the September 22, 2025 through September 23, 2025, licensing inspection. A plan of correction for documenting annual clinical evaluations was submitted and approved by the Department for the November 6, 2023, and September 20, 2024 annual licensing inspections. Completing annual clinical evaluations was again found to be a deficiency in the September 22, 2025 through September 23, 2025, licensing inspection. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Executive Director will ensure that plan of correction is followed 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, work schedule reviews, calendar reminders and consistent follow up during staff supervision. |