INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 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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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 a review of client records, the facility failed to obtain a valid consent form to include, specific information to be disclosed, in three out of seven client records.
Client #1 was admitted on November 14, 2023, and was still active at the time of the inspection. An incomplete consent form was signed and dated on November 14, 2023, for family/significant others.
Client #2 was admitted on October 4, 2023, and was still active at the time of the inspection. An incomplete consent form was signed and dated on October 4, 2023, for family/significant others.
Client #4 was admitted on September 12, 2023, and was discharged on October 12, 2023. An incomplete consent form was signed and dated on September 12, 2023, for family/significant others.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 1/23/2024, The Clinical Director corrected the release form for family and significant others in the TheraNest system. The release form states the following verbatim for the corrective action "The purpose of this release is to collaborate with family members and significant others.
The following information can be released. 1. The nature of the program 2. Prognosis 3. Whether the individual is in treatment or not 4. A brief description of progress in treatment. 5. If any relapse has occurred and the frequency of such relapse."
In order to ensure that this does not reoccur in the future, the clinical supervisor will inform staff during a staff meeting scheduled for 2/5/2024 of the form update. Clinical Supervisor will also randomly audit intakes to ensure the proper forms have been completed, signed, and dated. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in four out of five applicable records reviewed.
Client #1 was admitted on November 14, 2023, and was still active at the time of the inspection. The treatment plan was dated December 4, 2023.
Client #2 was admitted on October 4, 2023, and was still active at the time of the inspection. The treatment plan was dated October 10, 2023.
Client #3 was admitted on August 30, 2023, and was still active at the time of the inspection. The treatment plan was dated September 11, 2023.
Client #7 was admitted on June 22, 2023, and was discharged on August 28, 2023. The treatment plan was dated June 28, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To comply with 709.92 The Clinical Supervisor has scheduled a staff meeting on 2/5/2024 to inform and train staff to identify proposed support services with the client and document the proposed services on the comprehensive treatment plan.
In order to ensure that this does not reoccur in the future, the clinical supervisor and lead counselors will randomly audit files every Monday morning to ensure proper documentation is in place. |