INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 02, 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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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies upon hire in three of eight applicable records reviewed.Employee #7 was hired on September 24, 2024, as a counselor on September 24, 2024 and was still in the position as of the date of the inspection. The training was not completed until September 02, 2025.Employee #8 was hired on November 04, 2024, as a counselor and was still in the position as of the date of the inspection. The training was not completed until September 02, 2025.Employee #9 was hired on July 28, 2025, as a counselor and was still in the position as of the date of the inspection. The training was not completed until September 02, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective September 10, 2025, all new employees will be required to complete fire safety and emergency response training during orientation and before independently assuming their job responsibilities.
The facility's orientation checklist has been revised to include verification of fire safety training as a required step before working as a counselor or counselor assistant.
The clinical supervisor and the quality manager will review all new hire personnel files within the first 30 days of employment to ensure that fire safety and emergency training are documented.
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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 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 two out of seven records reviewed. Client #2 was admitted on April 24, 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 April 24, 2025; however, it did not indicate the name of the person, agency or organization to whom disclosure may be made.Client #6 was admitted on September 30, 2024, and was still active at the time of the inspection. A consent to release information form was signed and dated by the client, on September 30, 2024; however, it did not indicate the name of the person, agency or organization to whom disclosure may be made. These findings were 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 immediately, and all active clients missing any information will be corrected by October 10, 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.
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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.
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Observations
Based on review of client records, the facility failed to obtain a completed informed and voluntary consent which included the specific information to be disclosed in five out seven records reviewed. Client #1 was admitted on November 01, 2024, and discharged April 02, 2025. A release of information form to the funder, was signed and dated November 01, 2024; however, it did not include the specific information to be disclosed.Client #2 was admitted on April 24, 2025, and was still active at the time of the inspection. A release of information form to the funder, was dated and signed on April 24, 2025; however, it did not include the specific information to be disclosed. Client #4 was admitted on November 08, 2024, and discharged on December 09, 2024. A release of information form to the funder, was dated and signed on November 08, 2024; however, it did not include the specific information to be disclosed. Client #6 was admitted on September 30, 2024, and was still active at the time of the inspection. A release of information form to the funder was dated and signed September 30, 2024; however, it did not include the specific information to be disclosed. Client #7 was admitted on November 06, 2024, and discharged on May 08, 2025. A release of information form for the funder was dated and signed on November 06, 2024; however, it did not include the specific information to be disclosed.These findings were 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 include specific details of the information to be disclosed. This will be enforced by October 10, 2025.
This form requires staff to clearly document the specific information being disclosed (processing insurance claims, obtaining insurance authorizations, and any other information that is required).
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 the specific information to be disclosed and the importance of collecting signatures on the new form.
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 the specific information disclosed. Quarterly audits will also be conducted by the clinical supervisor and the compliance manager.
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