INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 13, 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 #4 was admitted on February 27, 2025 and discharged on July 31, 2025. 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 #6 was admitted on December 17, 2024 and discharged on March 5, 2025. 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 3, 2024 annual 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 #4 and #6 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.
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. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation at the first treatment appointment, per the facility policy. in two out of six applicable records.
Client #1 was admitted on April 8, 2025 and was still active at the time of the inspection. There was no documentation that a psychosocial evaluation was completed in the record.
Client #7 was admitted on October 9, 2024 and discharged on February 24, 2025. There was no documentation that a psychosocial evaluation was completed in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In reviewing Client #1 and #7, it appears there was a lack of communication between the staff completing the initial visit with the client and the staff completing the first treatment visit. To avoid this moving forward the following has occurred/will occur:
- Project Director reminded staff during a staff meeting to ensure biopsychosocials are completed when a client is transferring between counselors (8/21/2025)
- Project Director will review policy related to initial documentation to ensure language is clear regarding initial visit requirements versus first treatment visits (9/30/2025)
- If any changes are made to relevant policy(s), they will be reviewed and training provided to staff. (Target date 11/15/2025)
- For active client #1, they have not engaged in treatment in over 30 days. Project Direct has asked direct therapist to discharge this client.
- 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 three out of five applicable records reviewed.
Client #1 was admitted on April 8, 2025 and was still active at the time of the inspection. A treatment plan was completed on May 21, 2025, and the next update was due no later than July 20, 2025; however, there was no documentation that one was completed.
Client #2 was admitted on January 12, 2023 and was still active at the time of the inspection. A treatment plan was completed on March 5, 2025, and the next update was due no later than May 4, 2025; however, there was no documentation that one was completed.
Client #4 was admitted on February 27, 2025 and discharged on July 31, 2025. A treatment plan was completed on March 27, 2025, and the next update was due no later than May 26, 2025; however, it was not completed until June 26, 2025.
This is a repeat citation from the June 3, 2024 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For Client #4, missing appointments and sporadic attendance contributed to the lapse in treatment plan. For Client #1 and #2, 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 three of six applicable client records.
Client #1 was admitted on April 8, 2025 and was still active at the time of the inspection. A case consultation was due no later than July 8, 2025; however, there was no documentation that one occurred.
Client #2 was admitted on January 12, 2024 and was still active at the time of the inspection. A case consultation occurred on March 5, 2025, and the next one was due no later than June 5, 2025; however, there was no documentation that one was completed.
Client #7 was admitted on October 9, 2024 and was discharged on February 24, 2025. A case consultation was due no later than January 9, 2025; however, there was no documentation that one occurred.
This is a repeat citation from the July 18, 2023 and June 3, 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. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information sixty days after discharge, per the facility policy, in three out of three applicable discharged records reviewed.
Client #5 was admitted on January 9, 2025 and discharged on February 18, 2025. A follow up was due no later than April 18, 2025; however, there is no documentation that one occurred.
Client #6 was admitted on December 17, 2024 and discharged on March 5, 2025. A follow up was due no later than May 5, 2025; however, there is no documentation that one occurred.
Client #7 was admitted on October 9, 2024 and discharged on February 24, 2025. A follow up was due no later than April 24, 202; however, there is no documentation that one was completed.
This is a repeat citation from the July 18, 2023 and June 13, 2024 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the time Clients #5, #6, and #7 discharged from services, Case Managers were completing and documenting follow ups with clients. The agency is no longer providing case management services though, as of 7/1/2025.
On July 23, 2025, Project Director met with Customer Engagement Manager and a Customer Engagement staff member to review the process for post-discharge follow up. This staff member has taken over the process of sending follow up surveys to all clients discharged 7/1/2025 and forward. A report is run at least once weekly to identify clients needing follow up. Documentation is added to the chart each time a follow up survey is sent.
Project Director will follow up with the Customer Engagement staff member to ensure the process to continuing and no further instruction is needed. (Target Date 9/15/2025)
Approved phrase: 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.
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 case consultations was submitted and approved by the Department for the July 18, 2023, and June 13, 2024, annual licensing inspections. Completing and documenting case consultations was again found to be a deficiency in the August 13, 2025.
A plan of correction for completing and documenting follow-up information was submitted and approved by the Department for the July 18, 2023, and June 13, 2024, annual licensing inspections. Completing and documenting follow-up information was again found to be a deficiency in the August 13, 2025.
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) |