INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17-18, 2023, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #5 was hired as a counselor on February 2, 2022 and was due to have the communicable disease trainings no later than February 2, 2023 . There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
This is a repeat citation from the September 21, 2022 licensing inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee # 5 has completed the Basic HIV online training effective 7//26/2023. Employee #5 is registered to take the TB/STD/Hepatitis training on 9/29/2023. To prevent this in the future, all new staff that require any of the core trainings, will be monitored monthly to make sure that the trainings are being obtained, in the appropriate time frames. The clinical Supervisor is responsible for Oversight.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for Project Directors.
Employee #1 was hired as a Project Director on August 1, 2014, and was still in the position as of the date of the onsite inspection. The training year reviewed was the period between October 1, 2021, through September 30, 2022. Employee #1's training record did not contain documentation of any of the required annual training hours for this cycle.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A meeting occurred with Employee #1 on 7/26/2023 regarding the training hours for the project director along with the documentation for said training hours. A monthly review will occur since we are need the end of this training year, to verify we are in compliance. Going forward, a Mid year review will occur with all staff to ensure there is good progress in obtaining the needed training hours. The mid year review will be conducted approximately on 4/01/2024 and the clinical Supervisor is responsible for Oversight. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for Counselors.
Employee #4 was hired as a Counselor on June 15, 2020, and was still in the position as of the date of the onsite inspection. The training year reviewed was the period between October 1, 2021, through September 30, 2022. Employee #4's training record contained documentation of only 18.25 hours required annual training hours for this cycle.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A staff meeting occurred on 7/26/2023 the findings were reviewed with all staff. Employee #4 was present. the required training hours for their position was reviewed, along with the documentation for said training hours. A monthly review will occur since we are need the end of this training year, to verify we are in compliance. Going forward a Mid year review will occur with all staff to ensure there is good progress in obtaining the needed training hours for all staff. The mid year review will be conducted approximately on 4/01/2024 and the clinical Supervisor is responsible for Oversight. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in five out of seven applicable records reviewed. The facility's policy states the comprehensive treatment plan must be completed by the second appointment.
Client #1 was admitted on January 31, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 7, 2023; however, the treatment plan was not completed until April 25, 2023.
Client #2 was admitted on June 22, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than June 29, 2023; however, there was no documentation of it being completed at the time of the inspection.
Client #5 was admitted on September 27, 2022 and discharged on January 19, 2023. A comprehensive treatment plan was due no later than October 24, 2022; however, it was not completed until November 3, 2022.
Client #6 was admitted on December 21, 2022 and discharged on March 14, 2023. A comprehensive treatment plan was due no later than February 28, 2023; however, there was no documentation of it being completed at the time of the inspection.
Client #7 was admitted on February 7, 2023 and discharged on April 3, 2023. A comprehensive treatment plan was due no later than February 20, 2023; however, it was not completed until March 21, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/15/2023 the treatment planning process, with all clients, was updated. Treatment planning with clients will occur with in the first 30 days, after having attended their 1st treatment visit, which will occur after the Level of Care assessment. If there are issues that prevent the treatment plan from being developed in the first 30 days, this will be noted in the client's chart with a plan to develop the treatment plan with the client during the next individual treatment session. Client # 2 had reviewed the treatment plan virtually with the clinician and signed the portal stating the treatment plan review was reviewed. This had not been notated in the Treatment plan service at the time. Going forward this will be done for any telehealth/virtual session. As part of the training that occurred with all staff on 8/15/2023 they were also asked to note in treatment plan for any virtual sessions that a signature has occurred. In person sessions, clients are asked to sign the treatment plan. Addiotnally the clinical supervisor will review this on quarterly review of charts, which the first one began 8/04/2023. |
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 a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in two out of two applicable records reviewed. The facility's policy states that case consultations must be completed every ninety days.
Client #1 was admitted on January 31, 2023 and was still active at the time of the inspection. There were no case consultations documented in the client record.
Client #3 was admitted on February 24, 2023 and was still active at the time of the inspection. There were no case consultations documented in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff training occurred on 7/27/2023 in brain storming steps to be taken to identify any steps that can be utilized to identify case consultations being completed in the 90 day time frame from the start of treatment. Staff related successful steps that have aided them in timely completion of the case consultations. A quarterly review of charts will occur to ensure completion of the case consultations. The clinical supervisor will conduct the Quarterly review, the first one began 8/04/2023.
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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 in three out of three discharged records reviewed.
Client #5 was admitted on September 27, 2022, and was discharged on January 19, 2023.
Client #6 was admitted on December 21, 2022, and was discharged on March 14, 2023.
Client #7 was admitted on February 7, 2023 and was discharged on April 3, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training occurred with Case management staff on 7/27/2023 regarding the time frame of follow up with clients who have been discharged from services. A monthly review will occur to verify needed follow up contacts have been made. This will be done on a monthly basis as part of the case management meetings that occur weekly. The monthly reviews will begin 8/25/2023, which will be conducted by Case manager 1, along with the clinical supervisor overseeing the process. |