INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29, 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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705.24 (4) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(4) Provide privacy in toilets by doors.
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Observations
Based on an inspection of the facility ' s physical plant, the facility failed to provide privacy in toilets by doors.The second-floor men ' s staff lavatory did not have a functioning lock on the first bathroom stall.The second-floor women ' s staff lavatory did not have a functioning lock on the fourth bathroom stall. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Being that the facility is leased, the TPALS Facility Director will meet with building owner to request bathroom repair. The facility Director will request that repair is completed by 3/16/2024.
In order to ensure that this does not reoccur in the future, facility director will conduct monthly laboratory checks to assess for any needed repairs. If a repair is needed, the facility director will immediately report to building owner and request that repair is completed within 30 days. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in five out of six applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days following admission.Client #1 was admitted on September 21, 2023 and was active at the time of the inspection. A comprehensive treatment plan was due no later than October 21, 2023; however, it was not completed until October 25, 2023. Client #4 was admitted on June 23, 2023, and was discharged on August 28, 2023. A comprehensive treatment plan was due no later than July 23, 2023; however, there was no documentation of it being completed at the time of the inspection.Client #5 was admitted on June 16, 2023, and was discharged on August 25, 2023. A comprehensive treatment plan was due no later than July 16, 2023; however, there was no documentation of it being completed at the time of the inspection. Client #6 was admitted on August 29, 2023, and was discharged on December 12, 2023. A comprehensive treatment plan was due no later than September 29, 2023; however, there was no documentation of it being completed at the time of the inspection. Client #7 was admitted on November 9, 2023, and discharged on December 22, 2023. A comprehensive treatment plan was due no later than December 9, 2023; however, there was no documentation of it being completed at the time of the inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It is currently agency policy to conduct the first comprehensive treatment plan within 30 days. The Clinical Director will adjust the policy to reflect that a comprehensive treatment plan will be completed reviewed within 60 days and reviewed at least every 60 days in order to accommodate when a client does not show for appointments which at times creates a barrier to completing a comprehensive treatment plan prior to discharge. The policy change to 60 days will comply with DDAP standards 709.92. It will be completed and placed in the policy and procedure manual by 3/30/2024.
All staff will be informed/trained on new policy by Clinical Director at the next full multilocation staff meeting which will occur on 3/4/2024.
In order to ensure that this error does not reoccur in the future, the clinical supervisor and lead counselors will randomly audit files every Monday morning to ensure that documentation is being completed to comply with 709.92. |
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 two out of two applicable records reviewed.Client #1 was admitted on September 21, 2023, and was still active at the time of the inspection. The treatment plan was dated October 25, 2023. Client #3 was admitted on September 27, 2023, and was still active at the time of the inspection. The treatment plan was dated October 23, 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. |