INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, 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 2, an abbreviated on-site inspection, conducted on February 4, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility policy and procedure manual, there was no documentation of the project director signing an annual update delineating project policies and procedures for the year 2020. The last documented was in September 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will work collaboratively with the Facility Director to review and sign off on an annual update delineating project policies for the year 2020 and each year thereafter. This will be completed in a Supervision with the Facility Director by 3/2/2021. |
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 one of eight client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in client record # 5.
Client # 5 was admitted on July 21, 2020 and was discharged on September 28, 2020. An informed and voluntary consent to disclose form, to a funding source, was not signed by the client until June 29, 2020. An informed and voluntary consent to disclose form to Children and Youth and to Probation was not signed by the client until July 21, 2020. After review of the client record, it was established that disclosures were occurring for the funding source , probation officer, and children and youth prior to the signature of the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will work collaboratively with the Clinical Supervisor to review with Counselors and Counselor Assistants that Informed and Voluntary Consents for all appropriate and agreed upon parties (CYS, Probation, etc.) should be completed upon the initial session with the client when information pertaining to these agencies is learned by the Counselor or Counselor Assistant. This topic will be addressed in both Individual Supervisions with each Counselor or Counselor Assistant as well as during a Group Supervision on 3/3/2021. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on six of seven applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan to include type and frequency of treatment and rehabilitation services.
Client # 1 was admitted on June 22, 2020 and was still active at the time of the inspection. An individual treatment and rehabilitation plan dated June 30, 2020 did not provide the type and frequency of services provided.
Client # 3 was admitted on September 1, 2020 and was still active at the time of the inspection. An individual treatment and rehabilitation plan dated September 15, 2020 did not provide the type and frequency of services provided.
Client # 4 was admitted on February 13, 2020 and was still active at the time of the inspection. An individual treatment and rehabilitation plan dated February 25, 2020 did not provide the type and frequency of services provided.
Client # 5 was admitted on April 6, 2020 and was discharged on September 28, 2020. An individual treatment and rehabilitation plan dated April 14, 2020 did not provide the type and frequency of services provided.
Client # 6 was admitted on November 5, 2019 and was discharged on July 28, 2020. An individual treatment and rehabilitation plan dated November 14, 2020 did not provide the type and frequency of services provided.
Client # 8 was admitted on May 29, 2020 and was discharged on December 3, 2020. An individual treatment and rehabilitation plan dated June 5, 2020 did not provide the type and frequency of services provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will implement Type and Frequency of Treatment into the Individualized Treatment Plan starting 3/1/2021. These will be "required" fields (meaning staff cannot sign the plan until these fields are filled in per an EMR technical feature) to be completed for all Individual Treatment Plans from 3/1/2021 and on by any staff member completing an Individualized Treatment Plan. |
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 three of seven applicable client records reviewed, the facility failed to provide documentation of treatment and rehabilitation plans being reviewed and updated at least every sixty days in client records # 2, 4, and 8.
Client # 2 was admitted on January 7, 2020 and was still active at the time of the inspection. A treatment plan update was completed on November 24, 2020 and the next update was due no later than January 24, 2021; however, there was no update documented in the record at the time of the inspection.
Client # 4 was admitted on February 13, 2020 and was still active at the time of the inspection. A treatment plan update was completed on June 17, 2020 the next update did not occur until September 2, 2020. A treatment plan update was completed on November 11, 2020 and the next update was due no later than January 11, 2021; however, there was no update documented in the record at the time of the inspection.
Client # 8 was admitted on May 29, 2020 and was discharged on December 3, 2020. A treatment plan update was completed on July 23, 2020 and the next update was due no later than September 23, 2020; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will work collaboratively with the Clinical Supervisor to re-educate staff of the proper procedure (plans are to be reviewed and updated every 60 days) regarding Individualized Treatment Plans. The company's EMR has an "Expiring Treatment Plans" Report that is easily accessible to all staff members that tracks due dates of plans. This will be addressed both in Individual Supervisions with each Counselor or Counselor Assistant as well as during a Group Supervision on 3/3/2021. |