INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility ' s fire drill log from March 2020 to present, the facility failed to conduct unannounced fire drills at least once a month.
There were no documented fire drills for March 2020, April 2020, May 2020, June 2020, July 2020, August 2020 and October 2020.
The findings were discussed with project staff during the licensing process.
This is a repeat citation from an inspection conducted on February 5, 2020.
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Plan of Correction
Clinical Supervisor will conduct unannounced fire drill on a monthly basis, even when solely utilizing telehealth services. Project Director will oversee that this is done monthly. Project Director will also seek guidance from DDAP if there is a need for any changes or questions. |
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 the facility ' s fire drill log from March 2020 to present, the facility failed to prepare alternate exit routes to be used during fire drills. The facility used the same exit in each fire drill conducted.
The findings were discussed with project staff during the licensing process.
This is a repeat citation from an inspection conducted on February 5, 2020.
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Plan of Correction
Project Director will implement additional exit routes for fire drills and train staff on additional exit routes. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility ' s fire drill log from March 2020 to present, the facility failed to set off a fire alarm or smoke detector during each fire drill. The fire drill log submitted stated a bell was rang during the fire drills conducted.
The findings were discussed with project staff during the licensing process.
This is a repeat citation from an inspection conducted on February 5, 2020.
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Plan of Correction
Project Director will coordinate fire drills with the building manager to utilize fire alarm system for unannounced fire drills. |
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 governing body failed to 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.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project CEO will add the following information to the TPALS website by 4/30/2021 which will be readily 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.
To ensure that this deficiency does not reoccur, the project CEO and clinical supervisor will meet annually to review the website to ensure that the information regarding the officers, directors, and principal shareholders is accurate. |
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.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project CEO will contract with CPA to conduct 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. This will be completed by 5/30/2021.
In order to ensure this does not reoccur in the future, CEO and clinical supervisor will schedule an annual financial meeting to discuss CPA contract and ensure that the audit has been completed each year. |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated client signature in seven of seven client records reviewed.
Client #1 was admitted on December 1, 2020 and was current at the time of the inspection. Three release of information forms, one to the funding source, one to a family member and one to an agency, were signed and dated by a witness; however, they did not have a dated client signature.
Client #2 was admitted on January 28, 2021 and was current at the time of the inspection. Three release of information forms, one to the emergency contact, one to the funding source and one to family members, were signed and dated by a witness; however, they did not have a dated client signature.
Client #3 was admitted on July 30, 2020 and was current at the time of the inspection. Two release of information forms, one to the emergency contact and one to the funding source, were signed and dated by a witness; however, they did not have a dated client signature.
Client #4 was admitted on February 1, 2021 and was current at the time of the inspection. Two release of information forms, one to the emergency contact and one to the funding source, were signed and dated by a witness; however, they did not have a dated client signature.
Client #5 was admitted on September 21, 2020 and discharged on November 21, 2020. Four release of information forms, one to the emergency contact, one to the funding source, one to a counselor and one to a doctor, were signed and dated by a witness; however, they did not have a dated client signature.
Client #6 was admitted on February 9, 2021 and discharged on March 10, 2021. Two release of information forms, one to the emergency contact and one to the funding source, were signed and dated by a witness; however, they did not have a dated client signature.
Client #7 was admitted on December 18, 2020 and was discharged on March 5, 2021. Three release of information forms, one to the emergency contact, one to the funding source and one to a family member, were signed and dated by a witness; however, they did not have a dated client signature.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project Director will ask all staff members to acquire clients utilizing telehealth to engage in the client portal to obtain signatures. Clinical Supervisor will conduct monthly chart audits to assure this is being followed through and report any concerns with Project Director. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records, the project failed to offer a copy of client consents to the client in seven of seven client records reviewed.
Client #1 was admitted on December 1, 2020 and was current at the time of the inspection. There was no indication that the client was offered a copy of the three release of information forms documented in the client record.
Client #2 was admitted on January 28, 2021 and was current at the time of the inspection. There was no indication that the client was offered a copy of the three release of information forms documented in the client record.
Client #3 was admitted on July 30, 2020 and was current at the time of the inspection. There was no indication that the client was offered a copy of the two release of information forms documented in the client record.
Client #4 was admitted on February 1, 2021 and was current at the time of the inspection. There was no indication that the client was offered a copy of the two release of information forms documented in the client record.
Client #5 was admitted on September 21, 2020 and discharged on November 21, 2020. There was no indication that the client was offered a copy of the four release of information forms documented in the client record.
Client #6 was admitted on February 9, 2021 and discharged on March 10, 2021. There was no indication that the client was offered a copy of the two release of information forms documented in the client record.
Client #7 was admitted on December 18, 2020 and was discharged on March 5, 2021. There was no indication that the client was offered a copy of the three release of information forms documented in the client record.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project Director updated medical electronic system to include all forms have whether or not a client accepted a copy of the form. Clinical Supervisor will conduct monthly chart audits to assure this is being followed through and report any concerns with Project Director. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on the review of client records, the project failed to obtain written acknowledgement that the project may not discriminate in the provision of services on the basis of creed, ethnicity and handicap in seven of seven client records reviewed.
Client #1 was admitted on December 1, 2020 and was current at the time of the inspection.
Client #2 was admitted on January 28, 2021 and was current at the time of the inspection.
Client #3 was admitted on July 30, 2020 and was current at the time of the inspection.
Client #4 was admitted on February 1, 2021 and was current at the time of the inspection.
Client #5 was admitted on September 21, 2020 and discharged on November 21, 2020.
Client #6 was admitted on February 9, 2021 and discharged on March 10, 2021.
Client #7 was admitted on December 18, 2020 and was discharged on March 5, 2021.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project Director updated Client Rights form to include "The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion." |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on the review of client records, the project failed to obtain written acknowledgement that the clients were informed of the right to inspect their own records, that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental and that the reason for removing sections shall be documented in the record in seven of seven client records reviewed.
Client #1 was admitted on December 1, 2020 and was current at the time of the inspection.
Client #2 was admitted on January 28, 2021 and was current at the time of the inspection.
Client #3 was admitted on July 30, 2020 and was current at the time of the inspection.
Client #4 was admitted on February 1, 2021 and was current at the time of the inspection.
Client #5 was admitted on September 21, 2020 and discharged on November 21, 2020.
Client #6 was admitted on February 9, 2021 and discharged on March 10, 2021.
Client #7 was admitted on December 18, 2020 and was discharged on March 5, 2021.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project Director corrected Client Rights form to include; Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on the review of client records, the project failed to obtain written acknowledgement that clients were informs that clients have the right to appeal a decision limiting access to their records in seven of seven client records reviewed.
Client #1 was admitted on December 1, 2020 and was current at the time of the inspection.
Client #2 was admitted on January 28, 2021 and was current at the time of the inspection.
Client #3 was admitted on July 30, 2020 and was current at the time of the inspection.
Client #4 was admitted on February 1, 2021 and was current at the time of the inspection.
Client #5 was admitted on September 21, 2020 and discharged on November 21, 2020.
Client #6 was admitted on February 9, 2021 and discharged on March 10, 2021.
Client #7 was admitted on December 18, 2020 and was discharged on March 5, 2021.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project Director updated Clients Rights form to include; Clients have the right to appeal a decision limiting access to their records to the director. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on the review of client records, the project failed to ensure that intake procedures included documentation of the disclosure to the client of the criteria for admission, treatment, completion and discharge in seven of seven client records reviewed.
Client #1 was admitted on December 1, 2020 and was current at the time of the inspection.
Client #2 was admitted on January 28, 2021 and was current at the time of the inspection.
Client #3 was admitted on July 30, 2020 and was current at the time of the inspection.
Client #4 was admitted on February 1, 2021 and was current at the time of the inspection.
Client #5 was admitted on September 21, 2020 and discharged on November 21, 2020.
Client #6 was admitted on February 9, 2021 and discharged on March 10, 2021.
Client #7 was admitted on December 18, 2020 and was discharged on March 5, 2021.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project Director created an Orientation Form that includes criteria for admission, treatment, completion and discharge in seven of seven client records reviewed. The Orientation Form has also been implemented into our intake process. Clinical Supervisor will conduct monthly chart audits to assure this is being followed through and report any concerns with Project Director. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on the review of client records, the project failed to ensure that intake procedures and client orientation included documentation of familiarization with the hours of operation in seven of seven client records reviewed.
Client #1 was admitted on December 1, 2020 and was current at the time of the inspection.
Client #2 was admitted on January 28, 2021 and was current at the time of the inspection.
Client #3 was admitted on July 30, 2020 and was current at the time of the inspection.
Client #4 was admitted on February 1, 2021 and was current at the time of the inspection.
Client #5 was admitted on September 21, 2020 and discharged on November 21, 2020.
Client #6 was admitted on February 9, 2021 and discharged on March 10, 2021.
Client #7 was admitted on December 18, 2020 and was discharged on March 5, 2021.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project Director created an Orientation form that includes; Intake procedures shall include documentation of: (2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following: (ii) Hours of operation. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on the review of client records, the project failed to ensure that intake procedures and client orientation included documentation of familiarization with the fee schedule in seven of seven client records reviewed.
Client #1 was admitted on December 1, 2020 and was current at the time of the inspection.
Client #2 was admitted on January 28, 2021 and was current at the time of the inspection.
Client #3 was admitted on July 30, 2020 and was current at the time of the inspection.
Client #4 was admitted on February 1, 2021 and was current at the time of the inspection.
Client #5 was admitted on September 21, 2020 and discharged on November 21, 2020.
Client #6 was admitted on February 9, 2021 and discharged on March 10, 2021.
Client #7 was admitted on December 18, 2020 and was discharged on March 5, 2021.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project Director created an Orientation form that includes; Intake procedures shall include documentation of: (2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following: (iii) Fee schedule. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on the review of client records, the project failed to ensure that intake procedures and client orientation included documentation of familiarization with the services provided in seven of seven client records reviewed.
Client #1 was admitted on December 1, 2020 and was current at the time of the inspection.
Client #2 was admitted on January 28, 2021 and was current at the time of the inspection.
Client #3 was admitted on July 30, 2020 and was current at the time of the inspection.
Client #4 was admitted on February 1, 2021 and was current at the time of the inspection.
Client #5 was admitted on September 21, 2020 and discharged on November 21, 2020.
Client #6 was admitted on February 9, 2021 and discharged on March 10, 2021.
Client #7 was admitted on December 18, 2020 and was discharged on March 5, 2021.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project Director created an Orientation form that includes; Intake procedures shall include documentation of: (2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following: (iv) Services provided. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of three applicable records, the facility failed to complete a discharge summary including the client's involvement with the project in all three records.
Client #5 was admitted on September 21, 2020 and discharged on November 21, 2020. There was not a discharge summary including the client's involvement with the project in the client record.
Client #6 was admitted on February 9, 2021 and discharged on March 10, 2021. There was not a discharge summary including the client's involvement with the project in the client record.
Client #7 was admitted on December 18, 2020 and was discharged on March 5, 2021. There was not a discharge summary including the client's involvement with the project in the client record.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project Director directed created a new discharge summary form and trained staff on appropriate discharge planning summary. Clinical Supervisor will review discharge charts. |