INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 29, 2017 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
A licensing renewal inspection was conducted on August 28, 2017. The facility failed to provide documentation of required HIV/AIDS and TB/STD training for employee records # 5, 7, and 8.
Employee # 5 was hired on 10/29/15 and is a counselor.
Employee # 7 was hired on 2/27/08 and is a receptionist.
Employee # 8 was hired on 5/13/09 and is a receptionist.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #5 will receive the required HIV/AIDS and TB/STD training prior to 11/1/17. Receptionists and other front office staff will receive the required training within 2 years of their hire date. Employees #7 and #8 will receive the required training prior to 11/1/17. The Director of Substance Abuse Treatment will review all new hires at six months to assure that they have attended the required training. If they have not, the employee will be directed to complete the training. Completion of the training will be monitored by the Clinical Supervisor and the Director of Substance Abuse Treatment. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
A licensing renewal inspection was conducted on August 29, 2017. Based on a review of the Staffing Requirements Facility Summary Report completed by the facility during the licensing process, the facility failed to ensure that staff caseloads remain at or under 35:1.
Based on the total number of hours per week devoted to clients, and the standard work week of 35 hours, employees # 5 and 6 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by the standard work week of 35 hours.
reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 5 to outpatient client treatment was 15 hours per week. The employee had 30 active clients as of 7/31/17.
-Employee # 5 (30/35= .4285 FTE *** 30 clients/.4285 FTE = 70/1 caseload)
reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 6 to outpatient client treatment was 2 hours per week. The employee had 5 active clients as of 7/31/17.
-Employee # 6 (2/35 = .0571 FTE *** 5 clients/.0571 FTE = 88/1 caseload)
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #5 and #6 (counselors) will monitor their caseload more closely and discharge non-active clients in a timely manner. Employee #5 has reduced their active client caseload to 15 and is working 15 client hours per week as of 9/20/2017. Employee #6 has increased her client hours to 5 hours per week and has a case load of 4 as of 9/20/2017. Clinical Supervisor and the Director of Substance Abuse treatment will monitor caseloads and add more staff hours or additional counselors as the need increases to ensure the caseloads are within the 35:1 FTE ratio. |
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
Six personnel records were reviewed on August 24, 2017. The facility failed to provide documentation of an annual written performance evaluation signed by the employee for employee records # 5 and 6.
Employee # 5 was hired on 10/29/15 and is a counselor. The annual performance evaluation documented in the employee's record, completed on 9/28/16, did not document the employee's signature.
Employee # 6 was hired on 10/5/10 and is a counselor. The annual performance evaluation documented in the employee's record, completed on 9/28/16, did not document the employee's signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee performance reviews will be conducted by 10/1/17. The clinical Supervisor and Director of Substance Abuse Treatment will obtain employees signatures on all performance reviews. |
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
Seven client records were reviewed on August 29, 2017. The facility failed to obtain an informed and voluntary consent for the client's funding source in client records # 2, 4, 5, 6, and 7.
Client # 2 was admitted into treatment on 12/5/16 and was still active in treatment.
Client # 4 was admitted into treatment on 11/8/16 and was discharged on 3/13/17.
Client # 5 was admitted into treatment on 12/12/16 and was discharged on 4/25/17.
Client # 6 was admitted into treatment on 4/10/17 and was discharged on 7/4/17.
Client # 7 was admitted into treatment on 10/31/16 and was discharged on 5/2/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisors will meet with all counselors/staff during weekly supervision and monthly staff meetings to review obtaining release of information to the client's funding source. Counselors will obtain a release of information to the funding source at the initial session with the client. Clinical supervisor will review active client records weekly through the electronic medical record services submitted by the counselors and provide increased feedback as necessary. Director of Substance Abuse Treatment will meet with the clinical supervisor weekly to discuss compliance. Client #2 meets with counselor once a month. Counselor will obtain release of information to funding source at the client's next attended appointment. Next session is 10/17/17. Facility will be in full compliance by 11/1/17. |
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
Seven client records were reviewed on August 29, 2017. The facility failed to document the type and/or frequency of treatment services on the individual treatment and rehabilitation plan for client records # 1, 2, 4, 5, 6, and 7.
Client # 1 was admitted into treatment on 3/7/17 and was still active in treatment. The master treatment plan was completed on 5/1/17.
Client # 2 was admitted into treatment on 12/5/16 and was still active in treatment. The master treatment plan was completed on 12/19/16.
Client # 4 was admitted into treatment on 11/8/16 and was discharged on 3/13/17. The master treatment plan was completed on 12/5/16.
Client # 5 was admitted into treatment on 12/12/16 and was discharged on 4/25/17. The master treatment plan was completed on 1/12/17.
Client # 6 was admitted into treatment on 4/10/17 and was discharged on 7/4/17. The master treatment plan was completed on 5/16/17.
Client # 7 was admitted into treatment on 10/31/16 and was discharged on 5/2/17. The master treatment plan was completed on 11/7/16.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 9/20/17 all counselors have been informed to specify type (individual or group) and frequency of treatment services by clinical supervisors. Clinical supervisor will follow up with counselors during weekly individual supervision and monthly staff meetings to ensure counselors are documenting the type of treatment recommended. Clinical supervisor will review active client records weekly through the electronic medical record services submitted by the counselors and provide increased feedback as necessary. Director of Substance Abuse Treatment will meet with the clinical supervisor weekly to ensure compliance. |
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
Seven client records were reviewed on August 29, 2017. The facility failed to document a treatment plan update at least every 60 days for client records # 1, 2, 4, 5, and 7.
Client # 1 was admitted into treatment on 3/7/17 and was still active in treatment. A master treatment plan was completed for the client on 5/1/17. A subsequent treatment plan update was then completed for the client on 8/17/17.
Client # 2 was admitted into treatment on 12/5/16 and was still active in treatment. A master treatment plan was completed for the client on 12/5/16. A subsequent treatment plan update was then completed for the client on 8/17/17.
Client # 4 was admitted into treatment on 11/8/16 and was discharged 3/13/17. A master treatment plan was completed for the client on 12/5/16. A treatment plan update was due to be completed by 2/5/17, and one was not documented in the client's record.
Client # 5 was admitted into treatment on 12/12/16 and was discharged on 4/25/17. A master treatment plan was completed for the client on 1/12/17. A treatment plan update was due to be completed by 3/12/17 and one was not documented in the client's record.
Client # 7 was admitted into treatment on 10/31/16 and was discharged on 5/2/17. A master treatment plan was completed for the client on 11/7/16. A treatment plan update was due to be completed by 1/7/17, and one was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Treatment planning will be reviewed with all staff. Staff will complete a master treatment plan with the client by the 3rd session and update the treatment plan every 60 days. Notes will be added to the client record to document the absence of the client or any gaps in treatment due to short term issues, i.e. inpatient treatment or incarceration. Clinical Supervisors will review client records to ensure treatment plans are created by the 3rd session and are being updated every 60 days. Deficiencies will be reviewed with the appropriate staff. Facility will be in full compliance by 10/1/17. |