INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on September 2, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-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(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of nine personnel records, the facility failed to provide documentation of supervision occurring weekly to include direct observation for employee # 9.
Employee # 9 was hired as a counselor assistant on January 13, 2020. Supervision notes provided did not include documentation of supervision the weeks of:
February 2-8, 2020
February 9-15, 2020
February 16-22, 2020
March 15-21, 2020
March 29-April 4, 2020
April 12-18, 2020
April 26-May 2, 2020
May 10-16, 2020
May 24-30, 2020
May 31-June 6, 2020
June 7-13, 2020
June 28-July 4, 2020
July 5-11, 2020
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide weekly supervision for Employee #9 as well as all other Counselor Assistant for each week going forward in the calendar year for the duration of the Counselor Assistant's time in the program in the position of Counselor Assistant. When a supervision is missed, the Clinical Supervisor will re-schedule with the Counselor Assistant for that week, if able, and provide supporting documentation for all missed or cancelled supervisions. The first post-inspection supervision took place on 9/8/2020. |
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 the review of nine personnel records, the facility failed to provide documentation of three staff receiving a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases training.
Employee # 1 was hired as the Project Director on December 28, 2018. A minimum of 4 hours of tuberculosis, sexually transmitted diseases training had not been provided within the regulatory timeframe.
Employee # 5 was hired as a counselor on August 16, 2019. A minimum of 4 hours of tuberculosis, sexually transmitted diseases training had not been provided within the regulatory timeframe.
Employee # 6 was hired as a counselor on August 16, 2019. A minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases training had not been provided within the regulatory timeframe.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resources Director will contact the Department of Drug and Alcohol Programs (DDAP) to obtain information on training date/times on the minimum 4 hours of tuberculosis, sexually transmitted diseases and other health related topics as well as the minimum of 6 hours of HIV/AIDS. This information will then be disseminated to the Project Director who will provide the training date/times to Employee #1, #5 and #6 in a Drug and Alcohol Group Staffing. The before-mentioned Employees will then make scheduling accommodations to attend the required trainings. The Human Resources Director will reach out to DDAP by 9/18/2020 and staff will be trained by 6/30/2021 in the deficient areas. |
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 the review of the Staffing Requirements Facility Summary Report, the facility failed to comply with the client/staff and client/counselor ratios during primary care hours. The FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients. The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility operating hours. 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 # 4 was hired as a counselor on January 17, 2020. Employee #4 was reported to have 5 hours per week devoted to their 5 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 5/37.5 = .1333 (FTE); 5/.1333= 37.5093, which equals to a client/counselor ratio of 38:1.
Employee # 5 was hired as a counselor on August 16, 2019. Employee #5 was reported to have 1 hour per week devoted to their 1 client on their caseload.
The FTE counselor ' s caseload calculation is as follows: 1/37.5 = 37.5 (FTE); 1/37.5= 37.5, which equals to a client/counselor ratio of 38:1.
Employee # 8 was hired as a counselor on November 1, 2017. Employee #8 was reported to have 21 hours per week devoted to their 20 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 21/37.5 = .56 (FTE); 20/.56= 35.7142, which equals to a client/counselor ratio of 36:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will address in Drug and Alcohol Group Staffing the FTE Ratio requirements and have staff accommodate their caseloads to adhere to this ratio going forward. Employee #4, #5, and #8 caseloads will then be assessed in Individual Supervision with the Clinical Supervisor or Project Director to ensure that accommodations have been made. Caseloads will be within the FTE ratio by 10/15/2020 to ensure clinical care of clients. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of the facility annual report, the facility failed to include a statement disclosing the names of officers, directors and principal shareholders, when applicable.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will include the names of officers, directors and principal shareholders, when applicable, on the Annual Report for the upcoming calendar year. This will continue to be made available to the public by way of newspaper and potentially on the company website. This board meeting is taking place on 9/18/2020. |