INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5, 2024, 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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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
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of seven records reviewed.
Client #4 was admitted on January 8, 2024 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director with the Case Manager reviewed the record in question, to obtain an ROI, in fact a current ROI for funding was found. This ROI had been signed on 1/03/2024, the week prior to starting counseling services, when the level of care assessment was completed. To ensure funding insurance ROI's are obtained, the case manager meets with the client prior to the level of care assessment occurring, this process will continue. |
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 four out of six applicable records reviewed.
Client #2 was admitted on November 9, 2023 and was still active at the time of the inspection. A treatment plan was completed on November 30, 2023, and the next update was due no later than January 30, 2024; however, the next update was not completed until February 8, 2024. A treatment plan update was completed on March 14, 2024, and the next update was due no later than May 14, 2024; however, the next update was not completed until May 24, 2024.
Client #4 was admitted on January 8, 2024 and was still active at the time of the inspection. A treatment plan was completed on January 12, 2024, and the next update was due no later than March 12, 2024; however, the next update was not completed until March 26, 2024.
Client #5 was admitted on January 9, 2024 and discharged on April 29, 2024. A treatment plan was completed on January 9, 2024, and the next update was due no later than March 9, 2024; however, the next update was not completed until April 1, 2024.
Client #7 was admitted on October 12, 2023 and was discharged on January 4, 2024. A treatment plan was completed on October 12, 2023, and the next update was due no later than December 12, 2023; however, the next update was not completed until December 14, 2023.
This is a repeat citation from the September 21, 2022 and July 23, 2023 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/13/2024 a staff training for all counselors occurred and instructed in the process of treatment plan reviews being completed before or on 60 day time frame from the creation of the treatment plan. Several methods, such as Excel spread sheet has been created by the facility director and given to the counselors to use in order to track the time frames need. On the other hand, they can use another method, such as keeping track of the time frames on their electronic work calendars. Counselors were required to pick a process they will be using. The counselors discussed the choice and began using it that day. The facility director will initially verify though a QI process monthly for 3 months, to verify the process is working to obtain the treatment plan reviews per our policy. IF not other methods will be utilized, if the treatment plan reviews are being completed per policy, the review by the facility director will go back to the quarterly review time frame. In order to verify the process is still occurring as needed. |
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 per the facility ' s policy and procedures manual of sixty days after discharge in one out of two applicable discharged records reviewed.
Client #7 was admitted on October 12, 2023 and discharged on January 4, 2024. A follow up contact was due no later than March 4, 2024; however, there is no documentation that one was completed.
This is a repeat citation from the July 25, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A training occurred by the facility director on 6/13/2024 with case managers, to retrain the process for follow up contacts. A process was developed where a weekly report will be run by case managers, to identify clients who are due a follow up questionnaire, in the upcoming week; per our policy of being completed by 60 days after discharge. The facility director will do a monthly review for the next three months, to verify the follow up questionnaires are being sent out. If not, adjustments will be made, to ensure this is occurring. If they are, then the QI review will go back to occurring quarterly. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(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.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting treatment plan updates was submitted and approved by the Department for the September 21, 2022, and July 25, 2023, annual licensing inspections. Completing and documenting treatment plan updates was again found to be a deficiency in the June 5, 2024, licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility Director will complete a monthly review of all corrective action plans for the next 3 months, to verify the corrective action plans are being followed. This will be reported to the facility director's immediate supervisor. If said corrective action plans are being maintained as required, the QI review will move back to the quarterly QI review, and be included in those reviews, in order to maintain completion of required policies. The first review will occur 7/01/2024 for the month of June 2024. |