INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 16, 2023 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 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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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review and a review of the project's 2022 federal income tax returns, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles that included reference to the drug and alcohol treatment activities for the 2022 fiscal year.
The project currently has a DDAP-approved exception for obtaining an annual financial audit; however, per DDAP Licensing Alert 01-11, the DDAP representative was unable to verify, from the income tax returns, the annual gross revenue received from the facility's drug and alcohol activities did not exceed $500,000.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/24/2023, Facility Director and Executive Director conducted a meeting regarding a plan for the financial audit. Executive Director will seek out a CPA and schedule a financial audit for 2022 to be completed by 6/30/2023. TPALS will ensure that 2023's audit will be completed by 6/30/2024. Each year, the audit for the previous year will be completed by 6/30 of the following year.
Tax forms will be available on site to be reviewed when next inspection takes place.
To ensure that this does not reoccur, executive director and clinical director will meet semi-annually to ensure that the proper documents are available to comply with the exception. The semiannual meeting will take place on 6/15/2023 and mid-June every year thereafter. |
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
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on individual treatment and rehabilitation plans in seven of seven client records reviewed.
Each individual treatment plan reviewed, in every client record reviewed, did not include documentation of the type and frequency of treatment and rehabilitation services to be provided to the client.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 02/16/2023, Clinical Supervisor conducted a meeting with staff regarding treatment planning. Clinical Supervisor trained the staff on how to include/document the type and frequency of treatment recommendations on the individual's treatment plan.
To ensure that this does not reoccur in the future, clinical supervisor will randomly audit client files to review the compliance of the staff with required documentation. Additionally, clinical supervisor will include treatment planning trainings for staff during regular staff meetings at least 3-4 per year and whenever a new staff is hired to ensure continued compliance. |