INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20, 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 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. |
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 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.
Employee #7 was hired as a Counselor on August 1, 2018 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 #7's training record contained documentation of only 17.50 hours required annual training hours for this cycle.
Employee #8 was hired as a Counselor on October 16, 2017, 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 #8's training record contained documentation of only 21.50 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's #4,#&, and #8 were 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. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical site inspection, it was determined that the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
It was observed, by DDAP Licensing staff, that the right hand rear exit of the facility, one of three means of egress, was obstructed by overgrown bushes and refuse which could present a slip, trip or fall hazard.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/20/2023 the maintenance Department was notified that the fire escape path had been overgrown and needed to cleared of of refuge as well. The clearing occurred on 7/24/2023. Pictures were taken 8/23/2023 and will be emailed for verification to the Licensing specialist. Regular monitoring of the fire exits will occur to make sure there is no debris or over growth to impede the fire exit. |
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 a consent to release information form prior to releasing information in one out of seven records reviewed. There was no consent to release information form for the funding source. Facility staff confirmed billing had occurred.
Client #7 was admitted on September 30, 2022 and was discharged on January 13, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Training for all staff occurred on 7/26/2023 in utilization of the ROI for funding services as well as any other individual the client would like communication with in regards to their treatment. Review of this will occur with all new staff as well as quarterly review of charts to verify ROI's completed correctly and in it entirety. The quarterly review began 8/04/2023 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 the client records, the facility failed to ensure that an individual treatment and rehabilitation plan be developed with the client in two out of four applicable client records reviewed.
Client #2 was admitted on November 7, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on December 21, 2022 with no client signature.
Client #7 was admitted on September 30, 2022 and discharged on January 13, 2023. A comprehensive treatment plan was developed on October 7, 2022 with no client signature.
Additonally, 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 four out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed by the second appointment.
Client #1 was admitted on April 24, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than May 8, 2023; however, the treatment plan was not completed until May 30, 2023.
Client #3 was admitted on June 2, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than June 30, 2023; however, there was no documentation of it being completed at the time of inspection.
Client #5 was admitted on March 16, 2023, and discharged on April 13, 2023. A comprehensive treatment plan was due no later March 23, 2023; however, there was no documentation of it being completed at the time of the inspection.
Client #6 was admitted on April 13, 2023 and discharged on June 12, 2023. A comprehensive treatment plan was due no later than May 11, 2023; however, there was no documentation of it being completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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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. |
709.92(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 three applicable client records reviewed.
Client #2 was admitted on November 7, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on December 21, 2022 and the next update was due no later than February 21, 2023; however, there was no update documented in the record until April 3, 2023. Additionally, an updated treatment plan was due no later than June 3, 2023; however, there was no update documented in the record until July 1, 2023.
Client #4 was admitted on April 21, 2023 and was still active at the time of the inspection. A comprehensive treatment was completed on April 30, 2023 and the next update was due no later than June 30, 2023; however, there was no update documented in the record at the time of the inspection.
This is a repeat citation from the September 28, 2021 and the September 21, 2022 licensing inspections.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff training occurred on 7/26/2023 in brain storming steps to be taken to identify any treatment plan reviews needing to be completed in the 60 day time frame from the previous treatment plan. Staff related successful steps that have aided them in timely completion of the treatment plan reviews. A quarterly review of charts will occur to ensure completion of the treatment plan reviews. The quarterly review began 8/04/2023 and the clinical Supervisor is responsible for Oversight. |
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 three out of three applicable records reviewed. The facility's policy states that case consultations must be completed every ninety days.
Client #1 was admitted on April 24, 2023, and was still active at the time of the inspection. There were no case consultations documented in the client record.
Client #2 was admitted on admitted on November 7, 2022, and was still active at the time of the inspection. As per the facility policy, a case consultation was due to be completed February 7, 2023; however, the case consultation was not completed until June 7, 2023.
Client #7 was admitted on September 30, 2022, and discharged on January 13, 2023. 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. |
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 one out of one applicable discharged record reviews.
Client #7 was admitted on September 30, 2022 and was discharged on January 13, 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 28, 2021 and September 21, 2022 annual licensing inspections.
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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.
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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 the review of client records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction was submitted to the Department for inspections occurring on September 28,2021 and September 21, 2022 addressing the requirement to document follow-up information in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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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. |