INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, TrueNorth Wellness Services 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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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of the facility's administrative documentation, the facility failed to provide verification of a written agreement with a licensed hospital or physician, for 24 hour emergency medical coverage.
The findings include:
The administrative documents were reviewed on July 25, 2013. The facility was unable to provide a written agreement with a licensed hospital or physician for 24 hour emergency medical coverage.
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Plan of Correction
The Facilities Director is in the process of drafting a letter of agreement to the local hospital for 24 hour medical coverage. The letter should be finished and sent by 30 August 2013. The Facilities Director will follow up with the process through the month of September until there is a signed agreement in place. This agreement will have our new name reflected in the contract. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include the proposed type of support services.
The findings include:
Five client records were reviewed for treatment plans on July 25, 2013. Two out of five client records lacked documentation of a treatment plan that included the proposed type of support services, specifically client records # 2, and 4.
The treatment plan for client #2 was completed on March 26, 2013 and did not include the proposed type of support services.
The treatment plan for client #4 was completed on October 2, 2012 and did not include the proposed type of support services.
The findings were discussed with the clinical supervisor.
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Plan of Correction
The Program Director will be planning a treatment team meeting during the month of September to document the findings of this inspection. During that meeting, clients names will be given to the appropriate clinician to document support services in the NOTE section of the EMR - as we can not alter existing documents. The Program Director will check by the end of September that this was completed.
To make sure that this is documented appropriately for future reference, the Program Director will be meeting with the EMR administrator to add a section in the EMR to document support services right on the treatment plan. This will be completed by October 30, 2013.
The Program Director will be monitoring Treatment Plans during the first 3 months starting in October, weekly, to ensure that this is being completed. This standard will then be monitored monthly after that to ensure compliance.
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709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based upon a review of the facility's policies and procedures and client records, the facility failed to document aftercare plans as per their policy.
The findings include:
The policy which specified the timeframe for the completion of aftercare plans included the following language:
Aftercare plans are to be completed upon successful discharge during the last scheduled outpatient session.
Two discharged client records were reviewed for aftercare plans on July 25, 2013. The facility failed to document an aftercare plan in one of two client records, specifically client #5.
Client #5 was discharged on January 17, 2013. As of the date of inspection, there was no aftercare plan documented for client # 5.
The findings were reviewed and confirmed with the clinical supervisor.
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Plan of Correction
The Program Director will meet with staff during the month of September to review the findings of this latest inspection. During that meeting, a review of the required paperwork will be done to include the required Aftercare Plan for any client who has successfully completed treatment.
The Program Director will conduct weekly reviews staring in October of any client successfully discharged to make sure that this standard is being met. If there is an issue, the clinician will be immediately reminded of this standard.
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