INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 24, 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(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 October 5, 2010, 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 3 hours required annual training hours for this cycle.
Employee #5 was hired as a Counselor on June 22, 2021 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 #5's training record contained documentation of only 24 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 & #5 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. |
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 five out of seven applicable client records reviewed.
Client #2 was admitted on January 4, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was developed on April 26, 2023, with no client signature.
Client #3 was admitted on June 14, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 29, 2023, with no client signature.
Client #4 was admitted on June 27, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 9, 2023, with no client signature.
Client #5 was admitted on December 13, 2022, and was discharged on March 14, 2023. A comprehensive treatment plan was developed on December 20, 2022, with no client signature.
Client #6 was admitted on February 14, 2023, and discharged on April 11, 2023. A comprehensive treatment plan was developed on February 23, 2023, with no client signature.
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, #4,#5, and #6, had reviewed their treatment plans 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. Client #3 did not have the treatment plan signed when created with the client, this error was reviewed with the clinician as well and all staff during the 8/15/2023 training, the need to sign in person or virtually. Addiotnally the clinical supervisor will review this on quarterly review of charts, which the first one began 8/04/2023. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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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 shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in four out of seven client records reviewed.
Client #2 was admitted on January 4, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was developed on April 26, 2023. The frequency of treatment was noted as " weekly/biweekly. "
Additionally, a treatment plan update was developed on June 23, 2023; the frequency of treatment was noted as " weekly/biweekly. "
Client #3 was admitted on June 14, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 29, 2023; the frequency of treatment was noted as " weekly/biweekly. "
Client #5 was admitted on December 13, 2022 and discharged on March 14, 2023. A comprehensive treatment plan was developed on December 20, 2022; the frequency of treatment was noted as " weekly/biweekly. "
Additionally, a treatment plan update was developed on February 7, 2023; the frequency of treatment was noted as " weekly/biweekly. "
Client #6 was admitted on February 14, 2023 and discharged on April 11, 2023. A comprehensive treatment plan was developed on February 23, 2023; the frequency of treatment was noted as " weekly/biweekly. "
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/15/2023 the the importance of specifying in the treatment plan the type: individual and or group sessions, length of time an hour hour and a half etc., along with the frequency was discussed in the over all staff training. The clinical supervisor will review this on quarterly review of charts, which 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 #6 was admitted on February 14, 2023 and was discharged on April 11, 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. |