INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 24, 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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709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
A licensing renewal inspection was conducted on August 24, 2017. The facility failed to ensure that their client capacity for the outpatient activity did not exceed the licensed client capacity of 35. The Staffing Requirements Facility Summary Report provided by the facility, which was completed on 7/31/17, indicated that the active client census was 108. As of the date of the inspection, the active client census was 75.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director submitted request to DDAP to increase capacity to 70 prior to inspection. Capacity was increased on 9/8/17 to 70. Census as of 9/25/17 is 67. Director of Substance Abuse Treatment will monitor counselor caseloads and meet with Facility Director monthly to determine future needs to increase 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
Seven client records were reviewed on August 24, 2017. The facility failed to obtain an informed and voluntary consent to release information for client records # 1, 2, and 3.
Client # 1 was admitted into treatment on 7/10/17 and was still active in treatment. A consent to release information to the client's treatment funding source was not documented in the client's record.
Client # 2 was admitted into treatment on 3/9/17 and was still active in treatment. A consent to release information to the client's treatment funding source was not documented in the client's record.
Client # 3 was admitted into treatment on 4/18/17 and was still active in treatment. A consent to release information to the client's treatment funding source 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
Clinical supervisors will meet with all staff to ensure they obtain a release of information to the funding source signed by clients by 9/12/17. All staff will obtain signed release of information to funding source during the first session immediately as of 9/13/17. Client #1 signed release of information to the funding source will be obtained at the client's next session on 10/12/17. A signed release of information to the funding source was obtained for client#2 on 9/13/17. Client #3 has been discharged so facility was unable to obtain a signed release of information to the funding source. Clinical supervisor will review active client records weekly through the electronic medical record services submitted by the counselors and provide increased feedback as necessary and review with counselors during weekly individual supervision and monthly staff meetings. Director of Substance Abuse Treatment will meet with the clinical supervisor weekly to discuss compliance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Seven client records were reviewed on August 24, 2017. The facility failed to document a complete psychosocial evaluation for client records # 6 and 7.
Client # 6 was admitted into treatment on 1/24/17 and was discharged on 3/27/17. The facility failed to document a complete psychosocial evaluation in the client's record.
Client # 7 was admitted into treatment on 2/13/17 and was discharged on 5/1/17. The facility failed to document a complete psychosocial evaluation in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The requirement to complete the psychosocial evaluation will be reviewed with the counseling staff during supervision by clinical supervisors prior to 10/1/17. The counselor for clients #6 and #7 is no longer employed at the site as of 8/25/17. Clinical supervisors will monitor clients records to ensure the completion of the psychosocial evaluation and increase supervision and feedback as necessary. 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 psychosocial evaluations are completed. Director of Substance Abuse Treatment will meet with the clinical supervisor weekly to discuss compliance. |
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
Seven client records were reviewed on August 24, 2017. The facility failed to document the type of treatment services on the individual treatment and rehabilitation plan for client records # 1, 2, 3, 4, 5, 6, and 7.
Client # 1 was admitted into treatment on 7/10/17 and was still active in treatment. The master treatment plan was completed on 8/21/17.
Client # 2 was admitted into treatment on 3/9/17 and was still active in treatment. The master treatment plan was completed on 3/29/17.
Client # 3 was admitted into treatment on 4/18/17 and was still active in treatment. The master treatment plan was completed on 4/27/17.
Client # 4 was admitted into treatment on 10/13/16 and was discharged on 1/16/17. The master treatment plan was completed on 10/27/16.
Client # 5 was admitted into treatment on 2/27/17 and was discharged on 4/24/17. The master treatment plan was completed on 3/6/17.
Client # 6 was admitted into treatment on 1/24/17 and was discharged on 3/27/17. The master treatment plan was completed on 2/2/17.
Client # 7 was admitted into treatment on 2/13/17 and was discharged on 5/1/17. The master treatment plan was completed on 3/1/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisors will review the requirement to document the type of treatment on the treatment plans specifying individual or group, frequency and length of session with counseling staff by 10/1/17. Clinical supervisors will monitor treatment plans to ensure compliance and increase supervision as necessary. 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 discuss compliance. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Five personnel records were reviewed for the counselor position on August 24, 2017.
Employee # 7 was hired into the counselor position on 2/16/17. The qualifications documented in the employee's record indicated that as of the date of hire, the employee had completed a Bachelor's degree in Human Development and Family Studies. Documentation of the employee's prior work experience failed to demonstrate that the employee acquired at least 1 year of prior clinical experience. Therefore, employee # 7 did not meet the qualifications for the counselor position when hired.
These findings was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisors will ensure that Bachelor level applicants for the position of counselor have the required 1 year of prior clinical experience or hire them as a Counselor Assistant, effective 9/1/17. |
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 24, 2017. The facility failed to provide documentation of required HIV/AIDS and TB/STD training for employee #'s 10, 11, and 13.
Employee # 10 was hired on 6/9/03 and is an office manager. The facility failed to provide documentation of HIV/AIDS and TB/STD training for this employee.
Employee # 11 was hired on 3/11/11 and is a receptionist. The facility failed to provide documentation of HIV/AIDS and TB/STD training for this employee.
Employee # 13 was hired on 2/14/12 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 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. Employees #10, #11, and #13 will receive the training as soon as possible 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 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 24, 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 # 4, 6, and 7 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 # 4 to outpatient client treatment was 13 hours per week. The employee had 16 active clients as of 7/31/17.
-Employee # 4 (13/35 = .3714 FTE *** 16 clients/.3714 FTE = 43/1 caseload)
reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 6 to outpatient client treatment was 25 hours per week. The employee had 35 active clients as of 7/31/17.
-Employee # 6 (25/35 = .7142 FTE *** 35 clients/.7142 FTE = 49/1 caseload)
reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 7 to outpatient client treatment was 25 hours per week. The employee had 35 active clients as of 7/31/17.
-Employee # 7 (25/35 = .7142 FTE *** 35 clients/.7142 FTE = 49/1 caseload)
These findings were reviewd with facility staff during the licensing process.
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Plan of Correction
As of 9/20/17 employee #4 reduced her caseload to 6 clients, employee #6 last day of employment was 8/25/17 (clients were discharged or transferred) and employee #7 has reduced her caseload to 25. Two other new counselors will be adding 14 hours and 8 hours at this site. Caseload reports will be reviewed with counselors during supervision with clinical supervisor. Staff will discharge inactive clients in a more timely manner to effectively manage their caseloads. The clinical supervisor and Director of Substance Abuse Treatment will closely monitor caseloads and assess need to increase staffing or capacity. |