INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection. The physical plant inspection was conducted on July 13, 2026, and the client record review was conducted on July 14, 2026, 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of administrative documents from August 2025- June 2026, the facility failed to conduct unannounced fire drills in five out of eleven months reviewed.There was no documentation of an unannounced fire drill occurring during the months of August, September, October, December 2025 and January 2026. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following steps will be put into place to ensure fire drills are completed every month:
1. The Quality Improvement Coordinator will ensure monthly fire drill completion by sending emails to the Building Supervisor to complete monthly fire drill by the end of each month starting August 2026.
2. The Building Supervisor coordinates with the Facility Manager, as needed, to notify the Fire Department of monthly fire drill.
3. The Quality Improvement Coordinator will email completed fire drill log every month to the SUT OP Manager.
4. The SUT OP Manager will place completed monthly fire drill log in location specific electronic file.
5. The SUT OP Manager will notify Quality Improvement Coordinator if completed fire drill log is not received by the last week of each month.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of administrative documents from August 2025- June 2026, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative in six out of six applicable fire drill records reviewed.The written fire drill logs for the months of November of 2025, February, March, April, May and June 2026 did not have the exit route used. The fire drill logs in the months of November 2025, February, May and June 2026 did not have documentation if the fire alarm or smoke detector was activated during the drill. The February 2026 fire drill log did not document the date the fire drill occurred. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following steps will be put into place to ensure fire drill logs are completed accurately each month:
1. The Quality Improvement Coordinator will update the fire drill log to include exit route used during the drill and if the method of notification activated during the drill by August 1st, 2026.
2. The Quality Improvement Coordinator will review the fire drill log updates with Building Supervisors by August 7th, 2026.
3. Building Supervisors will complete updated fire drill logs for monthly fire drill by August 31st, 2026.
4. Building Supervisors send completed fire drill logs to Quality Improvement Coordinator who then sends to SUT OP Manager.
5. SUT OP Manager will review fire drill log to ensure exit route and method of notification are completed on each log.
6. SUT OP Manager will contact Building Supervisor for missing data to ensure correct form completion.
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policy manual, the facility failed to ensure a complete client record included information relative to the client ' s involvement with the project, to include progress notes completed within 48 hours after therapy sessions, per facility policy, in three out of seven records reviewed. Client # 2 was admitted on April 20, 2026, and was still active at the time of the inspection. The record contained a progress note for an individual counseling session occurring on April 8, 2026 that was not completed until April 14, 2026. Client #6 was admitted on June 30, 2025, and discharged on December 19, 2025. The record contained a progress note for an individual counseling session occurring on August 1, 2025, that was not completed until August 17, 2026. The record also contained a progress note for an individual counseling session occurring on August 29, 2025, that was not completed until September 5, 2025. Client #7 was admitted on September 12, 2025, and discharged on January 23, 2026. The record contained a progress note for an individual counseling session occurring on September 12, 2025, that was not completed until September 19, 2025. The record also contained a progress note for an individual counseling session occurring on September 19, 2025, that was not completed until September 22, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For Client #2, Client #6 (discharged) and Client #7 (discharged) progress notes were not completed within 48 hours after the therapy session.
To address the issue, the following steps will be taken by the Facility Director:
1. Facility Director will hold a staff meeting in mid-August (currently scheduled for 8/19/2026) to review policies related to documentation. Focusing on progress notes needing to be completed within 48 business hours after a therapy session.
2. Facility Director will also review during August individual supervision with staff.
3. Facility Director will follow the agency Quality Improvement audit policy, reviewing charts 3 times per year, to ensure this regulation is being met.
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