INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 15, 2016 by staff from the Division of Drug and Alcohol 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.
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
The facility failed to meet the pre-submission guidelines for the annual licensing inspection. The time allotted for the onsite portion of the inspection did not allow for a thorough review of that material on site.
This matter was reviewed with facility staff during the licensing process.
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Plan of Correction
The Drug and Alcohol Director will complete and submit to DDAP, the DDAP staff training form promptly following receipt. The completed staffing form will be reviewed with the Facility Manager prior to submission to DDAP. If there are questions regarding the proper response, DDAP will be contacted for guidance prior to submission of the form. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Four personnel records were reviewed on August 10, 2016. Three out of the four personnel records were required to contain an annual evaluation for the employees. The facility failed to document an annual evaluation in employee record # 2.
Employee #2 was hired on June 18, 2001 and there was no documentation of an annual evaluation since October 2014.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The Project Director will complete an annual performance evaluation for employee #2 prior to October 1, 2016.
To ensure this does not recur, the TrueNorth Wellness Director of Drug and Alcohol Program will verify with HR by the second week in October that the performance evaluation is in the HR file. If it is not, the Drug and Alcohol Director will directly e-mail the CEO and inform them of the need to complete the performance evaluation. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Eight client records were reviewed on August 15, 2016. All were reviewed for informed and voluntary consent forms. The facility failed to document specific information disclosed on the informed and voluntary consent form for a government agency in client record, #4. The consent to release was dated April 12, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The requirement and the proper documentation of the specific information disclosed for a government agency will be reviewed by the Director of Drug and Alcohol Services with the counselor who failed to properly complete that section on a 1:1 basis and with the treatment team during staff supervision.
This will occur prior to October 1, 2016.
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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
Eight client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on August 15, 2016. The facility failed to document a treatment plan update at least every 60 days in client records, # 1, 2, 5 and 6.
Client # 1 was admitted on 3/8/2016 and discharge on 07/28/16. The client's master treatment plan was completed on 3/28/16. A treatment plan update was due by 5/28/16. There was no documentation of treatment plan update as of the date of the client's discharge.
Client # 2 was admitted on 4/19/2016 and still active at the time of the inspection. The client's master treatment plan was completed on 5/16/16. A treatment plan update was due by 7/16/16. There was no documentation of treatment plan update as of the date of the licensing inspection.
Client # 5 was admitted on 3/15/2016 and discharge 06/30/16. The client's master treatment plan was completed on 4/18/16. A treatment plan update was due on 6/18/16. There was no documentation of treatment plan update as of the date of the client's discharge.
Client # 6 was admitted on 2/10/2016 and discharge on 05/09/16. The client's master treatment plan was completed on 2/23/16. A treatment plan update was due on 4/23/16. There was no documentation of treatment plan update as of the date of the client's discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The requirement that treatment plans are completed within every 60 day period will be reviewed by the Director of Drug and Alcohol Services with the Counseling staff during supervision prior to October 1, 2016.
The Director of Drug and Alcohol Services will monitor the timeliness of the treatment plans and report aggregate results to the QI committee on a quarterly basis.
The Director of Drug and Alcohol Services will provide increased frequency of monitoring and feedback as necessary.
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