INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 29, 2017 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
A licensing renewal inspection was conducted on August 29, 2017. The facility failed to provide documentation of required HIV/AIDS and TB/STD training for employee records # 6 and 7.
Employee # 6 was hired on 2/29/16 and is a counselor. The facility failed to provide documentation of TB/STD training for this employee.
Employee # 7 was hired on 2/1/13 and is an office manager. The facility failed to provide documentation of HIV/AIDS and TB/STD training for this employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #6 completed TB/STD training on 8/28/17. Employee #7 will receive the required HIV/AIDS and TB/STD training by 11/1/17. Clinical supervisors will monitor new counselor training to ensure at the 6 month point they have signed up for the required training. The Director of Substance Abuse Treatment met with the front office staff supervisor for all 4 sites on 9/6/17 to develop a training plan for all front office staff to receive the required training within the first year of employment and to have all current front office staff who have not been trained to receive the required training by 11/1/17. The Director of Substance Abuse Treatment will review all new hires at six months to assure that they have attended the required training. If they have not, the employee will be directed to complete the training. Completion of the training will be monitored by the Director of Substance Abuse Treatment to ensure compliance. |
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
A licensing renewal inspection was conducted on August 29, 2017. Based on a review of the Staffing Requirements Facility Summary Report completed by the facility during the licensing process, the facility failed to ensure that staff caseloads remain at or under 35:1.
Based on the total number of hours per week devoted to clients, and the standard work week of 35 hours, employees # 5 and 6 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by the standard work week of 35 hours.
reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 5 to outpatient client treatment was 25 hours per week. The employee had 35 active clients as of 7/31/17.
-Employee # 5 (25/35 = .7148 FTE *** 35 clients/.7148 FTE = 49/1 caseload)
reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 6 to outpatient client treatment was 28 hours per week. The employee had 35 active clients as of 7/31/17.
-Employee # 6 (28/35 = .8 FTE *** 35 clients/.8 FTE = 48/1 caseload)
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #5 has reduced her active caseload to 24 clients as of 9/20/17. Employee #6 has reduced his active caseload to 12 clients as of 9/20/17. Staffing has been increased to ensure the client caseload of staff does not exceed the 35:1 ratio. New staff has been hired 9/5/17 and will provide 10 hours of client treatment per week. Counselors will closely monitor their caseloads and discharge inactive clients. Clinical supervisors will monitor staff caseloads and assess need to add additional staff as needed. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
A licensing renewal inspection was conducted on August 29, 2017. The facility failed to ensure that their client capacity for the outpatient activity did not exceed the licensed client capacity of 50. The Staffing Requirements Facility Summary Report provided by the facility, which was completed on 7/31/17, indicated that the active client census at that time was 70.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will closely monitor their caseloads and discharge inactive clients in a timely manner. Director of Substance Abuse Treatment will closely monitor capacity to ensure it does not exceed the limit and assess need to increase capacity. As of 9/20/17 there are 40 active clients at this site. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Six personnel records were reviewed on August 24, 2017. The facility failed to provide documentation of an annual written performance evaluation signed by the employee for employee record # 5.
Employee # 5 was hired on 6/2/10 and is a counselor. The annual performance evaluation documented in the employee's record, completed on 9/21/16, did not document the employee's signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Performance evaluations will be completed by 10/1/17. Clinical supervisor and the Director of Substance Abuse Treatment will ensure all evaluations are signed by the employee. |
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
Seven client records were reviewed on August 29, 2017. The facility failed to obtain an informed and voluntary consent for the client's funding source for client records # 1 and 2.
Client # 1 was admitted into treatment on 2/27/17 and was discharged on 8/25/17.
Client # 2 was admitted into treatment on 3/30/17 and was still active in treatment.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
9/20/17 Clinical supervisors met with staff to review proper consents. Release of Information to the funding source will be obtained by staff at the first client session. Clinical supervisors will review client records to ensure compliance during individual supervision with counselors. A signed release of information to the funding source for Client #2 will be obtained by 10/2/17. |
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
Seven client records were reviewed on August 29, 2017. The facility failed to document a treatment plan update at least every 60 days for client records # 1, 2, 4, and 7.
Client # 1 was admitted into treatment on 2/27/17 and was discharged on 8/25/17. A master treatment plan was completed for the client on 3/8/17. A treatment plan update was due to be completed by 5/8/17.
Client # 2 was admitted into treatment on 3/30/17 and was still active. A master treatment plan was completed for the client 5/24/17. A treatment plan update was due to be completed by 7/24/17.
Client # 4 was admitted into treatment on 3/9/17 and was discharged on 6/26/17. A master treatment plan was completed for the client on 3/13/17. A treatment plan update was due to be completed by 5/13/17.
Client # 7 was admitted into treatment on 12/27/16 and was discharged on 6/26/17. A master treatment plan was completed for the client on 1/16/17. A treatment plan update was due to be completed for the client by 3/16/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The requirement that treatment plans are updated every 60 days has been reviewed with all staff as of 9/13/17 by clinical supervisor and the Director of Substance Abuse Treatment. The treatment plan for client #2 will be updated with the client by 10/2/17. Clinical supervisors will monitor the timeliness of the treatment plans and report aggregate results to the QI committee on a quarterly basis. Treatment plans will be completed with the client by the 3rd session and updated every 60 days by counselors. Notes will be added to the client record to document the absence of the client or gaps in treatment due to short term issues, i.e. inpatient treatment or incarceration. Clinical supervisors reviewed this with staff on 9/20/17. Clinical supervisors will monitor client records through the electronic medical record system on a weekly basis and review with counselors during weekly individual supervision and monthly staff meetings to ensure that treatment plans are updated every 60 days. Director of Substance Abuse Treatment will meet with the clinical supervisor weekly to discuss compliance. |