INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 24, 2022, 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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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
Based on a review of three personnel records, it was determined that one employee hired as a counselor did not meet the one year clinical experience required for a counselor with a Bachelor ' s level education.
Employee #2 was hired as a counselor on November 1, 2021 and was current in that position at the time of the inspection. At the time of their hire, the employee had a bachelor ' s degree in a related field but no clinical experience.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee # 2 was moved to a counselor assistant on 3/3/2022 and will be supervised as such until she reaches her year of clinical experience. She will be promoted to a counselor upon her year of clinical experience.
Documentation of supervision will be placed in the employee file.
To ensure that this does not reoccur in the future, facility director and clinical supervisor will review the qualifications of clinical experience and consult prior to hiring any new staff in a counselor position. |
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 three personnel records, the facility failed to maintain documentation that counselor assistants receive direct observation of the provision of counseling services as part of their close supervision, in one of one applicable record reviewed.
Employee # 3 was hired as a high school level counselor assistant by the facility on February 10, 2021 and has remained in that position. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
on 3/9/2022, Clinical Supervisor reviewed the supervision notes and specifically documented the type of direct supervision that was conducted for employee #3
To ensure that this does not reoccur in the future, clinical supervisor will randomly audit staff files to ensure that the supervision notes remain in compliance and include both direct and indirect supervision documentation. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection on February 24, 2022, the facility failed to ensure privacy during counseling sessions as the space used for group counseling connected to a hallway with no floor-to-ceiling wall or door separating the spaces.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The findings of the inspection were reviewed with the project director and CFO. TPALS will install a door to close off the group room to the rest of the facility by 4/15/2022. The door will ensure that counseling sessions can not be seen or heard.
To ensure that this does not reoccur in the future, the project director has been informed of the regulations for group counseling sessions. He will inspect the facility on 4/20/2022 to ensure the project is completed and meets DDAP regulations for counseling sessions. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from April 2021 through December 2021, the facility failed to prepare alternate exit routes as the same exit route was documented in each drill.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
on 3/14/2022, A fire drill was conducted with 3 participants using an alternative exit strategy.
To ensure that this does not reoccur in the future, a staff training was held on 3/9/2022 which informed the staff of the need to utilize an alternative exit strategy several times per year. Clinical Supervisor will audit the fire drill form quarterly to ensure alternative routes are being used throughout the year. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
The facility failed to document that the annual report for 2020 and 2021 was made available to the public.
This is a repeat citation from the March 18, 2021 licensure renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical director will add the following information to the TPALs website by 4/10/2022. An annual report which includes but is not limited to, a statement disclosing the names of officers, directors, and principle shareholders.
To ensure this does not occur in the future, the clinical director and facility director will meet annually to ensure that the information is listed on the website. If it is not listed on the website for any technical reasons, the facility director will create an add in the paper to make the information available to the public. |
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
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 both 2020 and 2021. The Plan of Correction from the previous licensing inspection indicated that the 2020 financial audit would be completed by May 30, 2021, at the time of the inspection it had not been completed.
This is a repeat citation from the March 18, 2021 licensure renewal inspection.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
The project CFO has requested an exception from the annual audit which was accepted by DDAP and granted on 2/14/2022.
Project CFO has tax forms available on site to be reviewed when next inspection takes place.
To ensure that this does not reoccur, project CFO and clinical director will meet semi-annually to ensure that the proper documents are available to comply with the exception. The semi annual meeting will take place on 6/15/2022. |
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 a review of seven client records, the facility failed to ensure that consent to release information forms included the purpose of disclosure in two records reviewed.
Client #6 was admitted on October 15, 2021 and was active at the time of the inspection. The record contained consent to release information forms to a probation officer and a treatment provider signed by the client on October 15, 2021, that were missing the purpose of disclosure.
Client #7 was admitted on April 9, 2021 and was active at the time of the inspection. The record contained a consent to release information form to an attorney signed by the client on May 13, 2021, and a lab signed by the client on February 17, 2022, that were missing the purpose of disclosure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The release form has been updated on 3/9/2022 to include the following statement. "The purpose of this release is for continuity of care" The release form then proceeds to inform the client that the release allows the agency to inform the listed individual or agency of the client's diagnosis, attendance information, cooperation with treatment recommendations, prognosis, and relapse.
Counselors will replace current release forms with the new forms by having their clients sign the updated forms for all current releases by 5/14/2022. The newly signed updated forms will be uploaded to the EHR record.
To ensure that this does not reoccur, the release form has been updated on the EHR record so that every release in the future will list the purpose for the disclosure. |
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 a review of seven client records, the facility failed to ensure that consent to release information forms included the dated signature of the client in four records reviewed.
Client #1 was admitted on April 7, 2021 and was discharged on November 19, 2021. The record contained a consent to release information form to the funding source signed by the witness on April 7, 2021, that was missing the dated signature of the client.
Client #2 was admitted on May 3, 2021 and was discharged on October 4, 2021. The record contained a consent to release information form to the funding source signed by the witness on May 3, 2021, that was missing the dated signature of the client.
Client #3 was admitted on April 1, 2021 and was discharged on December 16, 2021. The record contained a consent to release information form to the funding source signed by the witness on April 1, 2021, that was missing the dated signature of the client.
Client #4 was admitted on October 5, 2021 and was discharged on January 19, 2022. The record contained a consent to release information form to the funding source signed by the witness on October 5, 2021, that was missing the dated signature of the client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will conduct a staff training on 3/18/2022 for counselors and counselor assistants regarding releases. Staff will be trained on the purpose for releases, what can be disclosed, as well as how to properly document and sign releases to include a client signature and date.
To ensure that this does not reoccur in the future, clinical supervisor will randomly audit files and regularly oversee the documentation of release forms. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of seven client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in four records reviewed.
Client #1 was admitted on April 7, 2021 and was discharged on November 19, 2021. A treatment and rehabilitation plan update was completed on June 9, 2021 and was due to be updated by August 9, 2021; however, the next treatment plan update was not completed until October 7, 2021.
Client #2 was admitted on May 3, 2021 and was discharged on October 4, 2021. The individual treatment and rehabilitation plan was completed on May 18, 2021 and a treatment plan update was due by July 18, 2021; however, no treatment plan updates were completed prior to client ' s discharge.
Client #3 was admitted on April 1, 2021 and was discharged on December 16, 2021. The individual treatment and rehabilitation plan was completed on April 1, 2021 and a treatment plan update was due by June 1, 2021; however, no treatment plan updates were completed prior to client ' s discharge.
Client #4 was admitted on October 5, 2021 and was discharged on January 19, 2022. A treatment and rehabilitation plan update was completed on October 28, 2021 and was due to be updated by December 28, 2021; however, no additional treatment plan updates were completed prior to the client ' s discharge.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/21/2022, clinical supervisor will conduct a staff training regarding treatment planning. Staff will be trained on how to write a treatment plan and the timeframes in which they are due to be updated and documented.
To ensure that this does not reoccur in the future, clinical supervisor will conduct client file audits and review that treatment plans are being being completed correctly. |
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 seven client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in six records reviewed.
Client #1 was admitted on April 7, 2021 and was discharged on November 19, 2021. The comprehensive treatment plan completed on April 8, 2021 indicated the frequency of group counseling sessions to be twice weekly; however, a total of four group sessions were documented as being held between April 19, 2021 and June 10, 2021.
Client #2 was admitted on May 3, 2021 and was discharged on October 4, 2021. The comprehensive treatment plan completed on May 18, 2021 indicated the frequency of group counseling sessions to be three times a week; however, a zero group sessions were documented as being held between May 11, 2021 and June 26, 2021.
Client #4 was admitted on October 5, 2021 and was discharged on January 19, 2022. The comprehensive treatment plan completed on October 6, 2021 indicated the frequency of group counseling sessions to be three times a week; however, no group sessions were documented as being held between October 28, 2021 and the client ' s discharge.
Client #5 was admitted on August 30, 2021 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on August 31, 2021 indicated the frequency of group counseling sessions to be three times a week; however, no group sessions were documented as being held between August 30, 2021 and the time of the inspection.
Client #6 was admitted on October 15, 2021 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on October 15, 2021 indicated the frequency of group counseling sessions to be three times a week; however, only two group counseling sessions were documented as being held during the weeks of January 3-7, 2022, January 17-21, 2022, and January 24, 2022.
Client #7 was admitted on April 9, 2021 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on August 19, 2021 indicated the frequency of group counseling sessions to be three times a week; however, no group sessions were documented as being held between August 23, 2021 and September 20, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will conduct a staff training on 3/23/2022 regarding the delivery of treatment services and documentation of treatment services. Counselors will be trained on how to monitor the client's treatment progress and attendance and document the progress in the EHR record.
Too ensure that this does not reoccur in the future, clinical supervisor will review client treatment progress in regular supervision sessions. Clinical supervisor will randomly pick 5 client records for each clinical supervision session. If the clients are not following their treatment recommendations, it will be clearly documented into the EHR record by either counselor or clinical supervisor along with the efforts to engage the client. |
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 a review of seven client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes in three records reviewed.
Client #2 was admitted on May 3, 2021 and was discharged on October 4, 2021. The client record did not contain documentation of case consultation notes.
Client #4 was admitted on October 5, 2021 and was discharged on January 19, 2022. The client record did not contain documentation of case consultation notes.
Client #5 was admitted on August 30, 2021 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/1/2022, clinical supervisor will conduct a staff training regarding case consultations. The meeting will consist of informing the employees of what a case consultation is and how to clearly document it in the EHR.
To ensure this does not reoccur in the future. Clinical Supervisor will randomly audit client files and monitor for documented case consultations. If there are no case consultations documented into the client file, clinical supervisor will meet with the counselor ASAP to conduct the consultation on the clients progress. |