INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 27th -29th 2018 of TrueNorth Wellness Services-Gettysburg by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, TrueNorth Wellness Services-Gettysburgwas 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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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The facility failed to provide patient # 's 3,7 and 8 with 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment.
Patient # 3 was admitted on May 19th, 2017 and was an active client at the time of inspection. In February 2018, the client had one hour of individual therapy and 0 hours of group therapy. In March 2018, the client had 0 hours of individual therapy and 3 hours of group therapy. In April 2018, the client had 120 minutes of individual therapy and 0 hours of group therapy. In May 2018, the client had 60 minutes of individual therapy and 0 hours of group therapy. In June 2018, the client had 90 minutes of individual therapy and 0 hours of group therapy. In July 2018, the client had 60 minutes of individual therapy and 0 hours of group therapy.
Patient # 7 was admitted on May 7th 2018 and was discharged August 13th 2018. In May 2018, the client had 120 minutes of individual therapy and 0 hours of group therapy. In June 2018, the client had 60 minutes of individual therapy and 0 hours of group therapy. In July 2018, the client had 60 minutes of individual therapy and 0 hours of group therapy.
Patient # 3 was admitted on December 8th, 2016 and was an active client at the time of inspection. In January 2018, the client had 120 minutes of individual therapy and 0 hours of group therapy. In February 2018, the client had 0 hours of individual therapy and 0 hours of group therapy. In May 2018, the client had 0 minutes of individual therapy and 1.5 hours of group therapy.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 9/24/18 the Director of Substance Abuse Services and clinical supervisor met with the Psychiatrist and staff for the Buprenorphine program to review compliance with the attendance requirements. The Psychiatrist will enforce that clients in the program must attend at least one hour of individual therapy per month as well as group therapy to meet the 2.5 hours of therapy per month requirement. Clients are required to meet with their counselor for an individual session before they may schedule a med check appointment. Clients will be reviewed during monthly treatment team meetings for attendance of individual and group psychotherapy. Counselors will alert Psychiatrist of clients not attending their individual and group therapy appointments. Clients identified as falling below the required minimum will be scheduled for their individual session and meet with their therapist before their next med check appointment with the Psychiatrist or risk discharge from the program. Clients are given verbal warnings and written warnings for not attending their individual and group sessions. Letters are sent to clients following a no show or cancellation. Clinical supervisor and Director of Substance Abuse Services will review active client records weekly through the electronic medical record services submitted by the counselors and provide increased feedback as necessary. Facility will be in full compliance by 10/1/2018. |
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
The facility failed to document treatment plan updates within the regulatory timeframe in 4 client records reviewed.
Client #4 was admitted on 2/26/18 and was discharged on 6/25/18.The comprehensive treatment plan was completed on 3/13/18 and the next update was due no later than 5/13/18; however, there was no update documented in the record until 6/5/18.
Client #5 was admitted on 4/16/18 and was discharged on 6/26/18.The comprehensive treatment plan was completed on 4/25/18 and the next update was due no later than 6/25/18; however, there was no update documented in the record at the time of inspection.
Client #6 was admitted on 2/14/18 and was discharged on 5/24/18 .The comprehensive treatment plan was completed on 2/19/18 and the next update was due no later than 4/19/18; however, there was no update documented in the record at the time of inspection.
Client #8 was admitted on 12/8/16 and was still active at the time of the inspection. A treatment plan update was completed on 10/4/17 and the next update was due no later than 12/4/17; however, there was no update documented in the record until 1/22/18.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will review treatment planning with all clinical staff during individual and group supervision. Staff will complete a master treatment plan with the client by the 3rd session and update the treatment plan every 60 days. Notes will be added to the client record to document the absence of the client or any gaps in treatment due to short term issues, i.e. inpatient treatment or incarceration. Clinical staff will obtain client signature on treatment plan update upon the clients return to treatment. Clinical supervisor will review client records to ensure treatment plans are created by the 3rd session and are being updated every 60 days. Deficiencies will be reviewed with the appropriate staff by the clinical supervisor. The facility will be in full compliance by 10/1/2018 |