INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17-19, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, TPALS Turning Point Alternative Living Solutions was found not 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of four personnel records, the facility failed to ensure that the one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #4 was hired September 16, 2024, and is still current in that position. Employee #4 has a high school diploma and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment and the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Employee #4 has documented supervision notes from September 16-November 4, 2024, that identified direct observation was occurring; however; there was no documentation of the required one hour of formal case review.
Close supervision is defined by regulation as follows: "Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective January 10, 2025, Tpals will implement a new plan to improve counselor supervision and documentation. The clinical supervisor will maintain a detailed log of direct observation and formal, one-hour case reviews, including notes on the counselor's strengths and areas for improvement. Both the direct observation and the case review will be documented, and the supervisor and counselor will sign the supervision notes upon completion. Tpals will clearly specify the dates and times for all case reviews to ensure consistency. Additionally, the clinical director will conduct quarterly audits of all supervision notes to ensure compliance with regulatory standards. |
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 client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of seven records reviewed.
Client #2 was admitted on June 28, 2024, and still active at the time of the inspection. There was no release of information for a funding source; however, the facility confirmed billing was occurring.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective January 10, 2025, Tpals will implement new procedures to ensure compliance with the consent to release information requirements. The facility will obtain and document a signed consent to release information form prior to releasing any client information to third parties, including funding sources. The facility will ensure that all client records contain appropriate consent forms before billing occurs. In instances where information needs to be shared, staff will be trained on the importance of obtaining the necessary consent form in advance. Tpals will conduct a training session on confidentiality to ensure all staff members understand the correct procedure for obtaining consent and release of information. Additionally, a follow-up staff training will be held to review the new procedure and address any questions or concerns that may arise during the quarterly inspections. This will help reinforce the process of obtaining signed consents and ensure compliance. All release of information forms will be properly maintained in client files. The clinical director will conduct quarterly audits of client records to ensure compliance with this requirement and to verify that proper consent to release information forms are completed and documented appropriately.
Client #2's release of information forms will be updated and corrected by February 10th, 2025, within 30 days of the effective execution date. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client to for the disclosure of information contained in the client record to include the name of the person, agency or organization in two out of seven records reviewed.
Client #2 was admitted on June 28, 2024, and was still active at the time of the inspection. A consent to release information form was signed and dated by the client, on June 28, 2024; however, it did not indicate the name of the person, agency or organization to whom disclosure may be made.
Client #5 was admitted on May 29, 2024, and was still active at the time of the inspection. A consent to release information form was signed and dated by the client, on May 29, 2024; however, it did not indicate the name of the person, agency or organization to whom disclosure may be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective January 10, 2025, Tpals will implement new procedures to ensure that all consent and release of information forms are completed in full and in compliance with confidentiality regulations. The facility will ensure that each consent form clearly indicates the name of the person, agency, or organization to whom the disclosure may be made, in addition to obtaining the client's informed and voluntary consent for the disclosure of their information. Going forward, all new consent forms will include this information. Tpals will conduct a staff training session on the importance of obtaining and documenting informed consent, including ensuring that the name of the recipient is specified on all release forms. A follow-up training will also be held to review the updated procedure and address any questions or concerns that may arise during quarterly inspections. The clinical director will monitor compliance with this process by conducting quarterly audits of client records to ensure that all consents to release information are complete, properly documented, and compliant with regulations.
Client #2's release of information forms will be updated and corrected by February 10th, 2025, within 30 days of the effective execution date.
Client #5's release of information forms will be updated and corrected by February 10th, 2025, within 30 days of the effective execution date. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information which must be in writing and include the specific information disclosed in four out of seven records reviewed.
Client #2 was admitted on June 28, 2024, and still active at the time of inspection. A release of information form was signed and dated by the client on June 28, 2024, for an emergency contact; however, it did not include the specific information to be disclosed.
Client #3 was admitted on July 11, 2023, and discharged on February 1, 2024. A release of information form was signed and dated by the client on July 11, 2023, for an emergency contact; however, it did not include the specific information to be disclosed.
Client #4 was admitted on April 22, 2024, and discharged on July 11, 2024. A release of information form was signed and dated by client on April 22, 2024, for an emergency contact; however, it did not include the specific information to be disclosed.
Client #5 was admitted on May 29, 2024, and still active at the time of the inspection. A release of information form was signed and dated by the client May 29, 2024, for the emergency contact; however, it did not include the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective January 10, 2025, Tpals will update its process to ensure that each consent form fully documents the specific information to be disclosed, as required by confidentiality regulations. All consent to release of information forms will be reviewed to guarantee they include the name of the person, agency, or organization to whom disclosure is being made, along with the specific information to be disclosed.
All staff completing initial assessments or providing services will thoroughly discuss the specifics of each updated consent form with the client before both parties sign. The forms will specifically outline what information will be shared with third parties, such as but not limited to, emergency contacts, treatment providers, and funding sources.
A staff training session will be conducted to ensure that all staff understand the updated procedures for obtaining informed and voluntary consent, including the inclusion of specific information on the forms. Additionally, a follow-up training will be held to reinforce the new process and address any questions or concerns that arise. The clinical director will audit client records quarterly to ensure full compliance with these updated procedures and verify that the specific information is consistently documented on consent forms.
Client #2's release of information forms will be updated and corrected by February 10th, 2025, within 30 days of the effective execution date.
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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one out seven records reviewed.
Client #4 was admitted on April 22, 2024, and discharged on July 11, 2024. A release of information signed and dated by the client on April 22, 2024, for the SCA did not include the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective January 10, 2025, Tpals will update its process to ensure that all consent forms for the disclosure of client information, including those for the Single County Authority (SCA), fully comply with confidentiality regulations.
The SCA consent form will outline what information will be shared, including but not limited to: the client's name, date of birth, diagnosis, identification of the funding source, financial statements supporting the need for funding, and a certified letter of termination or discontinuation of current insurance coverage. This form will clearly identify the purpose of the disclosure, which is to facilitate the necessary funding for the client's care through the SCA. This ensures that both the client and the third party are aware of what information will be disclosed and for what specific purpose.
All staff responsible for completing initial assessments or providing services will thoroughly discuss the specifics of each consent form with the client before obtaining signatures. This discussion will include a clear explanation of the purpose of the disclosure, specifically regarding the SCA funding process and any other third parties involved in the client's care.
In addition, Tpals will conduct staff training to review the updated procedure for obtaining informed consent, including the purpose of disclosure for SCA-related documentation. A follow-up session will be held to reinforce the process, address any questions, and ensure staff are aligned with the updated procedures. The clinical director will conduct quarterly audits of client charts to confirm compliance with all updated documentation procedures, ensuring the purpose of disclosure is clearly stated on all consent forms.
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709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the dated signature of client in two out of seven records.
Client #4 was admitted on April 22, 2024, and discharged on July 11, 2024. A release of information form dated April 22, 2024, for the SCA and an emergency contact did not include a dated signature of the client.
Client #7 was admitted on July 16, 2024, and still active at the time of the inspection. A release of information form dated July 16, 2024, to an emergency contact did not include the dated signature of the client.
These findings were disclosed with the facility staff during the licensing process.
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Plan of Correction
The facility will ensure that each consent form includes the dated signature of the client or guardian, as appropriate. Specifically, the release of information forms will be updated to include this essential component to comply with regulatory requirements.
Beginning January 10th, 2025 Tpals will begin to conduct a staff training session to ensure adherence to proper policies and procedures during client assessments and throughout treatment. The training will emphasize the importance of obtaining and documenting all required signatures and dates on client consents and paperwork.
The clinical director will conduct a quarterly audit of client records to ensure that all consent forms are fully completed, including the dated signatures of clients or guardians where applicable.
These actions will ensure that Tpals complies with confidentiality regulations and properly documents informed and voluntary consent for disclosure of client information.
Client #7 release of information forms will be updated and corrected by February 10th, 2025, within 30 days of the effective execution date.
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709.28 (c) (6) 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. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of the client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the date, event, or condition upon which the consent will expire in four out of seven records reviewed.
Client #2 was admitted on June 28, 2024, and still active at the time of the inspection. A release of information form for a funding source that was signed and dated on June 28, 2024, did not include the date, event or condition upon which the consent would expire.
Client #3 was admitted on July 11, 2024, and discharged on February 1, 2024. A release of information form for a funding source that was signed and dated July 11, 2024, did not include the date, event or condition upon which the consent would expire.
Client #5 was admitted on May 29, 2024, and still active at the time of the inspection. A release of information form for a funding source that was signed and dated May 29, 2024, did not include the date, event or condition upon which the consent would expire.
Client #6 was admitted on January 30, 2024, and still active at the time of the inspection. A release of information form for a funding source that was signed and dated January 30, 2024, did not include the date, event or condition upon which the consent would expire.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Beginning January 10th, 2025 Tpals will update all client consent forms to ensure full compliance with state and federal confidentiality standards. To achieve this, Tpals will collaborate with the state to revise the language in consent forms, incorporating the specific dates, events, or conditions under which the consents will expire. These updates will ensure that all documentation aligns with regulatory requirements.
Once the revisions are complete, Tpals staff will receive comprehensive training on the importance of accurately documenting expiration details in client consents. The clinical director will oversee the implementation of these updates, ensuring that all client records are properly maintained and meet regulatory standards. These changes will be seamlessly integrated into the clinical assessment process and the ongoing treatment of clients, establishing consistent compliance across all areas of care.
Client #2 release of information forms will be updated and corrected by February 10th, 2025, within 30 days of the effective execution date.
Client #5 release of information forms will be updated and corrected by February 10th, 2025, within 30 days of the effective execution date.
Client #6 release of information forms will be updated and corrected by February 10th, 2025, within 30 days of the effective execution date.
All revisions were addressed and corrected during each client's next scheduled individual session.
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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 ensure that the clients received counseling services according to their individual treatment plan in four out of seven applicable records reviewed.
Client #2 was admitted on June 28, 2024, and was still active at the time of the inspection. The treatment plan dated June 28, 2024, indicated one individual treatment session weekly and three groups weekly. There is no documentation that the client received a individual treatment session for the weeks of July 7-July13, August 4-10, and September 8-14. In addition, there is no documentation the client received three group sessions for the weeks of June 30- July 6, July 7-13, July 14-20, July 21-27 August 4-10, August 11-17, August 25-31, September 1-7, September 8-14, September 15-21, September 22-28, September 29-October 5, and October 6-12 and October 13-19.
Client #3 was admitted on July 11, 2023, and was discharged on February 1, 2024. The treatment plan dated September 18, 2023, indicated one individual treatment session weekly and three group sessions weekly. There is no documentation the client received three group sessions weekly for the weeks of September 22-28, September 29- October 5, October 6-12, October 13-29, October 20-26, October 27-November 2, November 3-9, November 10-16, November 17-23, November 24- 30, December 1-7, December 8-14, December 15-21, December 22-28, December 29- January 4, January 5-11, January 12-18, and January 19-25.
Client #5 was admitted on May 29, 2024, and was still active at the time of the inspection. The treatment plan dated May 29, 2024, indicated one individual treatment session weekly and one group session weekly. There is no indication the client received one individual treatment session for the weeks of July 7-13, July 14-20, August 18-24, and August 25-31. In addition, there is no documentation the client received three group sessions for the weeks of June 16-22, June 23-29, June 30- August 6, July 7-13, and July 14-20.
Client #7 was admitted on July 16, 2024, and was still active at the time of the inspection. The treatment plan dated July 16, 2024, indicated one individual treatment session and three groups weekly. There is no indication the client received one individual treatment session for the week of August 4-10. In addition, there is no documentation the client received three groups sessions for the weeks of July 14-20, July 21-27, July 28-August 3, August 4-10, August 11-17, August 18-24, August 25-31. September 1-7, September 8-14, September 15-21, and September 22-28.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
To address the identified deficiency regarding the failure to ensure clients received counseling services in accordance with their individual treatment plans, Tpals will implement a comprehensive plan to enhance service delivery, improve compliance monitoring, and maintain regulatory standards.
Tpals will hold weekly census meetings to assess client compliance with their recommended level of care and ensure alignment with treatment plans. Each counselor will be responsible for managing their own caseload and actively participating in these meetings. During the meetings, the following information will be reviewed for each client: client ID, intake date, current level of care, coordination of care with additional providers, documented case consultations with the clinical supervisor, and the client's compliance or non-compliance with the recommended treatment plan.
The clinical director will review clients identified by internal auditors, as compliant or non-compliant and provide guidance on appropriate actions to address any issues. The counselors will be responsible for documenting the discussions, reviews, and any follow-up actions in the clients' contact logs. Additionally, counselors will work closely with their clients to ensure compliance with the recommended level of care, addressing barriers to participation and developing strategies to maintain engagement.
Tpals will also implement a tracking system to monitor attendance and session completion for both individual and group counseling services. The system will include alerts for missed sessions to ensure timely follow-up and appropriate documentation. This will be reviewed on a daily basis by the counselor.
To maintain consistent oversight, the clinical director will review compliance during the weekly census meetings and conduct quarterly audits of client charts. These audits will ensure that all required counseling services are provided, accurately documented, and aligned with individual treatment plans. By implementing these measures, Tpals aims to strengthen client outcomes, ensure consistent oversight, and maintain compliance with state and federal regulatory standards. |