INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 1, 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(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
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.
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 7 hours per week devoted to their 12 clients on their caseload.
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.
The counselor ' s FTE caseload calculation is as follows: 7/37.5 = 0.1866666667 (FTE); 12/0.1866666667 = 64, which equals a client/counselor ratio of 64:1.
The overall facility FTE follows the above equation. The facility was reported to have 7 hours per week devoted to their 12 clients.
The facility FTE caseload calculation is as follows: 7/37.5 = 0.1866666667 (FTE); 12/0.1866666667 = 64, which equals to a client/counselor ratio of 64:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility acknowledges the deficiency regarding the outpatient FTE counselor caseload ratio for Employee #3. The facility identified that the hours reported as being devoted to the employee's active caseload did not provide sufficient counselor FTE to maintain the required maximum ratio of 35 active clients per 1.0 FTE counselor.
Immediate Corrective Action:
Upon identification of the deficiency, Program Manager reviewed Employee #3's current caseload, work schedule, and the number of hours devoted to counseling responsibilities. The employee's schedule and/or caseload will be adjusted to ensure that sufficient counselor hours are allocated to the 12 active clients so that the calculated FTE counselor caseload does not exceed 35:1.
For a 37.5-hour work week and a caseload of 12 active clients, the employee must have at least approximately 12.86 hours per week (0.343 FTE) devoted to the caseload to remain at or below the 35:1 maximum. The facility will allocate no less than 13 hours per week to counseling responsibilities for this caseload, or further reduce the caseload as necessary to maintain compliance.
Systemic Corrective Action:
The Program Manager will review the caseloads, work schedules, and hours devoted to counseling responsibilities for all outpatient counselors to verify compliance with 28 Pa. Code § 704.12(a)(6). Any counselor identified as exceeding the allowable FTE caseload ratio will have their caseload and/or designated counseling hours adjusted immediately.
The facility will implement an Outpatient Counselor FTE Caseload Monitoring Tool that documents:
Counselor name;
Total facility work week hours;
Hours per week devoted to the counselor's active caseload;
Number of active clients assigned;
Counselor FTE;
Calculated FTE client/counselor ratio; and
Whether the counselor is compliant with the maximum 35:1 ratio.
The Program Manager will review the monitoring tool monthly and whenever a counselor's caseload, schedule, or assigned counseling hours change. No additional clients will be assigned to a counselor if the assignment would cause the counselor's calculated FTE caseload to exceed the regulatory maximum of 35 active clients per 1.0 FTE counselor.
The Program Manager will also review the FTE caseload calculation with applicable supervisory and administrative staff to ensure that staff responsible for scheduling, caseload assignment, and completion of the Staffing Requirements Facility Summary Report understand how counseling FTE and caseload ratios are calculated.
Ongoing Monitoring:
The Program Manager will be responsible for ongoing monitoring of outpatient counselor FTE caseload ratios. Documentation of the monthly review will be maintained by the facility and made available for review during future licensing inspections.
Target Completion Date: 11/01/2026
Person Responsible: Program Manager, Facility Director and Compliance Manager |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on September 1, 2026, the facility failed to maintain hot water temperatures at or below 120 degrees Fahrenheit. The waiting room bathroom hot water temperature was recorded at 124.8 degrees Fahrenheit.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO contacted the landlord on September 1, 2026, the date of the licensing inspection, regarding the waiting room bathroom hot water temperature exceeding the maximum allowable temperature of 120 degrees Fahrenheit. The landlord adjusted the water temperature, and the facility verified by September 8, 2026, that the hot water temperature had been lowered to 120 degrees Fahrenheit or below, correcting the identified deficiency.
To prevent recurrence, beginning October 1, 2026, the Administrative Supervisor or designee will monitor and document the hot water temperature in all facility bathrooms on a monthly basis to ensure that the temperature does not exceed 120 degrees Fahrenheit. The results will be maintained on a water temperature monitoring log.
If a temperature above 120 degrees Fahrenheit is identified, the Administrative Supervisor will immediately notify the landlord/maintenance personnel for corrective action and will recheck and document the water temperature after the adjustment to verify that it is at or below 120 degrees Fahrenheit.
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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 #1 was admitted on April 8, 2026, and was active at the time of inspection. The treatment plan dated April 23, 2026, indicated three three-hour group sessions per week and one individual session per week. There was only documentation of two group sessions for the week of May 24-30, 2026, and documentation of one group session for the week of June 7-13, 2026. There was no documentation that the client received any individual sessions during the weeks of June 7-13, 2026, August 9-15, 2026, August 16-22, 2026, and August 23-29, 2026.
Client #2 was admitted on May 18, 2026, and was active at the time of inspection. The treatment plan dated May 28, 2026, indicated one individual session per week. There was no documentation of any individual sessions for the weeks of June 7-13, 2026, August 9-15, 2026, and August 16-22, 2026.
Client #3 was admitted on June 25, 2026, and was active at the time of inspection. The treatment plan dated June 25, 2026, indicated one individual session per week. There was no documentation of any individual sessions for the weeks of July 5-11, 2026, July 12-18, 2026, and August 9-15, 2026.
Client #6 was admitted on March 23, 2026, and was discharged on July 1, 2026. The treatment plan dated March 30, 2026, indicated one individual session per week. There was no documentation of any individual sessions for the weeks of April 5-11, 2026, May 3-9, 2026, May 17-23, 2026, May 31-June 6, 2026, June 14-20, 2026, and June 21-27, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective November 1, 2026, the Athens outpatient program 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 Athens location.
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