INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 24, 2014 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. 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 personnel training records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that the project director receive at least 12 clock hours of training annually.
The findings include:
According to the Staffing Requirements Facility Summary Report, the facility training year runs from October 1 through September 30.
The project director's record was reviewed specifically for training hours for the 2012-2013 training year on June 23, 2014. There was no documentation of any clock hours obtained for the 2012-2013 training year for in personnel record #1.
Employee # was hired as the project director on November 1, 2007. Employee # 1 did not have any documented clock hours of training during October 1, 2012 through September 3, 2013.
The findings were confirmed with the Drug and Alcohol coordinator.
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Plan of Correction
Our training year runs from October 1 through September 30. Employee #1 will be leaving the agency tentatively between 1 August 2014 and 1 October 2014. Once her replacement has been named, the new hire procedures will be completed within 7 days of hire to include the requirement of 12 documented training hours per training year. This standard will be reviewed monthly with the new employee to ensure compliance.
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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 an inspection of the facility's physical plant, the facility failed to ensure that exits from the facility were unobstructed.
The findings include:
A physical plant inspection was conducted with the clinical director on June 26, 2014 at around 9:07 AM. During the inspection it was found that the second exit, from the office suite which is accessed from the back hallway and discharges into and alley, was difficult to open and required an excessive amount of force to function.
This was confirmed by the clinical director during the physical plant inspection.
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Plan of Correction
The Clinical Supervisor discussed this with the Office Manager. The Office Manager will call the landlord today to report the problem. It is expected that this issue will be fixed no later than 8/1/2014. The Clinical Supervisor will monitor the progress of getting this situation addressed. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plans, in three out of nine client records.
The findings include:
Nine client records were reviewed on June 26, 2014. . The facility did not document services according to the individual treatment plan in client records # 3, 6, and 7.
Client # 3 was admitted on January 13, 2014 and still an active client at the time of inspection. The treatment plan for client #3 was completed on January 29, 2014. This treatment plan stated the client was to receive individual counseling sessions once a week. Client #3 received individual counseling sessions once a month; the last counseling session occurred on 5/16/14.
Client #6 was admitted on January 28, 2014 and discharged on April 8, 2014. The treatment plan for client #6 was completed on February 4, 2014. This treatment plan stated the client was to receive individual counseling sessions once a week. Client #6 received individual counseling on 2/4; 2/11; 3/4; 4/1; and 4/8.
Client #7 was admitted on January 7, 2014 and discharged on May 14, 2014. The treatment plan for client #7 was completed on January 7, 2014. This treatment plan stated the client was to receive individual counseling sessions once a week. Client #7 received individual counseling on 1/7; 2/4; and 3/31. The treatment was updated on March 31, 2014 at point the client was to receive individual counseling biweekly. The client was seen on 4/29 and 5/14 before being discharged successfully.
The findings were confirmed with the clinical director.
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Plan of Correction
The Clinical Director met with the Gettysburg clinicians on July 7, 2014. A review of this standard, having the treatment plan match the actual treatment sessions, was completed at that time. Records are being reviewed weekly until 1 October 2014. After that date, the review will take place monthly. Any issues will be brought to the clinician of record to update the record as indicated. |