INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28, 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 #'s 8 and 9.
Employee # 8 was hired on 2/14/12 and is an office manager. The facility failed to provide documentation of HIV/AIDS and TB/STD training for this employee.
Employee # 9 was hired on 10/25/05 and is a receptionist. The facility failed to provide documentation of HIV/AIDS and TB/STD training for this employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Substance Abuse Treatment met with the front office staff supervisor for all 4 sites on 9/6/17 to develop a training plan for all front office staff to receive the required HIV/AIDS and TB/STD training within the first year of employment and to have all current front office staff who have not been trained to receive the required training by 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 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 28, 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 24 hours per week. The employee had 35 active clients as of 7/31/17.
-Employee # 5 (24/35 = .6857 FTE *** 35 clients/.6857 FTE = 51/1 caseload)
reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 6 to outpatient client treatment was 30 hours per week. The employee had 35 active clients as of 7/31/17.
-Employee # 6 (30/35 = .8571 FTE *** 35 clients/.8571 FTE = 41/1 caseload)
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 9/20/17 employee #5 has increased her hours to 28 client hours and decreased her client caseload to 24 primary clients.Employee # 6 has decreased her caseload to 28. New staff has been hired on 9/5/17 and will be working 16 hours per week at this site. Two other new counselors will be adding 4 hours and 8 hours at this site. The clinical supervisor and Director of Substance Abuse Treatment will closely monitor caseloads to ensure that staff caseloads remain at or under 35:1 and assess need to increase staffing or capacity. |
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
Nine client records were reviewed on August 28-29, 2017. The facility failed to obtain an informed and voluntary consent for the clients funding source in client records, #1, 2, 4, 5, 7, 8, and 9.
Client # 1 was admitted into treatment on 2/28/17 and was still active in treatment.
Client # 2 was admitted into treatment on 6/27/17 and was still active in treatment.
Client # 4 was admitted into treatment on 10/11/16 and was discharged on 5/24/17.
Client # 5 was admitted into treatment on 1/10/17 and was discharged on 5/17/17.
Client # 7 was admitted into treatment on 4/25/17 and was discharged on 8/9/17.
Client # 8 was admitted into treatment on 5/8/17 and was discharged on 6/26/17.
Client # 9 was admitted into treatment on 9/29/16 and was still active in treatment.
Lastly, client # 3 was admitted into treatment on 9/14/16 and was still active in treatment. A consent to release information to the client's funding source documented the client's signature, but failed to have documented the date the client signed. Additionally, the consent form was signed by a witness on 1/27/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 9/20/17 clinical supervisor has met with all staff to review required documentation in clients records. Staff was reminded to obtain a release of information to the funding source for every client. Clinical supervisors will review client records to ensure staff are completing all required documentation on a weekly basis.Signed releases of information to the funding source for clients #1, #2 and #9 will be obtained by 10/3/17. Clinical supervisor will review active client records weekly through the electronic medical record services submitted by the counselors to ensure releases of information are obtained to the client funding source and filled out in their entirety to include date signed by the client, and provide increased feedback as necessary to counselors. Director of Substance Abuse Treatment will meet with the clinical supervisor weekly to discuss compliance. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Five client records were reviewed for the Buprenorphine-waiver activity on August 28-29, 2017. The facility failed to document that a pregnant patient had been fully informed of the possible risks of Buprenorphine maintenance treatment for client record # 9.
Client # 9, a pregnant patient, was admitted into treatment on 9/29/16 and was still active in treatment.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Consent to treat forms for the Buprenorphine program will be updated to include potential risks to pregnancy by 10/1/17. These risks will be reviewed with female clients and signature will be obtained at the first visit with the Psychiatrist. The facility Director will make the required changes to the consent to treat form in the electronic medical records system to include possible risks to female patients and their unborn child from the continued use of illicit drugs and use of, or withdrawal from Buprenorphine prescribed by the program. Director of Substance Abuse Treatment will monitor electronic medical records of female clients in the Buprenorphine program to ensure signed informed consent has been obtained. Director of Substance Abuse Treatment will review any deficiencies during the monthly treatment team meetings. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Five client records were reviewed for the Buprenorphine-waiver activity on August 28-29, 2017. The facility failed to document at least 2.5 hours of psychotherapy per month, and a minimum of 1 hour of individual psychotherapy per month, for client records # 1, 2, and 3.
Client # 1 was admitted into treatment on 2/28/17 and was still active in treatment. For the period of 5/28/17 - 8/28/17, the client only received an average of 2 hours of psychotherapy per month, which did not included 1 hour of individual psychotherapy.
Client # 2 was admitted into treatment on 6/27/17 and was still active in treatment. For the period of 7/3/17 - 8/3/17, the client did not receive any psychotherapy services.
Client # 3 was admitted into treatment on 9/14/16 and was still active in treatment. For the period of 5/28/17 - 8/28/17, the client only received an average of 2.42 hours of psychotherapy per month. Additionally, the client did not receive the required 1 hour of individual psychotherapy for the months of December 2016, January, February, April, May, June, and July 2017.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/25/17 the Director of Substance Abuse Treatment met with the Psychiatrist and staff for the Buprenorphine program to review compliance with the attendance requirements. The Psychiatrist will enforce clients in the program must attend at least one hour of individual therapy per month as well as group therapy to meet the 2.5 hours of therapy per month requirement. Clients are required to meet with their counselor for an individual session before they may schedule a med check appointment with the Psychiatrist. Client #1 received 3 1/2 hours of treatment one hour was individual psychotherapy for the period of 8/28/17 to 9/11/17. Client #2 for the period of 8/7/17 to 9/22/17 attended 5 groups and 4 hours of individual therapy. Client #3 for the period of 8/18/17 to 9/22/17 attended 2 groups and 1 hour of individual psychotherapy. Clients will be reviewed during monthly treatment team meetings for attendance of individual psychotherapy. Counselors will alert Psychiatrist of clients not attending their individual therapy appointments. Clients identified as falling below the required 1 hour minimum individual will be scheduled for their individual session before their med check appointment with the Psychiatrist. Clinical supervisor and Director of Substance Abuse Treatment 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. |
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
Nine client records were reviewed on August 28, 2017. The facility failed to document an individual treatment and rehabilitation plan for client record # 2. In addition, the facility failed to document the type and/or frequency of treatment services on the individual treatment and rehabilitation plan for client records # 4, 5, and 9.
Client # 2 was admitted into treatment on 6/27/17 and was still active in treatment. An individual treatment and rehabilitation plan was not documented in the client's record.
Client # 4 was admitted into treatment on 10/11/16 and was discharged on 5/24/17. The master treatment plan was completed on 12/28/16.
Client # 5 was admitted into treatment on 1/10/17 and was discharged on 5/17/17. The master treatment plan was completed on 1/16/17.
Client # 9 was admitted into treatment on 9/29/16 and was still active in treatment. The master treatment plan was completed on 10/12/16.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Master treatment plans will be completed with the client by the 3rd session and updated every 60 days. Notes will be added to the client record to document the absence of clients or gaps in treatment due to short term issues, i.e. inpatient treatment or incarceration. As of 9/20/17 clinical supervisors have met with all counselors to review treatment planning to ensure that the type of treatment,individual or group, and the frequency of treatment services are included in the individual treatment plans. Clinical supervisors will closely monitor client records through the electronic medical record system and review with counselors during weekly individual supervision and monthly staff meetings to ensure that treatment plans are completed by the 3rd session and specify the type of treatment. The treatment plan for client #2 was completed on 8/28/17. Director of Substance Abuse Treatment will meet with the clinical supervisor weekly to ensure compliance.
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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
Nine client records were reviewed on August 28, 2017. The facility failed to document a treatment plan update at least every 60 days for client records # 1, 4, 5, 6, and 9.
Client # 1 was admitted into treatment on 2/28/17 and was still active in treatment. The most recent treatment plan update documented in the client's record was completed on 6/6/17. A subsequent treatment plan update was due to be completed by 8/6/17.
Client # 4 was admitted into treatment on 10/11/16 and was discharged on 5/24/17. A master treatment plan was completed for the client on 12/28/16. A subsequent treatment plan update was due to be completed by 2/28/17.
Client # 5 was admitted into treatment on 1/10/17 and was discharged on 5/17/17. A master treatment plan was completed for the client on 1/16/17. A subsequent treatment plan update was due to be completed by 3/25/17.
Client # 6 was admitted into treatment on 1/5/17 and was discharged on 7/24/17. A master treatment plan was completed for the client on 1/13/17. A subsequent treatment plan update was due to be completed by 3/13/17.
Client # 9 was admitted into treatment on 9/29/16 and was still active in treatment. A master treatment plan was completed for the client on 10/12/16. The only treatment plan update documented in the client's record was completed on 8/17/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Master treatment plans will be completed with the client by the 3rd session and updated every 60 days. Notes will be added to the client record to document the absence of clients or gaps in treatment due to short term issues, i.e. inpatient treatment or incarceration. Clinical supervisors reviewed this with staff on 9/20/17. Clinical supervisors will closely monitor client records by reviewing services submitted daily through the electronic medical record system and review with counselors during weekly individual supervision and monthly staff meetings to ensure that treatment plans are updated every 60 days. Director of Substance Abuse Treatment will meet weekly with Clinical supervisor to ensure compliance. |