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 five personnel records, the facility failed to ensure two counselors met both the educational and clinical experience qualifications prior to being hired.
Employee #4 was hired on February 22, 2022, as a counselor with a qualifying bachelor ' s degree however, employee #4 did not have one year of clinical experience at the time of hire.
Employee #5 was hired on July 12, 2022, as a counselor with a qualifying bachelor ' s degree however, employee #5 did not have one year of clinical experience at the time of hire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Citation 1
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.
Employee #5 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, whomever is doing the hiring at the time. 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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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 January 19, 2022 and was still active at the time of the inspection. A treatment plan update was completed on March 14, 2022, and the next update was due no later than May 14, 2022; however, there was no update documented in the record until May 23, 2022.
Client #2 was admitted on September 16, 2021 and was still active at the time of the inspection. A treatment plan update was completed on April 27, 2022, and the next update was due no later than June 27, 2022 however, there was no update documented in the record at the time of inspection.
Client #3 was admitted on February 14, 2022 and was still active at the time of the inspection. A treatment plan update was completed on March 16, 2022, and the next update was due no later than May 16, 2022; however, there was no update documented in the record until June 23, 2022.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from an inspection conducted on September 28, 2021.
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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 with the entire team, 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 be 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 #3's counselor was be 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 monthly 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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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of seven client records, the facility failed to provide a complete client record, which is to include aftercare plan in one of the three applicable client records reviewed.
Client #5 was admitted on January 16, 2022 and was discharged on June 10, 2022 . There was not documentation of an aftercare plan being completed in the client record.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Client #5's counselor was re-trained, by the Clinical Supervisor, with the requirements for completing the aftercare plan when discharging a client successfully, to ensure an aftercare plan is completed, in order to comply with policy and procedures. The Clinical Supervisor has already completed a review of the discharge process during the staff meeting on 9/22/2022, which was the following day of the licensing inspection. There will also be a review quarterly of charts to ensure all staff are keeping up with requirements. New staff will also receive this training when hired to ensure there are no gaps in the documentation process. |