INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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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 Project Directors.
Employee #1 was hired as a Project Director on August 1, 2014, and was still in the position as of the date of the onsite inspection. The training year reviewed was the period between October 1, 2021, through September 30, 2022. Employee #1's training record did not contain documentation of any of the required annual training hours for this cycle.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A meeting occurred with Employee #1 on 7/26/2023 regarding the training hours for the project director along with the documentation for said training hours. A monthly review will occur since we are need the end of this training year, to verify we are in compliance. Going forward, a Mid year review will occur with all staff to ensure there is good progress in obtaining the needed training hours. The mid year review will be conducted approximately on 4/01/2024 and the clinical Supervisor is responsible for Oversight. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed by the second appointment.
Client #1 was admitted on January 20, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 2, 2023; however, the treatment plan was not completed until March 9, 2023.
Client #3 was admitted on June 12, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than July 10, 2023; however, there was no documentation of it being completed at the time of inspection.
Client #5 was admitted on September 1, 2022, and discharged on January 17, 2023. A comprehensive treatment plan was due no later September 14, 2022; however, the treatment plan was not completed until October 19, 2022.
Client #7 was admitted on December 21, 2022 and discharged on February 2, 2023. A comprehensive treatment plan was due no later than January 4, 2023; however, the treatment plan was not completed until January 11, 2023.
Additionally, based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan be developed with the client in four out of six applicable client records reviewed.
Client #2 was admitted on June 13, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 20, 2023, with no client signature.
Client #4 was admitted on June 22, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 12, 2023, with no client signature.
Client #5 was admitted on September 1, 2022, and discharged on January 17, 2023. A comprehensive treatment plan was developed on October 19, 2022, with no client signature.
Client #7 was admitted on December 21, 2022, and discharged on February 2, 2023. A comprehensive treatment plan was developed on January 11, 2023, with no client signature.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/15/2023 the treatment planning process, with all clients, was updated. Treatment planning with clients will occur with in the first 30 days, after having attended their 1st treatment visit, which will occur after the Level of Care assessment. If there are issues that prevent the treatment plan from being developed in the first 30 days, this will be noted in the client's chart with a plan to develop the treatment plan with the client during the next individual treatment session.
Client # 2 & Client #4 had reviewed their treatment plans virtually with their perspective clinicians and signed the client portal stating the treatment plan was developed. This had not been notated in the Treatment plan services at the time of the reviews, but has since been corrected for each specific client.
Client #5's treatment plan was developed when the client was utilizing telehealth services, before the option to sign a treatment plan was available via the portal. This has since been corrected to allow for documentation of telehealth signatures for treatment plans via the portal.
Client #7's clinician had failed to have the client sign the treatment plan form, a training was provided as part of the over all training that occurred on 8/15/2023 to correct this error. As part of the training that occurred with all staff on 8/15/2023 they were also asked to note in treatment plans for any virtual sessions, that a signature has occurred. During in person sessions, clients are asked to sign the treatment plan. Addiotnally, the clinical supervisor will review this on quarterly review of charts, which the first one began 8/04/2023. |
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 a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in one out of three applicable client records reviewed.
Client #6 was admitted on September 22, 2022, and discharged on April 6, 2023. A treatment plan update was completed on November 21, 2022, and the next update was due no later than January 21, 2023; however, it was completed on April 6, 2023.
This is a repeat citation from the September 21, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff training occurred on 7/26/2023 in brain storming steps to be taken to identify any treatment plan reviews needing to be completed in the 60 day time frame from the previous treatment plan. Staff related successful steps that have aided them in timely completion of the treatment plan reviews. A quarterly review of charts will occur to ensure completion of the treatment plan reviews. The quarterly review began 8/04/2023 and the clinical Supervisor is responsible for Oversight. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in three out of three applicable records reviewed. The facility's policy states that case consultations must be completed every ninety days.
Client #1 was admitted on January 20, 2023, and was still active at the time of the inspection. As per the facility policy, a case consultation was due to be completed on April 20, 2023; however, the case consultation was not completed until May 9, 2023.
Client #5 was admitted on admitted on September 1, 2022, and was discharged on January 17, 2023. As per the facility policy, a case consultation was due to be completed December 1, 2022; however, the case consultation was not completed until December 14, 2022.
Client #6 was admitted on September 22, 2022, and discharged on April 6, 2023. A case consultation was completed on November 21, 2022, as per the facility policy, the next case consultation was due to be completed February 21, 2023; however, the next case consultation was not completed until March 28, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff training occurred on 7/27/2023 in brain storming steps to be taken to identify any steps that can be utilized to identify case consultations being completed in the 90 day time frame from the start of treatment. Staff related successful steps that have aided them in timely completion of the case consultations. A quarterly review of charts will occur to ensure completion of the case consultations. The clinical supervisor will conduct the Quarterly review, the first one began 8/04/2023. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in three out of three applicable discharged record reviews.
Client #5 was admitted on September 1, 2022, and was discharged on January 17, 2023.
Client #6 was admitted on September 22, 2022 and was discharged on April 6, 2023.
Client #7 was admitted on December 21, 2022 and was discharged on February 2, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training occurred with Case management staff on 7/27/2023 regarding the time frame of follow up with clients who have been discharged from services. A monthly review will occur to verify needed follow up contacts have been made. This will be done on a monthly basis as part of the case management meetings that occur weekly. The monthly reviews will begin 8/25/2023, which will be conducted by Case manager 1, along with the clinical supervisor overseeing the process. |