INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on February 9, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
While conducting the physical plant inspection a counseling session could be heard in the hallway from the downstairs counseling office.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Facility Director and Clinical supervisor instructed D&A staff to be sure sufficient noise cancelling equipment is available and utilized during all sessions to ensure confidentiality on 2/16/2021. |
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 ensure that treatment plan updates were completed every 60 days in three client records.
Client #1 was admitted on September 19, 2020 and was still active at the time of the inspection. A treatment plan updated was created on July 21, 2020 and an update was due no later than September 21, 2020, however an update was not created until December 15, 2020.
Client #2 was admitted on January 29, 2020 and was still active at the time of the inspection. A treatment plan update was created on October 6, 2020 and an update was due on later than December 6, 2020, however no update was created until January 27, 2021.
Client #5 was admitted on August 31, 2020 and was discharged on December 30, 2020. A treatment plant update was created on September 17, 2020 and an update was due no later than November 17, 2020, however no update was completed until December 1, 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Clinical staff documents reasons for delay in treatment plan updates in a collateral note. This was done in the case of client #1, #2 and #3 prior to 2/9/2021. Facility Director and Clinical Supervisor discussed this with D&A staff on 2/16/2021 to ensure every delay in updating a treatment plan is documented in the client chart. |
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 three discharged client records, the facility failed to ensure that one client record contained follow up information.
Client Record #6 was admitted on September 15, 2020 and discharged on November 18, 2020. There was no documentation of follow up information in the client record.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The follow up with client #6 was completed by Medical records staff on 2/17/2021. Facility Director discussed obtaining additional help for our medical records staff with Project Director to ensure this will be completed within 60 days in the future. |