INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 15, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Licensure Programs. Based on the findings of the on-site inspection, Northern Tier Counseling, 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document semi-annual reviews for counselor assistants in one out of one record reviewed.
Employee #6 had one performance review dated May 19, 2021 between the timeframe of March 2020 through August 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will work with the Director of outpatient services and the Drug and Alcohol manager to review the performance of any/all counselor assistants on a semi-annual basis. The counselor assistant reviewed on May 19, 2021 will be reviewed again on or before November 19, 2021 by the Drug and Alcohol manager and every 6 months thereafter. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 12 clock hours of annual training for directors in four out of six records reviewed.
Employee #1 was hired on September 4, 1995 and was promoted to project director on December 1, 2002. The training year reviewed was from September 1, 2020 through August 31, 2021. Employee #1's record only documented 6.25 hours of annual training for the training year reviewed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will work with the Director of Outpatient services and the Drug and Alcohol manager to review staff development and training requirements and in coordination with compliance and HR staff, will facilitate quarterly communications with staff and review Relias training platform to ensure all requirements for training are being met. Beginning November 1, 2021, if any requirements are needed "out of house" these will be arranged and offered to staff within the next 90 days or before January 15, 2022. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training for counselors in four out of six records reviewed.
Employee #3 was hired as a counselor on April 26, 2020 and was still in that position at the time of the inspection. The training year reviewed was from September 1, 2020 through August 31, 2021. Employee #3's record only documented 6.25 hours of annual training for the training year reviewed.
Employee #5 was hired on May 31, 2016 and was promoted to counselor position on August 16, 2017. The training year reviewed was from September 1, 2020 through August 31, 2021. Employee #5's record only documented 10.25 hours of annual training for the training year reviewed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will work with the Director of Outpatient services and the Drug and Alcohol manager to review staff development and training requirements and in coordination with compliance and HR staff will facilitate quarterly communications with staff and review Relias to ensure all requirements for training are being met. Beginning November 1, 2021, if any requirements are needed "out of house" these will be arranged and offered to staff within the next 90 days or before January 15, 2022. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 30 clock hours of annual training for counselors in four out of six records reviewed.
Employee #6 was hired on November 15, 2016 and was promoted to counselor assistant on November 1, 2017. The training year reviewed was from September 1, 2020 through August 31, 2021. Employee #6's record documented zero hours of annual training for the training year reviewed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will work with the Director of Outpatient services and the Drug and Alcohol manager to review staff development and training requirements and in coordination with compliance and HR staff will facilitate quarterly communications with staff and review Relias to ensure all requirements for training are being met. Beginning November 1, 2021, if any requirements are needed "out of house" these will be arranged and offered to staff within the next 90 days or before January 15, 2022. |
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 the review of client records, the facility failed to obtain a completed valid consent to release information form prior to disclosing information in two out of six records reviewed.
Client #1 was admitted on March 9, 2021 and was still active at the time of the inspection. The client's record did not contain a consent form for the funding source. Verbal communication from the staff confirmed billing had occurred.
Client #6 was admitted on February 18, 2021 and discharged on July 20, 2021. Communication occurred between the facility and a doctor's office on February 18, 2021. The consent in the client's record showed the doctor was permitted to release information to himself, as the facility's name was not included on the consent, making it invalid.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director will work in collaboration with the Director of Outpatient Services and the Drug and Alcohol Manager to re-train counselors and counselor assistants on the importance of confidentiality via releases of information. Counselors and counselor assistants will complete confidentiality training on Relias and 2 supervisor trainings "in house" on completing releases of information in a valid manner. This in house training will begin November 1, 2021 and end November 10, 2021. Confidentiality training will need to be completed by December 31, 2021 on Relias. Quarterly audits will be completed at random by the compliance manager to ensure compliance with documentation procedures. |
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.
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Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client records in four out of six records reviewed. Additionally, three out of six client records were missing specific information to be released.
Client #1 was admitted on March 9, 2021 and was still active at the time of the inspection. A consent form to a family member was missing specific information to be disclosed. Two consents, both to government agencies, permitted discharge summary, medical history, social history, treatment plan, psychiatric/psychological reports and lab values.
Client #2 was admitted on March 9, 2021 and was still active at the time of the inspection. A consent forms to a family member dated March 8, 2021 was missing specific information to be disclosed. One consent dated Mar 8, 2021 to a government agency, permitted discharge summary, medical history, social history, treatment plan, psychiatric/psychological reports, drug and alcohol treatment and lab values. A consent form to a funding source permitted "other: ALL".
Client #5 was admitted on March 18, 2021 and discharged on July 27, 2021. Two consent forms dated April 5, 2021 and April 21, 2021 to a funding source permitted "other: ALL".
Client #6 was admitted on February 28, 2021 and discharged on July 20, 2021. Three consent forms to a family member, government agency and a support service was missing specific information to be disclosed. One consent to a government agency, permitted discharge summary, medical history, social history, treatment plan, psychiatric/psychological reports, drug and alcohol treatment and lab values. A consent form to a funding source permitted "other: ALL".
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director will work in collaboration with the Director of Outpatient Services and the Drug and Alcohol Manager to re-train counselors and counselor assistants on the importance of confidentiality via releases of information. Counselors and counselor assistants will complete training with focus on 4 Pa. Code 255.5 and the importance of only releasing the 5 points to government agencies as directed by law. This will be completed by December 31, 2021.Quarterly audits will be completed at random by the compliance manager to ensure compliance with documentation procedures. |
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 the review of client records, the facility failed to document a completed informed and voluntary consent to release information form, as the purpose of disclosure was missing in one out of six records reviewed.
Client #1 was admitted on March 9, 2021 and was still active at the time of the inspection. The form was to a family member.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director in collaboration with the Director of Outpatient Services and the Drug and Alcohol Manager will re-train/review with counselors and counselor assistants the need for and importance of the purpose for disclosure in a valid release of information during re-training on November 10, 2021.Quarterly audits will be completed at random by the compliance manager to ensure compliance with documentation procedures. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the facility failed to document a completed informed and voluntary consent to release information form, as the dated client signature was missing in one out of six records reviewed.
Client #1 was admitted on March 9, 2021 and was still active at the time of the inspection. The two forms were both to government agencies.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director in collaboration with the Director of Outpatient Services and the Drug and Alcohol Manager will re-train/review with counselors and counselor assistants the need for and importance of the purpose for obtaining client signatures in a valid release of information during re-training on November 10, 2021.Quarterly audits will be completed at random by the compliance manager to ensure compliance with documentation procedures. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on the review of client records, the facility failed to notify clients of their rights in six out of sis records reviewed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Compliance Manager in collaboration with the Project Director, Director of Outpatient Services, and Drug and Alcohol Manager, will develop documentation of written acknowledgement by clients that they have been notified of their client rights and liberties as a client receiving care or treatment under section 7. This will be completed as of October 15, 2021. Staff will be made aware of the change in documentation and where to find the form in the electronic health record while intaking new clients. Quarterly audits will be completed at random by the compliance manager to ensure compliance with documentation procedures |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on the review of client records, the facility failed to familiarize client during orientation on the hours of operation in six out of six records reviewed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Compliance Manager in collaboration with the Project Director, Director of Outpatient Services, and Drug and Alcohol Manager, will develop documentation of hours of operation and include this documentation in the client intake packet. This will be completed as of October 15, 2021. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on the review of client records, the facility failed to familiarize client during orientation on the fee schedule in six out of six records reviewed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Compliance Manager in collaboration with the Project Director, Director of Outpatient Services, and Drug and Alcohol Manager, will develop documentation of the fee schedule and include this documentation in the client intake packet. This will be completed as of October 15, 2021. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to include type and/or frequency of treatment and rehabilitation services in the client's treatment plan in two out of six records reviewed.
Client #4 was admitted on March 9, 2021 and discharged on September 7, 2021. A comprehensive treatment plan dated March 31, 2021 did not include the type of counseling.
Client #6 was admitted on February 18, 2021 and discharged on July 20, 2021. A comprehensive treatment plan dated March 3, 2021 did not include type and frequency of counseling services.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director will work with the Director of Outpatient Services and the Drug and Alcohol manager to review with counselors and counselor assistants that all treatment and rehabilitation plans must include the type and frequency of services and need to be reviewed with the client while developing them. This review/supervision will begin November 1, 2021 in group and individual supervision settings. Quarterly audits will be completed at random by the compliance manager to ensure compliance with documentation procedures |
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.
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Observations
Based on the review of client records, the facility failed to review and update treatment plans every 60 days in five out of six records reviewed.
Client #1 was admitted on March 9, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 12, 2021 with an update due no later than May 12, 2021; however, the update was completed on May 19, 2021.
Client #2 was admitted on March 9, 2021 and was still active at the time of the inspection. A treatment plan update was completed on June 29, 2021 with an update due no later than August 29, 2021. There were no updates documented in the client's record after June 29, 2021.
Client #3 was admitted on March 31, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was completed on June 9, 2021 with an update due no later than August 9, 2021; however, the update was completed on September 13, 2021.
Client #5 was admitted on March 18, 2021 and discharged on July 27, 2021. A comprehensive treatment plan was completed on April 21, 2021 with an update due no later than June 21, 2021; however, the update was completed on July 7, 2021.
Client #6 was admitted on February 18, 2021 and discharged on July 20, 2021. A comprehensive treatment plan was completed on March 3, 2021 with an update due no later than June 3, 2021; however, the update was completed on May 21, 2021.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director will work collaboratively with the Director of Outpatient services and the Drug and Alcohol manager to review with all counselor and counselor assistants the appropriate procedure for reviewing and updating individualized treatment plans every 60 days. The company's Electronic health record does allow access to "expiring treatment plan" report and manager will also review in staff meetings weekly to ensure due dates are being met beginning October 27, 2021. This issue will also be addressed in individual supervisions beginning November 1, 2021. |
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 the review of client records, the facility failed to provide counseling services according to the individual treatment and rehabilitation plan in four out of six records reviewed.
Client #1 was admitted on March 9, 2021 and was still active at the time of the inspection. The comprehensive treatment plan dated March 12, 2021 indicated one hour of group and individual counseling per week. The last documented group session was on June 9, 2021.
Client #2 was admitted on March 9, 2021 and was still active at the time of the inspection. The comprehensive treatment plan dated April 27, 2021 indicated group session three times per week. During the weeks of July 4 - 10, 2021 and July 11-17, 2021, the documentation showed the client attended sessions twice a week on July 6, July 8, July 12, and July 13, 2021. There was no documentation of missed appointments or no shows on the record of service.
Client #3 was admitted on March 31, 2021 and was still active at the time of the inspection. The comprehensive treatment plan dated June 9, 2021 indicated individual sessions every other week. There were no individual sessions between June 10 - July 11, 2021. There was no documentation of missed appointments or no shows on the record of service.
Client #5 was admitted on March 18, 2021 and discharged on July 27, 2021. The comprehensive treatment plan dated April 21, 2021 indicated weekly group sessions. There were no group sessions between April 29-May 11, May 27-June 8 and June 10- June 29, 2021. There was no documentation of missed appointments or no shows on the record of service.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director will work with the Director of Outpatient services and the Drug and Alcohol manager to review with counselor and counselor assistants the importance of individuals being provided services according to their comprehensive treatment plan. In addition, if there is an interruption in services (ie: a holiday or weather emergency) documentation of this interruption will be completed in client's chart. Staff will "amend" or update the treatment plan for any changes in services. This will be reviewed in both group and individual supervision beginning November 1, 2021 and reviewed in case consultations as well. |
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.
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Observations
Based on the review of client records and the facility's policy and procedures manual, the facility failed to follow their policy and procedures manual which states case consultations must occur every 90 days. The facility failed to follow the policy and procedures manual in four out of six records reviewed.
Client #2 was admitted on March 9, 2021 and was still active at the time of the inspection. There were no case consultations documented in the client's record.
Client #3 was admitted on March 31, 2021 and was still active at the time of the inspection. The only documented case consultation occurred on September 13, 2021.
Client #5 was admitted on March 18, 2021 and discharged on July 27, 2021. There only documented case consultation occurred on July 14, 2021.
Client #6 was admitted on February 18, 2021 and discharged on July 20, 2021. The only documented case consultation occurred on July 14, 2021.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director will work with the Director of Outpatient services and the Drug and Alcohol Manager to follow NTC policy and procedures and complete a case consultation on all Drug and Alcohol clients every 90 days. This policy will be reviewed with counselors and counselor assistants in group supervision on November 3, 2021 and by completing case consults weekly on every client discussed in staffing. A full list of active clients will be reviewed monthly and any client not discussed in group staffing will then be reviewed and a case consultation will be completed to review progress made beginning November 30, 2021. |
709.94(f)(1) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(1) Identifying persons in need of project services.
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Observations
Based on the review of the policy and procedures manual, the facility failed to develop a written plan for outreach services to include identifying persons in need of project services.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Compliance Manager along with HR will work to complete a written plan for providing outreach services in the local community to identify people in need of project services. This will be completed by November 1, 2021. |
709.94(f)(2) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(2) Alerting persons and their families to the availability of project services.
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Observations
Based on the review of the policy and procedures manual, the facility failed to develop a written plan for outreach services to include alerting persons to the availability of project services.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Compliance Manager along with HR will work to complete a written plan for providing outreach services in the local community to alert people of the availability of project services. This will be completed by November1, 2021. |
709.94(f)(3) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(3) Encouraging persons to utilize the service delivery system.
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Observations
Based on the review of the policy and procedures manual, the facility failed to develop a written plan for outreach services to include encouraging persons to utilize the service delivery system.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Compliance Manager along with HR will work to complete a written plan for providing outreach services in the local community encourage people to utilize project services. This will be completed by November 1, 2021. |