INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 14, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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 seven personnel records, the facility failed to ensure that one counselor assistant was given a semiannual performance evaluation.
Employee #7 was hired as a counselor assistant on November 1, 2017 and had not received an evaluation at the time of the inspection.
The finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Drug and Alcohol Manager will provide the Counselor Assistant with a semiannual performance evaluation by 11/1/2022 along with an updated Drug and Alcohol Individual Training Plan. The Drug and Alcohol Individual Training Plan has been revised to reflect the specific needs of the Counselor Assistant position. The Drug and Alcohol Manager will provide the Counselor Assistant with the next performance evaluation by May 1, 2023. The Drug and Alcohol Manager along with the Project Director will add this step to the hiring process for new counselor assistants starting in order to ensure compliance with this moving forward. HR staff will add this to their HR audit in order to add another layer of assurance. This will be completed by 11/1/2022. |
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 required for the project director in employee #1's employee record.
Employee #1 was hired as a project director on July 1, 2021 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2021 through June 30, 2022. Employee #1's employee record only documented 4.25 hours of annual training for the training year reviewed.
The finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Project Director will complete the Drug and Alcohol Individual training plan by November 1, 2022 in order to determine what trainings have been completed in the designated training areas. The Project Director will then complete at least 12 clock hours of training by June 30, 2023.The Compliance Manager will perform training audits periodically to ensure trainings are complete by June 30, 2023. |
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 required for counselors in employee #5's employee record.
Employee #5 was hired as a counselor on August 16, 2017 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2021 through June 30, 2022. Employee #5's employee record only documented 3.35 hours of annual training for the training year reviewed.
The finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Project Director along with the Drug and Alcohol Manager will provide all Drug and Alcohol counselors with a Drug and Alcohol Individual Training Plan that will need to be completed and reviewed by November, 1 2022. Counselors will then be responsible for obtaining the 25 clock hours required in regulation 704.11. Staff Development Program (f) Training requirements for counselors. The Project Director and the Drug and Alcohol Manager will work with the HR manager and the Compliance Manager to review the training certificates, as well as the Relias training platform to help counselors complete trainings within the training period of July, 1 2022 ? June 30, 2023. |
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 a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in five out of seven client records reviewed.
Client #1 was admitted on November 9, 2021 and was discharged on March 22, 2022. A treatment plan was completed on December 2, 2021 and the treatment plan update was due no later than February 2, 2022; however, there was no update completed at the time of the inspection.
Client #2 was admitted on November 3, 2021 and was discharged on March 17, 2022. A treatment plan was completed on December 22, 2022 and the treatment plan update was due no later than February 22, 2022; however, there was no update completed at the time of the inspection.
Client #3 was admitted on October 12, 2021 and was discharged on April 26, 2022. A treatment plan was completed on November 23, 2021 and the treatment plan update was due no later than January 23, 2022; however, there was no update completed at the time of the inspection.
Client #4 was admitted on April 5, 2022 and was discharged on August 15, 2022. A treatment plan was completed on May 2, 2022 and the treatment plan update was due no later than July 2, 2022; however, the treatment plan update was completed on July 18, 2022.
Client #6 was admitted on March 29, 2022 and was still active at the time of the inspection. A treatment plan was completed on June 20, 2022 and the treatment plan update was due no later than August 20, 2022; however there was no update completed at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Initial Treatment Plans and all treatment plan updates will be completed by the primary counselor assigned to that client. The Drug and Alcohol Manager will review the treatment plans that are coming due for each individual counselor during their individual supervision sessions weekly. The Drug and Alcohol Manager will also review the list of treatment plans coming due monthly in group supervision to make sure that the treatment plans that have been reviewed during individual supervision have been completed and signed by all parties. This will begin immediately and continue ongoing to ensure compliance. The Compliance Manager will continue to do random chart audits to ensure that treatment plans are being completed within the 60 days. |
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 a review of client records, the facility failed to provide counseling sessions according to the treatment plan in three out of the seven records reviewed..
Client #1 was admitted on November 9, 2021 and was discharged on March 22, 2022. The comprehensive treatment plan dated November 9, 2021, indicated one individual session per week. The record of service and progress notes indicated that the client did not receive individual sessions between November 24, 2021 and their date of discharge on March 22, 2022.
Client #2 was admitted on November 3, 2021 and was discharged on March 17, 2022. The comprehensive treatment plan dated December 22, 2021, indicated one individual session per week. The record of service and progress notes indicated that the client did not receive individual sessions between December 23, 2021 and their date of discharge on March 17, 2022.
Client #3 was admitted on October 12, 2021 and was discharged on April 26, 2022. The comprehensive treatment plan dated November 23, 2021, indicated one individual session per week and three group sessions per week. The record of service and progress notes indicated that the client did not receive individual sessions or group sessions between February 21, 2022 and their date of discharge on April 26, 2022.
The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Project Director in collaboration with the Drug and Alcohol Manager will review with Counselors and Counselor Assistants that any change in counseling services provided in accordance with the individual treatment plan will be documented and if need be, will complete an update to the current treatment and rehabilitation plan to reflect the changes. This will be reviewed with staff during Thursday afternoon workshops/group supervision beginning September 29, 2022, Training will be ongoing to ensure compliance. The Drug and Alcohol Manager will be monitoring the treatment plans in individual supervisions as well as monthly in group supervisions to ensure compliance with follow through/updates and changes that need to be made in the treatment plans. The Compliance Manager will continue to do random chart audits to monitor compliance. |
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 a review of client records, the facility failed to document case consultations according to the facility's written policy and procedure manual in three out of seven records reviewed. The facility's policy manual indicated case consultations would be documented every ninety days after the client is admitted to treatment.
Client #1 was admitted on November 9, 2021 and was discharged on March 22, 2022. A case consult was due no later than February 9, 2022; however, client #1 did not have a case consult completed until March 21, 2022.
Client #2 was admitted on November 3, 2021 and was discharged on March 17, 2022. A case consult was due no later than February 3, 2022; however, client #2 did not have a case consult completed until March 6, 2022.
Client #3 was admitted on October 12, 2021 and was discharged on April 26, 2022. A case consult was due no later than January 12, 2022; however, client #3 did not have a case consult completed until April 13, 2022.
The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Project Director, as well as the Drug and Alcohol Manager will work with the Compliance Manager to update the Case Consultation policy to reflect the change in need for Case Consultations and will begin completing these once per year in accordance with the 709.93 regulation. The update to the policy will be completed by October 17, 2022. The policy update will be provided to Staff during group supervision in the week of 10/17/2022. The Drug and Alcohol Manager will monitor case consultations during monthly staff meetings to ensure that case consultations are being completed at least once per year. |