INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5, 2024, 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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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 an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of seven records reviewed.
Client #7 was admitted on October 25, 2024 and was discharged on February 5, 2024. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An attempt was made to reach client #7, in regards to informing the client a ROI had not been attained by the agency, also provided awareness of the information that was related to their funder, specifically their diagnosis code, dates, and times of services.
In order to prevent this from happening in the future, A training occurred on 6/13/2024 with case managers, completed by the facility Director. A process was developed where a weekly report will be run by case managers to verify any changes in funding for clients. Any new ROI's will be completed with the client at that time, or as soon as the client is able to come in person or sign one on their client portal. This will be reviewed by the facility director as part of the QI process that will occur monthly for the next three months, if the ROI' are obtained as needed, then the QI process will return to a quarterly basis to verify it occurring as needed.
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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 that includes written documentation of the type and frequency of treatment and rehabilitation services in four out of seven applicable client records reviewed.
Client #3 was admitted on April 10, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on April 30, 2024, that did not include a specific frequency for the short and long term goals. The frequency identified was not definitive as multiple time frames were listed.
Client #4 was admitted on September 29, 2023 and was discharged on November 1, 2023. A comprehensive treatment plan was developed on October 16, 2023, that did not include a specific frequency for the short and long term goals. The frequency identified was not definitive as multiple time frames were listed.
Client #5 was admitted on October 18, 2023 and was discharged on December 11, 2023. A comprehensive treatment plan was developed on October 24, 2023, that did not include a specific frequency for the short and long term goals. The frequency identified was not definitive as multiple time frames were listed.
Client #6 was admitted on March 27, 2024 and was discharged on May 1, 2024. A comprehensive treatment plan was developed on March 27, 2024, that did not include a specific frequency for the short and long term goals. The frequency identified was not definitive as multiple time frames were listed.
This is a repeat citation from the July 24, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility Director completed a staff meeting on 6/13/2024 and instructed clinicians on noting the correct type and frequency of service recommended in the treatment plan to be more specific, to include what is being recommended weekly or bi weekly, and what is being recommended monthly. Example documentation could include: weekly group session and biweekly 1-1 session, not to simply say weekly/bi weekly. This will be reviewed by the facility director during the QI process, quarterly, to ensure the correct frequency is noted. |
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 one out of three applicable records reviewed.
Client #2 was admitted on November 7, 2023 and was still active at the time of the inspection. A treatment plan was completed on January 16, 2024, and the next update was due no later than March 16, 2024; however, the next update was not completed until April 5, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/13/2024 a staff training for all counselors occurred and instructed in the process of treatment plan reviews being completed before or on 60-day time frame from the creation of the treatment plan. Several methods, such as Excel spread sheet has been created by the facility director and given to the counselors to use in order to track the time frames need. On the other hand, they can use another method, such as keeping track of the time frames on their electronic work calendars. Counselors were required to pick a process they will be using. The counselors discussed the choice and began using it that day. The facility director will initially verify though a QI process monthly for 3 months, to verify the process is working to obtain the treatment plan reviews per our policy. IF not other methods will be utilized, if the treatment plan reviews are being completed per policy, the review by the facility director will go back to the quarterly review time frame. In order to verify the process is still occurring as needed. |
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 the review of client records, the facility failed to document case consultations within the timeframe established by the facility ' s policy and procedures manual of every ninety days in two out of three applicable client records.
Client #1 was admitted on December 22, 2023 and was still active at the time of the inspection. A case consultation was due no later than March 22, 2024; however, it there was no documentation that one was completed.
Client #2 was admitted on November 7, 2023 and was still active at the time of the inspection. A case consultation was due no later than February 7, 2024; however, there was no documentation that one was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/13/2024 a staff training for all counselors occurred and instructed in the process of case consultations being completed before or on the 90 day time frame from being admitted to treatment. Several methods, such as Excel spread sheet has been created by the facility director and given to the counselors to use in order to track the time frames needed. On the other hand, they can use another method, such as keeping track of the time frames on their electronic work calendars. Counselors were required to pick a process they will be using. The counselors discussed the choice and began using it that day. The facility director will initially verify though a QI process monthly for 3 months, to verify the process is working to obtain the completion of the case consultations minimally every 90days, per our policy. IF not other methods will be developed, if the case consultations are being completed per policy, the QI review by the facility director will go back to the quarterly review time frame; In order to verify the process is still occurring as needed. |
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 per the facility ' s policy and procedures manual of sixty days after discharge in three out of three applicable discharged records reviewed.
Client #4 was admitted on September 29, 2023 and discharged on November 1, 2023. A follow up contact was due no later than January 1, 2024; however, it was not completed until January 12, 2024.
Client #5 was admitted on October 18, 2023 and discharged on December 11, 2023. A follow up contact was due no later than February 11, 2024; however, it was not completed until February 26, 2024.
Client #7 was admitted on October 25, 2024 and discharged on February 5, 2024. A follow up contact was due no later than April 5, 2024; however, it was not completed until April 12, 2024.
This is a repeat citation from the July 24, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A training occurred by the facility director on 6/13/2024 with case managers, to retrain the process for follow up contacts. A process was developed where a weekly report will be run by case managers, to identify clients who are due a follow up questionnaire, in the upcoming week; per our policy of being completed by 60 days after discharge. The facility director will do a monthly review for the next three months, to verify the follow up questionnaires are being sent out. If not, adjustments will be made, to ensure this is occurring. If they are, then the QI review will go back to occurring quarterly. |