INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26, 2014 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel training records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that the project director receive at least 12 clock hours of training annually.
The findings include:
According to the Staffing Requirements Facility Summary Report, the facility training year runs from October 1 through September 30.
The project director's record was reviewed specifically for training hours for the 2012-2013 training year on June 23, 2014. There was no documentation of any clock hours obtained for the 2012-2013 training year for in personnel record #1.
Employee # was hired as the project director on November 1, 2007. Employee # 1 did not have any documented clock hours of training during October 1, 2012 through September 3, 2013.
The findings were confirmed with the Drug and Alcohol coordinator.
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Plan of Correction
Our training year runs from October 1 through September 30. Employee #1 will be leaving the agency tentatively between 1 August 2014 and 1 October 2014. Once her replacement has been named, the new hire procedures will be completed within 7 days of hire to include the requirement of 12 documented training hours per training year. This standard will be reviewed monthly with the new employee to ensure compliance.
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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
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plans, in two out of eight client records.
The findings include:
Eight client records were reviewed on June 24, 2014. The facility did not document services according to the individual treatment plan in client records # 4 and 7.
Client #4 was admitted on April 7, 2014 and still active at the time of inspection. The treatment plan for client #4 was completed on April 21, 2014. This treatment plan stated the client was to receive individual counseling sessions once a week. Client #4 ' s last counseling session occurred on 4/21/14 no re-engagement letter had been sent.
Client #7 was admitted on August 12, 2013 and discharged on April 7, 2014. The treatment plan for client #7 was completed on November 18, 2013. This treatment plan stated the client was to receive individual counseling sessions once a week. Client #7 was not seen in treatment between 11/12/13 and 4/7/14. No re-engagement letter had been sent.
The findings were confirmed with the clinical director.
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Plan of Correction
The Clinical Director is working towards meeting with all therapists to discuss this standard. The Clinical Director is meeting with this office on 5 August 2014 to review this standard. Once this meeting takes place, a review of treatment plans and client attendance will take place, first weekly within the first 3 months, then monthly. Any concerns or issues will be addressed immediately by voice mail or instant message through the electronic medical record.
For client #4, there is a letter attached to the file dated June 2, requesting the client contact the agency to schedule an appointment. As of this date there has been no response from the client and the Clinical Supervisor will instruct the therapist of record to close the case. |