INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17-18, 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(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of ten personnel records, the facility failed to ensure that three counselor assistants were counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.Employee #8 was hired on September 16, 2024, as a counselor assistant and is still current in that position. Employee #8 has an associate degree and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first nine months of employment. Employee #8 has documented supervision notes from September 16, 2024 - November 15, 2024, that identified direct observation was occurring; however, there was no documentation of the required one hour of formal case review. Employee #9 was hired March 3, 2023, and is still current in that position. Employee #9 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 #9 has documented supervision notes from January 1-March 3, 2024, that identified direct observation was occurring; however, there was no documentation of the required one hour of formal case review.Employee #10 was hired September 3, 2024, and is still current in that position. Employee #10 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 #10 has documented supervision notes from September 3-November 25, 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. " These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective January 9, 2025, Tpals will implement a structured plan to improve counselor supervision documentation. The following measures will be put into place for each counselor's supervision notes:
Direct Observation: Supervision notes will include a detailed account of direct observation during sessions.
Specific Areas of Focus for Improvement: The notes will highlight areas where the counselor requires improvement and focus.
Additional Support Needed: Documentation will also identify any additional support or resources the counselor may need.
Formal Case Review: A formal case review lasting at least one hour will be conducted and clearly documented in the supervision notes.
Signatures: Both the attending supervisor and the counselor will sign the supervision notes to confirm the completion of the review.
This plan aims to ensure consistent and thorough supervision practices to promote growth and professional development for counselors.
To ensure the effective implementation of the plan of correction, Tpals will improve and specify the dates and times for supervision and case reviews. The Clinical Director at Tpals will conduct quarterly audits of counselor files to ensure all documentation is in compliance with the requirements set forth by the Department of Drug and Alcohol Programs (DDAP).
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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 two out of seven records reviewed.Client #5 was admitted on June 18, 2024, and was still active at time of the inspection. There was documentation that information was disclosed to a primary care physician on June 18, 2024, however the record did not contain documentation that the client signed a release of information form for the primary care physician. Client #6 was admitted February 29, 2024, and discharged on April 1, 2024. There was documentation that information was disclosed to a healthcare provider on February 29, 2024, however the record did not contain documentation that the client signed a release of information for the healthcare provider. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the findings in the DDAP inspection report, Tpals has outlined the following steps to ensure proper handling of client information and adherence to consent procedures:
Consent and Release of Information Process:
If a client mentions a primary care physician (PCP) or any other medical provider during a health and wellness assessment, the clinician conducting the assessment will obtain a release of information and consent to communicate with that provider.
Staff Training:
Tpals will conduct a training session to ensure that all staff members understand the correct procedure for obtaining consent and releasing information. This training will emphasize the importance of client confidentiality and compliance with the consent process.
Monitoring and Auditing:
To monitor adherence to this procedure, the Tpals Clinical Director will conduct quarterly inspections of client charts. These inspections will ensure that the release of information and consent process is being followed appropriately.
Follow-Up Training:
A follow-up staff training session will be held to review the procedure and address any issues or questions that may arise from the quarterly inspections. This will help reinforce the correct implementation of the process.
By implementing these steps, Tpals aims to ensure compliance with best practices for client information handling and safeguard confidentiality while maintaining effective communication with healthcare providers. |
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 review of client records, the facility failed to obtain a completed informed and voluntary consent which included the specific information to be disclosed in six out seven records reviewed. Client #1 was admitted on February 2, 2024, and was still active at the time of the inspection. A release of information form for a lab, was signed and dated on February 2, 2024; however, it did not include the specific information to be disclosed.Client #2 was admitted on February 5, 2024, and discharged on September 4, 2024. A release of information form for an emergency contact, was dated and signed on February 13, 2024; however, it did not include the specific information to be disclosed. Client #3 was admitted on March 21, 2024, and was still active at the time of the inspection. A release of information form for an emergency contact, was dated and signed on March 28, 2024; however, it did not include the specific information to be disclosed. Client #4 was admitted on March 11, 2024, and discharged on May 6, 2024. A release of information form for an emergency contact and local a SCA, was dated and signed March 11, 2024; however, neither included the specific information to be disclosed. Client #5 was admitted on June 18, 2024, and was still active at the time of the inspection. A release of information form for an emergency contact, was dated and signed on June 18, 2024; however, it did not include the specific information to be disclosed. Client #6 was admitted on February 29, 2024, and discharged on April 1, 2024. A release of information form for an emergency contact, was dated and signed on February 29, 2024; however, it did not include the specific information to be disclosed. These findings were reviewed with facility staff during licensing process.
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Plan of Correction
Based on the findings of this inspection, Tpals plans to address the following concerns:
Consent Forms: Tpals will ensure that their consent forms clearly specify the details of the information being disclosed to a third party. This includes ensuring that staff conducting initial assessments or providing counseling services thoroughly discuss the specifics of each updated consent form with the client before both parties sign it. The forms will explicitly outline what information will be shared with third parties, including but not limited to:
SCA (Service Coordination Agency): Name, date of birth, diagnosis, current funding sources, financial statements supporting the need for funding, and certified letter of termination or discontinuation of current insurance coverage.
Agies Lab: Name, date of birth, diagnosis, current funding sources, address, phone number, and medications prescribed (including PRN or daily medications).
Emergency Contact: Name, date of birth, diagnosis, and information regarding the client's compliance or non-compliance with treatment.
Staff Training: To ensure that all policies and procedures are understood and properly implemented, Tpals will conduct a staff training session focused on these updated procedures and consent forms.
Quarterly Chart Reviews: Tpals' Clinical Director and Lead Counselor will conduct quarterly reviews of client charts to verify compliance with these updated consent procedures.
These actions will help ensure that Tpals' practices are in line with legal and ethical standards regarding client consent and information sharing with third parties. |
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 a completed informed and voluntary consent which included the purpose of the disclosure in one out of seven records. Client #5 was admitted on June 18, 2024, and was still active at the time of the inspection. A release of information form for a funding source, signed and dated June 18, 2024, did not include the purpose of disclosure. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Based on the findings of this inspection, Tpals plans to address the following concerns:
Consent Forms: Tpals will ensure that their consent forms clearly specify the details of the information being disclosed to a third party. This includes ensuring that staff conducting initial assessments or providing counseling services thoroughly discuss the specifics of each updated consent form with the client before both parties sign it. The forms will explicitly outline what information will be shared with third parties, including but not limited to:
SCA (Single County Authority): Name, date of birth, diagnosis, current funding sources, financial statements supporting the need for funding, and certified letter of termination or discontinuation of current insurance coverage.
Staff Training: To ensure that all policies and procedures are understood and properly implemented, Tpals will conduct a staff training session focused on these updated procedures and consent forms.
Quarterly Chart Reviews: Tpals' Clinical Director and Lead Counselor will conduct quarterly reviews of client charts to verify compliance with these updated consent procedures.
These actions will help ensure that Tpals' practices are in line with legal and ethical standards regarding client consent and information sharing with third parties.
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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 a completed informed and voluntary consent which included the dated signature of the client in four out of seven records.Client #3 was admitted on March 21, 2024, and still active at the time of the inspection. A release of information dated by a witness on March 21, 2024, for a funding source did not include a dated signature of the client. Client #4 was admitted on March 11, 2024, and discharged on May 6, 2024. A release of information dated by a witness on March 11, 2024, for the SCA did not include a dated signature of the client. Client #5 was admitted on June 18, 2024, and was still active at the time of the inspection. A release of information dated by a witness on June 18, 2024, for the SCA did not include a dated signature of the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction for Inspection Findings:
Staff Training:
Staff will receive training to ensure adherence to the proper policies and procedures during client assessments and throughout the course of treatment. The training will emphasize the importance of obtaining and documenting all required signatures and dates on client paperwork.
Ongoing Compliance Monitoring:
To ensure that policies and procedures are consistently followed, the Clinical Director will conduct quarterly reviews of client charts. Any discrepancies or omissions will be addressed immediately, and corrective actions will be implemented as needed.
Documentation Review:
The Clinical Director will ensure that all necessary signatures and dates are properly documented in the client's chart, as specified by internal policy and regulations. |
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 clients that recorded the date, event, or condition upon which the consent will expire in three out of seven records reviewed.Client #2 was admitted on February 5, 2024, and discharged on September 4, 2024. A release of information form to a funding source did not document the date, event or condition upon which the consent would expire. Client #4 was admitted on March 11, 2024, and discharged on May 6, 2024. A release of information form to an emergency contact did not document the date, event or condition upon which the consent would expire.Client #5 was admitted on June 18, 2024, and was still active at the time of the inspection. A release of information form to a funding source did not document the date, event or condition upon which the consent would expire. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Tpals Plan of Correction
Update Client Records:
Tpals will collaborate with the state agency to revise specific language in client records, ensuring that all documentation complies with state and federal standards for client confidentiality.
Revise Consent Forms:
Tpals will update all consent forms to reflect necessary corrections, including specifying the relevant dates and circumstances under which the forms may expire.
Clinical Director Oversight:
The Clinical Director will oversee the process to ensure that all client paperwork meets regulatory standards. This includes integrating these updates into the assessment process and ongoing treatment of clients. |
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 five out of seven applicable records reviewed.Client #1 was admitted on February 2, 2024, and was still active at the time of the inspection. The treatment plan dated February 2, 2024, indicated one individual treatment session weekly and groups three times a week. There is only documentation the client received two group session the weeks of February 11-17, February 18-24, February 26-March 2, March 3-9, March 10-16, March 17-23, March 31- April 6, April 14-20, April 21-27, April 28-May 4, May 5-11, June 2-8, June 19-15, June 16-22 and June 23-28. In addition, there is no documentation that the client received any group therapy for the weeks of May 12-18, and May 19-25. Client #2 was admitted on February 5, 2024, and discharged September 4, 2024. The treatment plan dated February 13, 2024, indicated one individual treatment session weekly and group sessions as needed. There was no documentation that the client received individual sessions for the weeks of March 3-9, March 17-23, and March 31- April 6. Client #3 was admitted on March 21, 2024, and was still active at the time of the inspection. The treatment plan dated March 28, 2024, indicated one individual session weekly and groups three times a week. There is only documentation of one group session for the weeks of March 31- April 6, April 7-13, May 5-11, June 16-22, July 7-13, July 14-20, July 21-27, September 1-7, and September 22-28, and only documentation of two group sessions for the weeks of April 14-20, April 21-27, May 12-18, May 19-25, June 9-15, June 30- July 6, July 28-August 3, and August 4-10. In addition, there is no documentation that the client received any group therapy for the weeks of June 2-8, June 23-29, September 8-14, and September 15-21. Client #5 was admitted on June 18, 2024, and was still active at the time of the inspection. The treatment plan dated June 18, 2024, indicated one individual session weekly and groups three times a week. There was no documentation that the client received individual therapy for the weeks of September 1-7, and September 8-14. There is only documentation of two group sessions for the weeks of June 30- July 6, July 7-13, July 14-20, July 21-27, August 4-10, September 1-7, and only documentation of one group session for the weeks of July 28-August 3, August 18-24, and August 25-31. In addition, there is no documentation the client received any group therapy for the weeks of August 11-17, September 29-October 5, October 6-12, October 13-19, October 20-26, October 27-November 2. Client #7 was admitted on April 29, 2024, and was still active at the time of the inspection. The treatment plan dated April 29, 2024, indicated one individual session weekly and groups three times a week. There was no documentation the client received three group sessions for the weeks of May 12-18, May 19-25, June 9-15, July 21-27, July 28-August 3, August 11-17, August 18-24, August 25-31, September 1-7, September 15-21. The treatment plan and case consultation dated July 22, 2024, indicated two individual sessions weekly, and groups three times a week. There is only documentation of one individual session for the weeks of August 18-24, August 25-31, and September 1-7. The treatment plan dated September 23, 2024, indicated a decrease in therapy to one individual session weekly and two group sessions weekly. There is no documentation the client received any individual sessions for the weeks of October 6-12, and October 20-26 or group sessions for the weeks September 29-October 5 and October 6-12.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the findings in the DDAP inspection, Tpals will implement weekly census meetings to assess client compliance with their designated level of care. Each counselor will be assigned a specific list of clients they are responsible for managing, which will include the following information:
Client ID
Client Intake Date
Client's Current Level of Care
Care Coordination with Additional Providers
Case Consultations with Supervisor Review
Additional Information Section (Marked as Compliant or Non-Compliant)
To ensure the procedure is being followed, Tpals' Clinical Director will review clients, identified by internal auditor, as non-compliant with their counselors. Counselors will then document the consultation in the client's contact log to ensure proper documentation of the discussion and actions taken.
Counselors will actively work with clients to facilitate compliance with their designated level of care. The Clinical Director will review compliance during both the weekly meetings and quarterly inspections of client charts to ensure that the procedure is being properly implemented and documented.
This systematic approach aims to strengthen adherence to care protocols and improve client outcomes by maintaining consistent oversight and follow-up. |