INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 27th 2018 of TrueNorth Wellness Services by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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709.28 (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
The facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client record #5.
Client #5 was admitted on 2/6/18and was discharged on 5/15/18. There was documentation that information was sent to an attorney on 3/15/18; however, there was no proper consent to release information form signed by the client prior to disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will meet with all clinical staff during weekly individual and group supervision to review confidentiality and proper release of information. Clinical supervisor will review active client records weekly through the electronic medical record services submitted by clinical staff and provide increased feedback as necessary to ensure compliance. Clinical staff will attend additional confidentiality training as needed. The facility will be in full compliance by 10/1/2018 |
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
The facility failed to document treatment plan updates within the regulatory timeframe in three of seven records reviewed.
Client #2 was admitted on 4/19/18 and was still active at the time of the inspection. A treatment plan update was completed on 4/26/18 and the next update was due no later than 6/26/18 ; however, there was no update documented in the record at the time of the inspection.
Client #3 was admitted on 6/22/18 and was still active at the time of the inspection. A treatment plan update was completed on 6/27/18 and the next update was due no later than 8/27/18; however, there was no update documented in the record at the time of the inspection.
Client #4 was admitted on 7/18/17 and was discharged 3/5/18. A treatment plan update was completed on 9/5/17 and the next update was due no later than 11/05/17; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will review treatment planning with all clinical staff during individual and group supervision. Staff will complete a master treatment plan with the client by the 3rd session and update the treatment plan every 60 days. Notes will be added to the client record to document the absence of the client or any gaps in treatment due to short term issues, i.e. inpatient treatment or incarceration. Clinical staff will obtain client signature on treatment plan update upon the clients return to treatment. Clinical supervisor will review client records to ensure treatment plans are created by the 3rd session and are being updated every 60 days. Deficiencies will be reviewed with the appropriate staff by the clinical supervisor. The facility will be in full compliance by 10/1/2018 |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The facility failed to document that the clients received counseling services according to their individual comprehensive treatment plan in three of seven records reviewed.
Client #1 was admitted on 7/2/18 and was still active at the time of the inspection. The comprehensive treatment plan, dated 7/18/18, indicated 1 Weekly individual session. The chart's record of service and progress notes indicated that the client did not receive an individual session for the weeks of 7/8-7/14, 7/22-7/28, 7/29-8/4, and 8/5-8/11.
Client #2 was admitted on 4/19/18 and was still active at the time of the inspection. The comprehensive treatment plan, dated 4/26/18, indicated 1 weekly individual session. The chart's record of service and progress notes indicated that the client did not receive an individual session for the weeks of 4/29-5/5, 5/13-5/19, 5/20-5/26, 5/27-6/2,6/10-6/16, 6/24-6/30, 7/1-7/7, 7/8-7/14, 7/22-7/28, 7/29-8/4, 8/5-8/11 and 8/12-8/18.
Client #4 was admitted on 7/18/17 and was discharged on 3/5/18. The treatment plan update, dated 9/5/17, indicated 1 weekly individual session. The chart's record of service and progress notes indicated that the client did not receive an individual session for the weeks of 10/15-10/21, 10/29-11/4, 11/5-11/11, 11/19-11/25, 12/3-12/9, 12/17-12-23, 12/24-12/30, 12/31-1/6 and 1/7-1/13.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will review the requirement to document in the treatment plans the type of treatment, frequency and length of session with clinical staff during individual and group supervision by 10/1/18. Clinical supervisor will review active client records weekly through the electronic medical record services submitted by clinical staff and provide increased feedback as necessary. Clinical staff will document the absence of the client through a collateral note in the client record when an appointment is cancelled or the client does not show for their session. Clinical staff will update treatment plans to reflect any change in frequency of sessions as clients needs change. Director of Substance Abuse Services will meet with the clinical supervisor weekly to discuss compliance and review client records. The facility will be in full compliance by 10/1/2018. |