INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection. The physical plant inspection was conducted on August 13, 2025, and the client records review inspection was conducted on August 14, 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 two out of seven records reviewed.
Client #3 was admitted on July 18, 2022 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.
Client #4 was admitted on October 31, 2024 and discharged on December 11, 2024. 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 7, 2024 licensing inspection.
These findings were 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 and #4 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 record 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. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in two out of six applicable client records reviewed.
Client #5 was admitted on July 23, 2024 and was discharged on November 1, 2024. A comprehensive treatment plan was developed on August 15, 2024. The plan did not document the type or frequency of treatment and rehabilitative services.
Client #7 was admitted on November 5, 2024 and discharged on January 10, 2025. A comprehensive treatment plan was developed on November 14, 20224. The plan did not document the type or frequency of treatment and rehabilitative services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For both Client #5 and Client #7 the treatment plan was completed, but the portion containing the type and frequency of the service was not. Project Director made staff aware during a staff meeting 8/21/2025 that they need to ensure completion of the service portion of the treatment plan.
Project Director will address the treatment plan process in detail during a staff meeting in mid-September (currently scheduled for 9/18/2025). An example of this error will be shown, as well as walking through the proper way to complete the document.
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. |
709.92(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 two out of four applicable records reviewed.
Client #3 was admitted on July 18, 2022 and was still active at the time of the inspection. A treatment plan was completed on March 3, 2025, and the next update was due no later than May 3, 2025; however, one was not completed until June 25, 2025.
Client #5 was admitted on July 23, 2024 and discharged on November 1, 2024. A treatment plan was completed on August 15, 2024, and the next update was due no later than October 15, 2024; however, there was no documentation that one was completed.
This is a repeat citation from the September 21, 2022, July 20, 2023, and June 7, 2024, annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For Client #3, missing appointments and sporadic attendance contributed to the lapse in treatment plan. For Client #5, the client not returning for services, and a delay in discharge, contributed to the late treatment plan.
To address both of the issues, the following steps will be taken by the Project Director:
- Reiterate the requirement to update treatment plans every 60 days in staff meeting (8/21/2025)
- Hold a staff meeting specific to treatment plans and the treatment planning process (target date 9/18/2025)
- Review policies related to treatment planning and add clear processes for addressing treatment plan completion when a client is not present for services (target date 9/30/2025)
- Review policy related to discharging clients and add clear processes for documenting when a treatment plan is not being completed due to needing to discharge the client from services (target date 9/30/2025)
- Review revised policies with staff during a staff meeting by mid November and provide training on any related process changes (target date 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)(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 facility policy, in two of seven client records.
Client #3 was admitted on July 18, 2025 and was still active at the time of the inspection. A case consultation was completed on March 3, 2025, and the next one was due no later than June 3, 2025; however, it was not completed until June 25, 2025.
Client #5 was admitted on July 23, 2024 and discharged on November 1, 2024. A case consultation was due no later than October 23, 2024; however, there is no documentation that one occurred.
This is a repeat citation from the July 20, 2023, and June 7, 2024, annual licensing inspection.
These findings were 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. |
709.17(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, July 20, 2023, and June 7, 2024, annual licensing inspections. Completing and documenting treatment plan updates was again found to be a deficiency in the August 14, 2025, annual licensing inspection.
A plan of correction for completing and documenting case consultation was submitted and approved by the Department for the July 20, 2023, and June 7, 2024, annual licensing inspections. Completing and documenting case consultations was again found to be a deficiency in the August 14, 2025, annual 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) |