INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 7, 2024, 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 client 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 three out of seven records reviewed.
Client #2 was admitted on February 6, 2024 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 December 27, 2023 and discharged on February 29, 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.
Client #5 was admitted on January 12, 2024 and discharged on April 30, 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 finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/13/2024 client #2 was contacted and and a ROI for their funder was obtained.
An attempt was made to reach client #4 and client # 5, in regards to informing them a ROI had not been attained by the agency, to make the individuals aware that we had not obtained one, but also provided awareness of the information that was related to their funder, specifically their diagnosis code, dates, and times of services.
In order to prevent this from happening in the future, A training occurred on 6/13/2024 with case managers and counselors; completed by the facility director. A process was developed were a weekly report will be run by case managers to verify their is an current ROI on file for funders or if any changes have occurred in funding for clients. Any new ROI's will be completed with the client at that time, or as soon as the client is able to come in person or sign one on their client portal. Addiotnally counselors were asked to double check at the time of initial contact that an ROI was filled out, as well as completing one with the client during treatment, any time they are told that the insurance funding has changed.
This will be reviewed by the facility director as part of the QI process that will occur monthly for the next three months, if the ROI' are obtained as needed, then the QI process will return to a quarterly basis to verify it occurring as needed. |
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 one out of three applicable records reviewed.
Client #1 was admitted on February 13, 2024 and was still active at the time of the inspection. A treatment plan was completed on March 14, 2024 and the next update was due no later than May 14, 2024; however, the next update was not completed until May 20, 2024.
This is a repeat citation from the September 21, 2022 and July 20, 2023 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/13/2024 a staff training for all counselors occurred and instructed in the process of treatment plan reviews being completed before or on 60 day time frame from the creation of the treatment plan. Several methods, such as Excel spread sheet has been created by the facility director and given to the counselors to use in order to track the time frames need. On the other hand, they can use another method, such as keeping track of the time frames on their electronic work calendars. Counselors were required to pick a process they will be using. The counselors discussed the choice and began using it that day. The facility director will initially verify though a QI process monthly for 3 months, to verify the process is working to obtain the treatment plan reviews per our policy. IF not other methods will be utilized, if the treatment plan reviews are being completed per policy, the review by the facility director will go back to the quarterly review time frame. In order to verify the process is still occurring as needed. |
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 within the timeframe established by the facility ' s policy and procedures manual of every ninety days in one out of three applicable client records.
Client #1 was admitted on February 13, 2024 and was still active at the time of the inspection. A case consultation was due no later than May 13, 2024; however, it there was no documentation that one was completed.
This is a repeat citation from the July 20, 2023 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/13/2024 a staff training for all counselors occurred and instructed in the process of case consultations being completed before or on the 90 day time frame from being admitted to treatment. Several methods, such as Excel spread sheet has been created by the facility director and given to the counselors to use in order to track the time frames needed. On the other hand, they can use another method, such as keeping track of the time frames on their electronic work calendars. Counselors were required to pick a process they will be using. The counselors discussed the choice and began using it that day. The facility director will initially verify though a QI process monthly for 3 months, to verify the process is working to obtain the completion of the case consultations minimally every 90days, per our policy. IF not other methods will be developed, if the case consultations are being completed per policy, the QI review by the facility director will go back to the quarterly review time frame; In order to verify the process is still occurring as needed. |
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 and July 20, 2023 annual licensing inspections. Completing and documenting treatment plan updates was again found to be a deficiency in the June 7, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will review the completion of the Corrective action plan monthly, for the next three months, in order to verify the corrective action plans submitted to DDAP are continuing to address the Identified deficiencies. If this has occurred, the QI review by the facility director will go back to the quarterly review time frame; In order to verify the process is still occurring as needed. Additionally, the results of the QI reports will be reviewed with the facility director's immediate supervisor, in order that the corrective action plan is known to be maintained. |