INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20-21, 2022, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of seven personnel records, the facility failed to ensure one counselor hired met both the required education and clinical experience for the position.
Employee #4 was hired as a counselor on February 22, 2022 with a qualifying bachelor ' s degree. Employee #4 did not meet the one year of clinical experience at the time of hire.
There findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 will be moved to a Counselor Assistant Position status and will have weekly documentation of appropriate supervision placed in personnel file, by the clinical supervisor. Once the appropriate amount of experience is reached, documentation will be noted with in the employee file of the advancement to counselor status, by the Clinical Supervisor.
In the future Careful verification of potential employee experiences will be made prior to hiring a counselor at counselor status, by the Clinical Supervisor. If the proposed counselor meets the education qualifications, but not the experience requirement, the individual will be hired as a Counselor Assistant.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of seven personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that two employees received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #6 was hired as a Counselor on June 15, 2020 and was due to have the communicable disease trainings no later than June 15, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training at the time of the inspection.
Employee #7 was hired as a counselor on June 30, 2021 and was due to have the communicable disease trainings no later than June 30, 2022. There was no documentation in the personnel file of the completion of the HIV/AIDS training until August 20, 2021 and the TB/STD training at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee # 6 will receive Basic HIV training approved by DDAP as soon as it is available. This will be reviewed with Employee #6, by the clinical supervisor weekly, until the individual is registered and trained. To prevent further issues in regard to the communicable disease training, or any other required training, a detailed training plan has been developed, so that any counselor that is newly hired, and missing the required trainings, will be aware of the required training and the clinical supervisor will be able to track progress toward completed trainings, until the trainings occur.
Employee # 7will receive Basic HIV and the TB/STD trainings, both approved by DDAP, as soon as it is available. This will be reviewed with
Employee #7, by the clinical supervisor weekly, until the individual is registered and trained. To prevent further issues in regard to the communicable disease training, or any other required training, a detailed training plan has been developed, so that any counselor that is newly hired, and missing the required trainings, will be aware of the required training and the clinical supervisor will be able to track progress toward completed trainings, until the trainings occur.
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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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in three client records reviewed.
Client #1 was admitted on December 6, 2021 and was still active at the time of the inspection. A treatment plan update was completed on May 24, 2022 and the next update was due no later than July 24, 2022; however, there was no update documented in the record until August 30, 2022.
Client #2 was admitted on January 11, 2022 and was still active at the time of the inspection. A treatment plan update was completed on March 10, 2022 and the next update was due no later than May 10, 2022, however, there was no update documented in the record until May 24, 2022.
Client #7 was admitted on May 6, 2021 and was discharged on January 6, 2022. A treatment plan update was completed on October 28, 2021 and the next update was due no later than Decmeber 28, 2021; 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
Client #1's counselor was re-trained with the requirements for completing a treatment plan review minimal every 60 days, whether or not the client is present, to ensure the appropriate time frame is met for policy and procedures. The Clinical Supervisor has already completed a review of the treatment plan update requirements, which occurred in the staff meeting on 9/22/2022; the following day of the licensing inspection. There will also be a review quarterly of charts, by the Clinical Supervisor, to ensure all staff are keeping up with requirements. New staff will also receive this training, by the Clinical Supervisor, when hired to ensure there are no gaps in the documentation process.
Client #2's counselor was re-trained with the requirements for completing a treatment plan review minimal every 60 days, whether or not the client is present, to ensure the appropriate time frame is met for policy and procedures. The Clinical Supervisor has already completed a review of the treatment plan update requirements, which occurred in the staff meeting on 9/22/2022; the following day of the licensing inspection. There will also be a review quarterly of charts, by the Clinical Supervisor, to ensure all staff are keeping up with requirements. New staff will also receive this training, by the Clinical Supervisor, when hired to ensure there are no gaps in the documentation process.
Client #7's counselor was re-trained with the requirements for completing a treatment plan review minimal every 60 days, whether or not the client is present, to ensure the appropriate time frame is met for policy and procedures. The Clinical Supervisor has already completed a review of the treatment plan update requirements, which occurred in the staff meeting on 9/22/2022; the following day of the licensing inspection. There will also be a review quarterly of charts, by the Clinical Supervisor, to ensure all staff are keeping up with requirements. New staff will also receive this training, by the Clinical Supervisor, when hired to ensure there are no gaps in the documentation process.
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