INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection. The client records review inspection was conducted on August 11, 2025, and the physical plant inspection was conducted on August 13, 2025, 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(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 twenty-five clock hours of annual training required for counselors.
Employee #4 was hired as a counselor on January 24, 2022 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from October 1, 2023 through September 30, 2024. Employee # 4's record only documented fifteen hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 was made aware that her training requirements were not met for the training plan year of 10/1/23-9/30/24. She was given the opportunity to provide any additional trainings which may have been missed.
The Project Director will take the following steps for correction:
- Review training requirements in staff meeting (9/18/2025)
- Assess tracking system implemented by former supervisor (9/18/2025)
- Make adjustments to current tracking system, if necessary. Necessity will be determined by staff's understanding of the process and success in following through with the process. If all staff are currently in compliance with trainings with the current process, no need to change (9/30/2025).
- Project Director and/or Facility Director (depending on hiring of new manager) will monitor trainings in accordance with the tracking system noted above and at least twice during the training plan year will send reminders to staff and ensure counts of trainings are accurate. |
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 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 three out of eight records reviewed.
Client #1 was admitted on January 15, 2025 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the funding source was billed for the services.
Client #3 was admitted on December 18, 2023 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the funding source was billed for the services.
Client #8 was admitted on January 8, 2025 and discharged on March 11, 2025. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the funding source was billed for the services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In May 2025 the agency implemented a new Consent for Treatment, Payment, and Operations. It was developed by the agency COO and Compliance Committee. This Consent TPO was reviewed during the audit visit and will meet the requirement for informed and voluntary consent for the funding source moving forward. Client #1, #3, and #8 entered services prior to the Consent TPO being implemented.
Staff in the SUT program received information about the Consent TPO during meetings in May 2025 and August 2025. Project Director will revisit again in October 2025 to ensure understanding and compliance.
For active Client #1 and #3, Project Director has added a warning in client records to have client sign Consent TPO and has emailed direct therapist to ask that the client sign the Consent TPO at next scheduled visit.
Project Director and/or Facility Director (depending on hiring of new manager) will follow the agency Quality Improvement audit policy, reviewing charts 3 times per year, to ensure this regulation is being met. |
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 every ninety days, per facility procedure, in one out of three applicable client records.
Client #5 was admitted on January 8, 2025 and was discharged on April 15, 2025. A case consultation was due no later than April 8, 2025; however, there was no documentation that one occurred.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director reviewed timeline expectations of case consultations with staff during a staff meeting 8/21/2025.
Moving forward, Project Director will review the agency's current policy and adjust language related to frequency. Clients who become unengaged with services within a 90 day period cause disruption to meeting the 90 day frequency of case consultations.
After the policy is revised, it will be reviewed with staff, by the Project Director, in a staff meeting, with a target date of 11/15/2025.
Project Director and/or Facility Director (depending on hiring of new manager) will follow the agency Quality Improvement audit policy, reviewing charts 3 times per year, to ensure this regulation is being met. |