INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 03, 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 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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709.28 (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 seven outpatient client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in three of the seven records reviewed. Client #2 was admitted on August 18, 2025, and still active at the time of the inspection. There was documentation that information was disclosed to the funder on August 21, 2025, however the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information.Client #3 was admitted on August 18, 2025, and still active at the time inspection. There was documentation that information was disclosed to the funder on August 18, 2025, however the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information. Client #4 was admitted on July 21, 2025, and discharged on August 19, 2025. There was documentation that information was disclosed to the funder on July 29, 2025, however, the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All active clients will have updated consents to release information to the funder completed by October 10, 2025. The form requires staff to clearly document the specific information being disclosed (processing insurance claims, obtaining authorizations, and other necessary information).
All administrative staff were retrained on September 4, 5, and 9, 2025, on confidentiality requirements, including the necessity of obtaining informed and voluntary consent prior to any disclosure of client information. Training emphasized proper completion of consent forms, documentation of specific information to be disclosed, and the requirement for client signatures prior to disclosure.
The clinical supervisor and compliance manager will review all new admissions within the next 30 days to ensure consent forms are fully completed and all active clients have completed consents. Quarterly audits will be conducted thereafter to monitor ongoing compliance. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of outpatient client records, the facility failed to obtain an informed and voluntary consent from the client to for the disclosure of information contained in the client record to include the name of the person, agency or organization in one out of seven records reviewed. Client #1 was admitted on July 07, 2025, and was still active at the time of the inspection. A consent to release information form was signed and dated by the client, on July 07, 2025; however, it did not indicate the name of the person, agency or organization to whom disclosure may be made.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All active clients will have completed updated consents to release information to the funder, which includes the name of the person, agency, or organization to whom disclosure is made. This will be enforced on September 11, 2025.
This form requires staff to clearly document the name of the person, company, or agency to whom the information is being disclosed.
All administrative staff were retrained on September 4, 5, and 9, 2025. The training was on how to properly complete consents, with emphasis on documenting who is receiving the information and what specific information is to be disclosed.
The clinical supervisor and the compliance manager will review all new admissions within the next month to verify that consent forms are fully completed, including to whom the information is to be disclosed. Quarterly audits will also be conducted by the clinical supervisor and the compliance manager. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to develop written policies and procedures on clients rights and document written acknowledgement by clients that they have been notified of those rights in three out of seven records reviewed.Client #2 was admitted on August 18, 2025, and still active at the time of the inspection. There was no documentation of written acknowledgement by the client that they had been informed of client rights. Client #3 was admitted on August 18, 2025, and still active at the time of the inspection. There was no documentation of written acknowledgement by the client that they had been informed of client rights.Client #4 was admitted on July 21, 2025 and discharged on August 19, 2025. There was no documentation of written acknowledgement by the client that they had been informed of client rights. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has developed procedures outlining the importance of the administration staff receiving written acknowledgment by the client that they were notified of their rights, effective immediately.
All active clients will review and sign the updated Client Rights Acknowledgement Form by October 10, 2025. Documentation will be maintained in the client record.
Staff were retrained on September 4, 5, and 9 of 2025 on the requirement to review client rights with each client at admission and obtain a signed acknowledgement.
The clinical supervisor and compliance manager will review all new admissions within 30 days to verify documentation of client rights acknowledgement is present in each record. Quarterly audits will also be conducted to ensure continued compliance. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility's intake procedures failed to include documentation of the consent to treatment, in three out of seven records reviewed. Client #2 was admitted on August 18, 2025, and still active at the time of the inspection. There was no documentation of consent to treatment during intake. Client #3 was admitted on August 18, 2025, and still active at the time of the inspection. There was no documentation of consent to treatment during intake.Client #4 was admitted on July 21, 2025, and discharged on August 19, 2025. There was no documentation of consent to treatment during intake.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All active clients who did not previously sign a consent to treatment will complete the updated form by October 10, 2025. Documentation will be maintained in the client record.
All administrative staff were retrained on September 4, 5, and 9 of 2025 regarding the requirement to obtain and document signed consent to treatment before initiating service.
The clinical supervisor and compliance manager will review all new admissions within 30 days to ensure the consent to treatment is present in each record. Quarterly audits will be conducted to ensure ongoing compliance. |