INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 21, 2025, 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 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:
|
Plan of Correction
|
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a review of the August 2024 through April 2025 fire drill logs during the inspection, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
As of May 23, 2025, DDAP approved Northern Tier Counseling's fire drill exception. This allows the agency to use an alternative method for announcing fire drills. This method is designed to effectively alert individuals within the facility's occupied space without disrupting other tenants in the building.
The fire alarm will be intentionally activated once per year to verify that the system is fully operational and functioning as intended.
This plan of correction has already been implemented. |
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.
|
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 that included the specific information to be disclosed in six out of seven records reviewed.
Client #2 was admitted on March 14, 2025 and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to a funding source signed by the client on March 14, 2025, that did not have documentation of specific information to be disclosed.
Client #3 was admitted on February 17, 2025 and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to a funding source signed by the client on February 17, 2025, that did not have documentation of specific information to be disclosed.
Client #4 was admitted on February 26, 2025 and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to a funding source signed by the client on February 26, 2025, that did not have documentation of specific information to be disclosed.
Client #5 was admitted on May 1, 2025 and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to a funding source signed by the client on May 1, 2025, that did not have documentation of specific information to be disclosed.
Client #6 was admitted on February 24, 2025 and was discharged on March 27, 2025. The record contained one informed and voluntary consent to release information to a funding source signed by the client on February 24, 2025, that did not have documentation of specific information to be disclosed.
Client #7 was admitted on January 28, 2025 and discharged on May 5, 2025. The record contained one informed and voluntary consent to release information to a funding source signed by the client on January 28, 2025, that did not have documentation of specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Northern Tier Counseling Drug and Alcohol Program will revise its documentation process by consolidating the current insurance authorization form and the release of information form into a single document. The finalization of this new form will be completed by June 30, 2025, with full implementation scheduled for July 1, 2025.
To ensure compliance and consistency, the administrative staff will be responsible for presenting the combined form to clients at the time of registration for their initial intake/assessment appointment. Staff will obtain client signatures at this time, ensuring all necessary authorizations are in place before the start of services.
Training will be provided to all administrative personnel before July 1st to ensure proper use and documentation procedures are followed. Compliance will be monitored by the program manager and the compliance manager through regular chart audits.
All current clients will sign this new authorization form starting on July 1, 2025, as they come in for scheduled appointments. |
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of four applicable records reviewed.
Client #3 was admitted on February 17, 2025 and was still active at the time of the inspection. A treatment plan was completed on March 7, 2025, and the next update was due no later than May 6, 2025; however, the next update was completed on May 12, 2025.
Client #7 was admitted on January 28, 2025 and discharged on May 5, 2025. A treatment plan was completed on February 17, 2025, and the next update was due no later than April 17, 2025; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Drug & Alcohol Department Manager will review regulatory guidelines regarding treatment plan updates with all clinical staff during the next scheduled supervision meeting. This review will emphasize the requirement that treatment plan updates must be completed within the mandated 60-day timeframe, regardless of client availability for signature.
Staff will be instructed that if a client is unavailable at the time the treatment plan is due, the counselor must still complete the treatment plan by the 60-day deadline. The plan should then be reviewed and signed by the client at their next attended session.
This Plan of Correction will be implemented and effective as of June 10, 2025. The compliance manager and D&A manager will monitor compliance through routine chart audits and supervision reviews. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in five out of seven applicable records reviewed.
Client #1 was admitted on March 10, 2025 and discharged on May 14, 2025. The treatment plan dated April 7, 2025, indicated two groups and one individual session a week. There was no documentation of the client receiving group therapy the weeks of April 7, 14, 21, and 28, 2025. In addition, there was no documentation that the client received individual therapy the week of April 28, 2025.
Client #2 was admitted on March 14, 2025 and was still active at the time of the inspection. The treatment plan dated March 27, 2025, indicated one weekly individual session and two groups a week. There was no documentation that the client received individual sessions the week of March 31, April 28 and May 5, 2025. In addition, there was no documentation that the client received two group sessions the weeks of April 7, 21 and May 5, 2025.
Client #3 was admitted on February 17, 2025 and was still active at the time of the inspection. The treatment plan dated March 7, 2025, indicated one individual and two group sessions weekly. There was no documentation that the client received individual therapy the weeks of March 31, April 21, 28 and May 5, 2025. In addition, there was no documentation that the client received two group sessions the weeks of March 24, 31, April 7, 14, 21, 28, May 5, and 12, 2025.
Client #4 was admitted on February 26, 2025 and was still active at the time of the inspection. The treatment plan dated March 20, 2025, indicated one individual and two group sessions a week. There was no documentation that the client received individual therapy the weeks of March 31, April 7, 14, 21, and 28, 2025. In addition, there was no documentation that the client received group therapy the weeks of March 31, April 7, 14, 21, and 28, 2025.
Client #6 was admitted on February 24, 2025 and was discharged on March 27, 2025. The treatment plan dated February 27, 2025, indicated one individual session a week. There was no documentation that the client received individual therapy the week of March 10, 2025.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Counselors will be required to document the attendance status of each client for scheduled group and individual counseling appointments. This will be done by selecting one of the following standardized notations: Kept, Did Not Show, Cancelled by Client, or Cancelled by Therapist. This documentation will ensure clear accountability and adherence to treatment plans. This plan of correction is effective on June 10, 2025.
A chart audit process has been implemented. The compliance manager and the D&A manager will randomly review at least five charts per month to ensure that counseling services align with the documented treatment plan. Any variances will be addressed immediately with corrective supervision |