INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 14, 2023 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(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of personnel records, the facility failed to provide counselor assistant supervision by a full-time qualified clinical supervisor or counselor in one of two applicable personnel records reviewed.
Employee #8 was hired as a counselor assistant on November 1, 2022. There was no documentation in the record of supervision during the months of November 2022 through July 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The D&A Department Manager will implement written documentation of weekly supervision of all counselors and counselor assistants. This documentation will be reviewed in supervision with the Project Director on a monthly basis. This plan of correction has been implemented. |
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 personnel records, the facility failed to ensure the project director and facility director completed at least 12 clock hours of annual training during the facility's July 2022 through June 2023 training year.
Employee #1 was hired as the project director on July 1, 2021. The personnel record documented 3 hours of annual training during the period reviewed.
This is a repeat citation from the September 15, 2021 and the September 14, 2022 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will complete the Drug and Alcohol Individual training plan by November 1, 2023. The Clinical Supervisor will then complete at least 12 clock hours of training by January 31, 2024. The Compliance Manager will perform training audits periodically to ensure training is complete by January 31, 2024. Additionally, the Clinical Supervisor's progress on the training plan will be reviewed and documented on a monthly basis with the Project Director. |
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 personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training during the facility's July 2022 through June 2023 training year in two of three applicable personnel records reviewed.
Employee #4 was hired as a counselor on February 1, 2022. The record documented 20 hours of annual training during the period reviewed.
Employee #6 was hired as a counselor on August 16, 2017. The record documented 21.35 hours of annual training during the period reviewed.
This is a repeat citation from the September 15, 2021 and the September 14, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will develop and implement a training plan program inclusive of participation and coordination with each individual counselor and counselor assistant. The plan will include overall training requirements, specific training courses identified to meet these requirements, and dates by which each training course will be completed.
The overall training plan will be adopted on a new year, the first training year being completed on January 31, 2024; and running each following year from February 1 to January 31 to coincide with licensing expectation timeframes and performance review periods.
Training plans will be reviewed regularly and documented in individual supervision to ensure progress toward timely completion. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on review of personnel records, the facility failed to ensure that all personnel are trained to perform assigned tasks during emergencies upon employment in three of three applicable employees reviewed.
Employee #3 was hired as a clinical supervisor on August 9, 2023. There was no documentation that the emergency preparedness training was provided at the time of the inspection.
Employee #7 was hired as a counselor assistant on August 1, 2023. There was no documentation that the emergency preparedness training was provided at the time of the inspection.
Employee #8 was hired as a counselor assistant on November 1, 2022. There was no documentation that the emergency preparedness training was provided at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Emergency Preparedness Training will be included in onboarding procedures for new staff effective 11/1/23 through the Relias online training platform. Current staff will be assigned Emergency Preparedness Training in their Relias curricula to be completed by November 15, 2023. The Clinical Supervisor will review the progress toward completion of this training in individual supervision. The Compliance Manager will confirm the completion of this training for all project staff by November 15, 2023. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on review of the facility's September 2022 through July 2023 fire drill logs, the facility failed to identify the time of the fire drill, on their fire drill logs, for the months of September 2022 through December 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Current policies related to fire drills and fire drill logs will continue to be followed, inclusive of the time of the fire drill. The Compliance Manager will consult with the Project Director following each drill to ensure the accuracy and full completion of the log. |
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 forms in four of seven applicable client records reviewed.
Client #2 was admitted on January 12, 2023 and was active at time of inspection. A release of information form to probation and parole was signed and dated by the client on January 12, 2023; however, the purpose of the disclosure was not included on the release form.
Client #4 was admitted on December 30, 2022 and was discharged on June 1, 2023. A release of information form to probation and parole was signed and dated by the client on January 4, 2023; however, the purpose of the disclosure was not included on the release form.
Client #7 was admitted on May 8, 2023 and was active at the time of inspection. A release of information form to probation and parole was signed and dated by the client on May 15, 2023; however, the purpose of the disclosure was not included on the release form.
Client #8 was admitted on December 29, 2022 and was active at the time of inspection. A release of information form to a government agency was signed and dated by the client on May 25, 2023; however, the purpose of the disclosure was not included on the release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Northern Tier Counseling Drug and Alcohol Release of Information Consent form will be modified. Modifications will include the mandatory completion of a "Purpose of Disclosure" section clearly outlining the purpose and limitations of the release form. Modifications will also include documentation that the client was offered a copy of the release following its completion. Form modifications will be complete by November 15, 2023. Monthly audits will be completed by the Compliance Manager to ensure the completion of this new portion of the release form. |
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 a review of client records, the facility failed to document the dated signature of client on release of information forms in one of seven applicable client records reviewed.
Client #3 was admitted on November 21, 2022 and was discharged on June 9, 2023. There were release of information forms to probation/parole and an emergency contact where both were dated December 19, 2022; however, the dated signature of the client was not included on either release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will conduct training for all D&A project staff reviewing the process of obtaining client Release of Information forms, including the necessity for client signatures. The Compliance Manger will complete monthly audits of client charts to ensure all release forms are being completed with a dated client signature. The training will be complete and documented by October 31, 2023. |
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 that a copy of a client consent to release information form was offered to the client in five of seven applicable client records.
Client #1 was admitted on December 12, 2022 and was discharged on May 3, 2023. There was a release of information form to the funding source signed and dated by the client on December 12, 2022; however, there was no documentation indicating a copy of the release form was offered to the client.
Client #2 was admitted on January 12, 2023 and was discharged on May 23, 2023. There was a release of information form to the funding source signed and dated by the client on January 12, 2023; however, there was no documentation indicating a copy of the release form was offered to the client.
Client #3 was admitted on November 21, 2022 and was discharged on June 9, 2023. There was a release of information form to the funding source signed and dated by the client on November 21, 2022; however, there was no documentation indicating a copy of the release form was offered to the client.
Client #7 was admitted on May 8, 2023 and was active at the time of inspection. There were release of information forms to the funding source signed and dated by the client on May 8, 2023, May 15, 2023, and July 10, 2023; however, there was no documentation indicating a copy of either release form was offered to the client. Additionally, there was a release of information form to a physician signed and dated by the client on May 15, 2023; however, there was no documentation indicating a copy of the release form was offered to the client.
Client #8 was admitted on December 29, 2022 and was active at the time of inspection. There were release of information forms to the funding source signed and dated by the client on December 29, 2022 and May 25, 2023; however, there was no documentation indicating a copy of either release form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Northern Tier Counseling Drug and Alcohol Release of Information Consent form will be modified. Modifications will include the mandatory completion of a "Purpose of Disclosure" section clearly outlining the purpose and limitations of the release form. Modifications will also include documentation that the client was offered a copy of the release following its completion. Form modifications will be complete by November 15, 2023. Monthly audits will be completed by the Compliance Manager to ensure the completion of this new portion of the release form. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records and the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of the death or serious injury due to trauma, suicide, medication error or unusual circumstances.
Client #5 was admitted December 7, 2020 and was discharged on June 9, 2023. The facility was notified of the client's off-site death on June 5, 2023. There was no documentation this incident was reported to the Department within 3 business days.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project policies currently require the completion of an internal incident report form following occurrence as defined in § 709.34, including the death or serious injury due to trauma, suicide, medication error or unusual circumstances. This internal form will be modified to include a prompt to complete reporting to the Department, and documentation of said reporting. This change will be completed by October 31, 2023. The Compliance Manager will ensure said reporting's completion when provided the internal incident report as dictated by current policy. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of an event at the facility requiring the presence of police, fire, or ambulance personnel.
On April 11, 2023 and on June 13, 2023, police and ambulance personnel were required at the facility; however, there was no documentation that either unusual incident was reported to the Department within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project policies currently require the completion of an internal incident report form following occurrence as defined in § 709.34, including an event at the facility requiring the presence of police, fire, or ambulance personnel. This internal form will be modified to include a prompt to complete reporting to the Department, and documentation of said reporting. This change will be completed by October 31, 2023. The Compliance Manager will ensure said reporting's completion when provided the internal incident report as dictated by current policy. |
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 ensure treatment and rehabilitation plans are reviewed and updated at least every sixty days in three of four applicable client records reviewed.
Client #1 was admitted on December 12, 2022 and was discharged on May 3, 2023. A treatment plan update was completed on February 15, 2023, and the next update was due no later than April 15, 2023; however, the update was not completed prior to discharge.
Client #5 was admitted on December 7, 2020 and was discharged on June 9, 2023. A treatment plan update was completed on March 15, 2023, and the next update was due no later than May 15, 2023; however, the update was completed on June 5, 2023.
Client #6 was admitted on January 30, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on February 6, 2023, and the first update was due no later than April 8, 2023; however, the update was completed on April 12, 2023. Additionally, a treatment plan update was completed on June 7, 2023, and the next update was due no later than August 7, 2023; however, the update was not completed as of the date of inspection.
This is a repeat citation from the September 15, 2021 and September 14, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective November 1, 2023, internal Project procedures will be supplemented to include a 45-day treatment plan best practice guideline, complimenting the current 60-day cycle. Treatment planning will be reviewed on a 45-day timeframe from this point forward, with regular review of approaching due dates occurring in supervision conducted by the Clinical Supervisor. The Compliance Manager will conduct monthly chart reviews to ensure the new 45-day best practice timeframe is maintaining the 60-day review mandate. |
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.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include follow-up information, in two of two applicable client records reviewed.
Client #1 was admitted December 12, 2022 and was discharged on May 3, 2023. There was no documentation of follow-up information at the time of inspection.
Client #2 was admitted January 12, 2023 and was discharged on May 23, 2023. There was no documentation of follow-up information at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project's follow-up policy specifies a survey be mailed to all successfully discharged clients 60 days following their completion of treatment. These surveys have not been consistently documented in client charts upon mailing and (if applicable) their return. The Clinical Supervisor will confirm with Project staff these surveys are being scanned to client charts in the context of ongoing supervision at 45 days following discharge. The Compliance Manager will complete monthly audits of discharged client charts to ensure the provision of this follow-up information is documented. |
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 and personnel records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for not completing treatment plan updates within the regulatory timeframe was submitted and approved by the Department for the September 15, 2021 and September 14, 2022 annual licensing inspections. Not completing treatment plan updates within the regulatory timeframe was again found to be a deficiency in the September 14, 2023, licensing inspection.
A plan of correction for counselors not completing 25 hours of annual training was submitted and approved by the Department for the September 15, 2021 and September 14, 2022 annual licensing inspections. Counselors not completing 25 hours of annual training was again found to be a deficiency in the September 14, 2023, licensing inspection.
A plan of correction for the project director/facility director not completing 12 hours of annual training was submitted and approved by the Department for the September 15, 2021 and September 14, 2022 annual licensing inspections. The project director/facility director not completing 12 hours of annual training was again found to be a deficiency in the September 14, 2023, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective action plans that have not been fully implemented in the past have resulted in repeat citations from the Department. Northern Tier Counseling will therefore implement a D&A Program Plan of Correction Committee to conduct regular reviews of the implementation of all plans of correction outlined here. The Committee will consist of the Project Director, the Clinical Supervisor, the Compliance Manager, and one representative of the Project staff. The committee will meet once per month to review plan implementation, compliance, and any barriers that require address. The initial meeting of this Committee will take place prior to October 31. The Committee's agenda and progress will be reported quarterly to the Facility Manager, and will continue to occur each month until September 2024, when progress will be assessed both internally and by the Department. |