INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 2, 2026, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #9 and #10 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics using a Department approved curriculum within the regulatory timeframe.
Employee #9 was hired as an administrative staff on December 18, 2023, and was due to have the communicable disease trainings no later than December 18, 2025. Documentation of the completion of Department approved curriculums was not provided during the licensing process.
Employee #10 was hired as an administrative staff on December 21, 2023, and was due to have the communicable disease trainings no later than December 21, 2025. Documentation of the completion of Department approved curriculums was not provided during the licensing process.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
704.11 Employees #9 and #10 will be assigned the Department-approved 6-hour HIV/AIDS training and will complete the training no later than November 1, 2026. Documentation of successful completion will be maintained in each employee's personnel/training record.
Employees #9 and #10 will also be registered for the soonest available Department-approved 4-hour TB/STD and other health-related topics training. If the training is currently full, the employees will be added to the waiting list for the earliest available session and registered for the next available session. Documentation of registration and/or placement on the waiting list will be maintained until the training is completed. Upon completion, the training certificates will be maintained in the employees' personnel/training records.
To prevent recurrence, the Administrative Supervisor, Program Manager, Compliance and Human Resources will review the training records of all current staff to verify compliance with the mandatory communicable disease training requirements outlined in 28 Pa. Code § 704.11(c)(1). Going forward, required HIV/AIDS and TB/STD training will be identified at the time of hire and added to each employee's training plan with a completion deadline that falls within the applicable regulatory timeframe.
The Administrative Supervisor, Human Resources and Compliance Manager will monitor required training deadlines and will notify the employee and Program Manager of approaching training requirements sufficiently in advance to allow registration and completion before the regulatory deadline. The Human Resources Department will provide oversight of this process and verify compliance through periodic review of the staff training records.
This corrective action and monitoring process will be implemented by November 1, 2026, and will remain ongoing.
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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 and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the Project Director and Facility Director.
Employee #1 was hired as the project director and facility 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 February 1, 2025, through January 31, 2026. Employee #1's record only document 10.5 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.11(d)(2) Annual Training Requirements
Effective October 1, 2026, the Facility/Project Director's annual training requirements will be monitored Quarterly to ensure progress towards completion and documentation of a minimum of 12 clock hours of applicable training during each established training year.
The Facility/Project Director will submit training certificates or other documentation for all completed trainings outside of Relias, to the Human Resources Department. Human Resources will maintain the documentation in the employee's personnel/training record and ensure that all completed training hours are accurately reflected in the facility's training records.
The CEO and Facility/Project Director will review the total documented training hours at least quarterly to ensure the Director is on track to complete the required 12 clock hours before the end of the training year. The annual performance evaluation will serve as an additional review point to verify compliance with annual training requirements.
If a quarterly review identifies that the Facility/Project Director is not on track to meet the 12-hour requirement, additional applicable training will be identified and scheduled to ensure completion within the required training year.
This corrective action and monitoring process will be implemented October 1, 2026, and will remain ongoing.
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
Employee #3 was hired as a counselor on November 1, 2023, and was still in that position at the time of the inspection. Employee #3 was reported to have 23 hours per week devoted to their 24 clients on their caseload.
Employee #3 ' s counselor FTE caseload calculation is as follows: 23/37.5 = 0.6133 (FTE); 24/0.61333 = 39.13, which equals to a client/counselor ratio of 39:1.
Employee #4 was hired as a counselor on March 1, 2021, and was still in that position at the time of the inspection. Employee #4 was reported to have 5 hours per week devoted to their 5 clients on their caseload.
Employee #4 ' s counselor FTE caseload calculation is as follows: 5/37.5 = 0.133333 (FTE); 5/0.133333 = 37.5, which equals to a client/counselor ratio of 37:1.
The overall facility FTE follows the above equation. The facility was reported to have 96 hours per week devoted to their 59 clients.
The facility FTE caseload calculation is as follows: 96/37.5 = 2.56 (FTE); 96/2.56 = 23.05, which equals a client/counselor ratio of 23:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will monitor the caseload ratio and implement ongoing monitoring to ensure compliance with 28 Pa. Code § 704.12(a)(6), which requires that the FTE counselor caseload for outpatient counseling not exceed 35 active clients per 1.0 FTE counselor.
Employee #3's caseload ratio temporarily exceeded the required FTE ratio due to coverage needs associated with another counselor's medical leave. Upon the counselor's return to their normal full-time schedule, client assignments and staff hours devoted to Drug and Alcohol services will be adjusted to bring Employee #3 and the overall facility FTE counselor/client ratio into compliance.
Employee #4 will maintain a maximum caseload of five (5) active Drug and Alcohol clients while devoting ten (10) hours per week to Drug and Alcohol counseling services, unless a change in hours and/or caseload is reviewed and determined to remain within the required FTE ratio.
The Program Manager met with the applicable staff on September 8, 2026, to review caseload assignments, staffing hours, and the FTE requirements. All necessary caseload and staffing adjustments will be completed by October 12, 2026.
To prevent recurrence, the Program Manager will review counselor caseloads and the number of hours each counselor devotes to Drug and Alcohol clients on a monthly basis and whenever there is a change in staffing, counselor schedules, medical leave coverage, or client assignments. The review will include calculation of each counselor's FTE and client-to-counselor ratio to ensure that no counselor exceeds the regulatory maximum.
If monitoring identifies that a counselor is approaching the maximum allowable FTE ratio, the Program Manager will adjust client assignments and/or counselor hours before additional clients are assigned. Documentation of the caseload review and any necessary corrective adjustments will be maintained by the facility.
This monitoring process will be implemented by October 12, 2026, and will remain ongoing.
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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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two out of seven records reviewed.
Client #4 was admitted on January 8, 2026, and was discharged on March 5, 2026. The record included a consent to release information for a funding source signed by the client on January 8, 2026, with an expiration date of January 8, 2026; as well as a second release of information for the funding source that was signed by the client on February 3, 2026, and had an expiration date of February 3, 2027. The facility confirmed the funding source was billed for services between January 9, 2026, and February 2, 2026.
The record also included a consent to release information form for a probation officer signed by the client on January 8, 2026, with an expiration date of January 7, 2026. A second release of information form was signed by the client on January 21, 2026, and had an expiration date of January 21, 2027. The record indicated communication with the probation officer occurred on January 8, 2026.
Client #5 was admitted on March 13, 2026, and was discharged on June 3, 2026. There was no documentation that the facility obtained an informed and voluntary consent for the funding source until May 6, 2026. The facility confirmed that billing occurred prior to May 6, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective November 1, 2026, the Program Manager and Compliance Department will implement additional monitoring to ensure that an informed and voluntary consent to release information (ROI) is properly completed and valid prior to the disclosure of client information.
The Program Manager will review Releases of Information submitted with initial Level of Care assessments to verify that each ROI is complete and contains accurate effective and expiration dates prior to information being disclosed to the identified individual, agency, funding source, or other entity.
Staff will be reminded that a valid ROI must be obtained before disclosure of client information occurs, when a consent is required. Pennsylvania licensing findings under §709.28(c) identify the absence of a properly documented consent before disclosure as noncompliance.
The Program Manager and Compliance Department will provide training/re-education to applicable staff by November 1, 2026, regarding the completion and review of Releases of Information, with specific attention to:
- ensuring the ROI is signed and dated by the client;
- verifying that effective and expiration dates are accurate;
- ensuring that the ROI has not expired;
- verifying that a valid ROI is in place prior to disclosure when consent is required; and
- ensuring completed ROIs are maintained in the client's record.
In addition, the Program Manager will conduct an audit of active client ROIs at the beginning of each calendar year to verify that releases remain current and contain appropriate expiration dates. Any errors or expired releases identified during the audit will be addressed with the responsible staff member, and a new valid consent will be obtained when necessary before further disclosure of client information.
The Compliance Department will provide ongoing oversight through periodic record reviews to verify adherence to the facility's confidentiality procedures and §709.28(c). Any identified patterns of noncompliance will result in additional staff education and increased monitoring.
Responsible Persons: Program Manager and Compliance Department
Implementation Date: November 1, 2026
Monitoring: Ongoing
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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 ensure that clients received counseling services according to their individual treatment plan in four out of seven records reviewed.
Client #2 was admitted on May 13, 2026, and was still active at the time of inspection. The individual treatment plan dated May 22, 2026, indicated two group sessions per week and one individual session per week. The record documented only one group session during the weeks of May 31 - June 6, 2026, June 14-20, 2026, and June 21-27, 2026. There was no documentation of individual sessions during the weeks of May 24-30, 2026, June 14-20, 2026, and June 28 - July 4, 2026.
Client #3 was admitted on March 23, 2026, and was still active at the time of inspection. The individual treatment plan dated April 2, 2026, indicated three groups per week and one individual session per week. The record documented only two group sessions during the week of May 24-30, 2026. The treatment plan updated June 12, 2026, indicated two groups per week and one individual session per week. The record documented only one group session during the weeks of June 21-27, 2026, and August 9-15, 2026. There was no documentation of any individual sessions during the weeks of May 24-30, 2026, and August 9-15, 2026.
Client #5 was admitted on March 13, 2026, and discharged on June 3, 2026. The individual treatment plan dated March 17, 2026, indicated one group session per week and one individual session per week. There was no documentation of any individual sessions during the weeks of April 26 - May 2, 2026, and May 24-30, 2026.
Client #6 was admitted on April 13, 2026, and discharged on June 3, 2026. The individual treatment plan dated April 22, 2026, indicated three group sessions per week and one individual session per week. There was no documentation of any individual sessions during the weeks of May 17-23, 2026, and May 24-30, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective November 1, 2026, theTowanda outpatient programs will implement additional monitoring to ensure that counseling services are provided in accordance with each client's individual treatment and rehabilitation plan.
All counselors will be retrained on the requirements of 709.92(c) during individual supervision. Counselors will review each client's treatment plan and ensure that the frequency of individual and group counseling services provided is consistent with the frequency identified in the current treatment plan.
When a scheduled or required counseling service does not occur due to circumstances such as client cancellation, client illness, vacation, work obligations, inability to attend, counselor absence, or other interruption in service, the counselor will document the reason for the gap in service in the client record through the appropriate progress note, session status, cancellation/no-show documentation, or contact note, as applicable. The counselor will also document appropriate follow-up efforts when indicated.
If a client's attendance pattern or other circumstances indicate that the frequency of services identified on the treatment plan is no longer clinically appropriate or achievable, the counselor will address the change with the client and update the treatment plan as clinically appropriate rather than allowing ongoing discrepancies between the treatment plan and services being provided.
The Program Manager will review compliance during individual supervision and through ongoing chart reviews with the assistance of the Compliance Manager Reviews will compare the frequency of individual and group counseling identified on the client's treatment plan with the actual services provided and documented in the client record.
When a discrepancy is identified, the Program Manager will address the deficiency with the counselor and ensure that appropriate corrective action is taken. Identified patterns of noncompliance will result in additional training and increased chart monitoring.
This corrective action and monitoring process will be implemented by November 1, 2026, and will remain ongoing at the Towanda location.
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