This report is a result of an on-site licensure renewal inspection conducted on September 29, 2008 and October 1, 2008 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on November 4, 2008.
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Plan of Correction
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Observations
Three of three discharged client records reviewed on September 30, 2008 failed to include documentation of client follow-up activities within two months of discharge as required by facility policy and procedure.
Findings:
Client record # 4 - Admitted on January 1, 2008 , discharged on February 4, 2008. Follow-up activities needed to be completed by April 4, 2008 A review of the record and an interview with the project director and clinical supervisor on September 30, 2008 further verified that follow-up services were not completed.
Client record # 5 - Admitted on December 11, 2007, discharged on January 13, 2008. Follow-up activities needed to be completed by March 13, 2008. A review of the record and in interview with the project director and clinical supervisor on September 30, 2008 further verified that follow-up services were not completed.
Client record # 6 - Admitted on April 30 2008, discharged on June 25 2008. Follow-up activities needed to be completed by August 25, 2008. A review of the record and in interview with the project director and clinical supervisor on September 30, 2008 further verified that follow-up services were not completed
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Plan of Correction
NTC's policy states an aftercare plan is completed for each client to provide direction and guidance after leaving treatment, and provides appointments and correspondence for a 2 month period. At the end of the 2nd month an aftercare survey is generated and mailed to every successfully discharged client; however, prior to this past review this survey was not being sent out to individuals that came in for an evaluation only. There will be several changes made in this POC resulting from this citation; firstly, the aftercare letter and survey will be sent out to all individuals that have been seen at the clinic by the D&A Clinical staff, and in addition to the follow-up letter and survey a phone call will also be made and the correspondence will be documented in each case file. |