INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection. The client records review inspection was conducted on August 12, 2025, and the physical plant inspection was conducted on August 13, 2025, 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 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 #3 was admitted on April 9, 2025 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 is a repeat citation from the June 5, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In May 2025 the agency implemented a new Consent for Treatment, Payment, and Operations. It was developed by the agency COO and Compliance Committee. This Consent TPO was reviewed during the audit visit and will meet the requirement for informed and voluntary consent for the funding source moving forward. Client #3 entered services prior to the Consent TPO being implemented.
Staff in the SUT program received information about the Consent TPO during meetings in May 2025 and August 2025. Project Director will revisit again in October 2025 to ensure understanding and compliance.
For active Client #3, Project Director has added a warning in client records to have client sign Consent TPO and has emailed direct therapist to ask that the client sign the Consent TPO at next scheduled visit.
Project Director and/or Facility Director (depending on hiring of new manager) will follow the agency Quality Improvement audit policy, reviewing charts 3 times per year, to ensure this regulation is being met. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent which included the name of the person, agency or organization to whom disclosure is made in two out of seven records reviewed.
Client #6 was admitted on November 13, 2024 and discharged on May 6, 2025. The client record contained a release of information form to a medical provider dated November 13, 2024, that did not include the name of the person, agency or organization the disclosure is made.
Client #7 was admitted on October 2, 2024 and discharged on January 23, 2025. The client record contained two releases of information forms to a medical and legal provider that was dated October 2, 2024 that did not include the name of the person, agency or organization the disclosure is made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The releases of information with missing details for clients #6 and #7 were completed within the client portal by the clients themselves. Clients leaving releases blank and/or not filling them out completely is a known issue. The following actions have already been taken to try to address this:
- Services completed by clients in the portal are not able to be deleted or moved elsewhere. A task ticket was submitted to our EHR vendor alerting them to this issue and asking for a solution. They are unable to change this process to allow for those services to be altered, deleted, or moved.
- Staff is educated on our policy to review content of releases of information prior to actually releasing information. If they encounter a blank/incorrect portal release of information, information is either not released, or they complete a new valid release with the client prior to releasing.
- The Consent for TPO developed by COO and Compliance committee, implemented May 2025, does reduce the occurrence of this error for treatment, payment, and operations related entities.
- For Clients #6 and #7, a client note has been entered alerting all staff that the portal releases completed are not valid. This information has also been added to the contact section for each client, noting the contacts are "invalid" and there is no release of information obtained.
- Project Director and/or Facility Director (depending on hiring of new manager) will follow the agency Quality Improvement audit policy, reviewing charts 3 times per year, to ensure this regulation is being met. |
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 the review of client records, the facility failed to document case consultations every ninety days, per the facility policy. in two of five applicable client records.
Client #1 was admitted on March 6, 2025 and was still active at the time of the inspection. A case consultation was due no later than June 6, 2025; however, there was no documentation that one occurred.
Client #6 was admitted on November 13, 2024 and was discharged on May 6, 2025. A case consultation was due no later than February 13, 2025; however, it was completed on February 17, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director reviewed timeline expectations of case consultations with staff during a staff meeting 8/21/2025.
Moving forward, Project Director will review the agency's current policy and adjust language related to frequency. Clients who become unengaged with services within a 90 day period cause disruption to meeting the 90 day frequency of case consultations.
After the policy is revised, it will be reviewed with staff, by the Project Director, in a staff meeting, with a target date of 11/15/2025.
Project Director and/or Facility Director (depending on hiring of new manager) will follow the agency Quality Improvement audit policy, reviewing charts 3 times per year, to ensure this regulation is being met. |
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 within sixty days of discharge, per the facility policy, in three out of four discharged records reviewed.
Client #4 was admitted on August 28, 2024 and discharged on March 3, 2025. A follow up was due no later than May 3, 2025; however, there is no documentation that one occurred.
Client #5 was admitted on March 5, 2025 and discharged on April 23, 2025. A follow up was due no later than June 23, 2025; however, there is no documentation that one occurred.
Client #6 was admitted on November 13, 2024 and discharged on May 6, 2025. A follow up was due no later than July 6, 2025; however, it was completed on July 23, 2025.
This is a repeat citation from the July 23, 2023 and June 5, 2024 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
During the time Clients #4, #5, and #6 discharged from services, Case Managers were completing and documenting follow ups with clients. The agency is no longer providing case management services though, as of 7/1/2025.
On July 23, 2025, Project Director met with Customer Engagement Manager and a Customer Engagement staff member to review the process for post-discharge follow up. This staff member has taken over the process of sending follow up surveys to all clients discharged 7/1/2025 and forward. A report is run at least once weekly to identify clients needing follow up. Documentation is added to the chart each time a follow up survey is sent.
Project Director will follow up with the Customer Engagement staff member to ensure the process to continuing and no further instruction is needed. (Target Date 9/15/2025)
Project Director and/or Facility Director (depending on hiring of new manager) will follow the agency Quality Improvement audit policy, reviewing charts 3 times per year, to ensure this regulation is being met. |
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 follow-up information was submitted and approved by the Department for the July 23, 2023 and June 5, 2024, annual licensing inspections. Completing and documenting follow-up information was again found to be a deficiency in the August 12, 2025.
This is a repeat citation from the June 5, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In the absence of a direct manager for the OP SUT program at this time, Project Director will address this administrative plan of correction. The following steps will be taken to improve compliance with plans of correction moving forward.
- Project Director will review policies relevant to the areas requiring improvement. If necessary, revisions will be made to policies to more clearly define time frames, processes, and expectations. Any revised policies will be shared with staff and any necessary training will be provided. (Target date 11/15/2025)
- Project Director will review items on our current QI self-audit, with QI Coordinator, and ensure each item with a POC is captured on the audit. If something is missing, it will be added as an area to audit. (Target date 11/30/2025)
- When a new manager is hired (acting as Facility Director/Clinical Supervisor), review of submitted POCs will be part of their training. (Target date 12/31/2025, however this is dependent on hiring for the position) |