INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on March 12, 2019. Based on the findings of the on-site inspection, Turning Point Alternative Living Solutions (TPALS) was found to 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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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
During an onsite inspection on March 12, 2019, the project director failed to develop a comprehensive staff development program for agency personal and an overall plan for addressing these needs. There was no documentation of a training plan during the inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Project Director and Clinical supervisor developed a written staff development plan on 3/14/18 to comply with 704.11. This plan will be utilized throughout the year to ensure any current staff/new hires receive the appropriate amount of education/training needed. Clinical Supervisor will continuing assess training needs throughout yearly individual training sessions. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
During an onsite inspection on March 12, 2019, the project director failed to develop a comprehensive staff development program for agency personnel and indicating who is responsible and the time frames for completion. There was no documentation of the annual comprehensive staff development program nor an annual evaluation of the overall training plan. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Project Director have developed a written annual evaluation of the overall training plan to comply with 704.11 on 3/18/19. Clinical Supervisor and Project Director will meet annually on 12/1 to evaluate the training plan and assess if anything on the overall plan or on a staff members plan may need improvements or adjustments. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
During a review of records on March 12, 2019 the facility failed to ensure staff # 1 received HIV/AIDS training. Staff #1 was hired on January 1, 2016 as the Project and Facility Director. The staff had no documentation of HIV/AIDS training. This was a repeat citation from the April 14, 2017 facility inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director will schedule an approved DDAPP HIV/AIDS training as soon as one becomes available. Clinical Supervisor will also be monitoring the training monthly to ensure all current staff members or new hires in need of the training receive it in a timely manner. All staff training will be monitored utilizing the 704.11 staff development program. Once the training is received, it will be documented on the individual staff training plan. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
During a review of fire drill logs on March 12, 2019, the facility failed to document whether the fire alarms or smoke detector were operative. Fire drills documented from January 3, 2018 through February 25, 2019 failed to document whether the fire alarms or smoke detector were operative on the fire drill log. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On 4/3/19 the fire alarm survey form has been adjusted adding an additional question with the exact verbiage Was the fire alarm or smoke detector operative at the time of the drill?".
The next drill will take place on 4/20/19.
Project Director will monitor the monthly evacuation and ensure that the findings are accurate. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
During a physical site inspection on March 12, 2019, the facility failed to ventilate bathrooms by exhaust fan or window. The men ' s and women's bathrooms had no window nor functioning exhaust fans for ventilation. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Project Director will meet with the owner of the building on 4/1/19 and request that the ventilation system in the bathrooms be repaired. This facility has an exhaust fan located in each bathroom. Clinical Supervisor will monitor the bathrooms monthly to ensure proper functioning.
On 4/1/19, the owner of the building informed Project director that he will contact a maintenance person and have the ventilation systems fixed no later than 5/1/19. |
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
During a review of records on March 12, 2019, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of seven records. Client #6 was admitted on July 24, 2018 and was still active at the time at the time of the inspection. Information was documented being sent to Pamela and Christine at the County however there was no consent to release information to either found in the record. These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
A staff training was held on 3/27/19 on clinical documentation specifically, obtaining appropriate releases. Confidentiality was briefly reviewed as well as the correct way to fill out a release form. Staff members were also educated on the importance of obtaining releases if client's become involved in other agencies throughout their treatment.
Additionally, clinical supervisor will review the file after evaluation to ensure that releases are obtained. If any information is missing, the assigned counselor will obtain this information in the next individual session.
Finally, during regular case consultations, clinical supervisor will regularly monitor that the appropriate releases have been obtained. |
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
During a review of records on March 12, 2019, the facility failed to include age, national origin, and marital status in whom they may not discriminate in the provision of services in four out of seven records. Client records # 1, 4, 5 and 6 did not include this documentation. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A new client's rights form has been developed on 2/12/19 to include the exact verbiage; "A right to treatment regardless of age, sex, national origin, marital status, race, color, creed,sexual orientation, ethnicity, political affiliation, handicap, or religion. All of the old forms have been removed from blank intake packets and replaced with the new form. Clinical Supervisor has directed counselors and counselor assistants to fill out new form with all existing patients when they present for the next individual appointment and replace them in the file. Clinical supervisor will double check all existing files during file audits. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
During a review of records on March 12, 2019, the facility failed to document preliminary treatment and rehabilitation plans in four out of seven records. Client # 1 was admitted on August 15, 2018 and was still active at the time of the inspection. Client #1 had no documentation of a preliminary treatment or rehabilitation plan. Client # 3 was admitted on July 16, 2018 and was still active at the time of the inspection. Client # 3 had no documentation of a preliminary treatment or rehabilitation plan. Client # 6 was admitted on July 24, 2018 and was still active at the time of the inspection. Client # 6 had no documentation of a preliminary treatment or rehabilitation plan. Client # 7 was admitted on May 24, 2018 and was discharged on January 6, 2019. Client # 7 had no documentation of a preliminary treatment or rehabilitation plan. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A staff training is to be held on 4/3/19 to review clinical documentation which will specify treatment planning. Staff will be educated on the importance of treatment planning and the impact it serves on client progress in treatment. Staff members will be educated on the proper way to develop a treatment plan and how to consistently monitor the plan throughout treatment. Preliminary treatment plans will be developed during the initial evaluation. Counselors/counselor assistants will upload and save the treatment plans and updated treatment plans on the electronic health record system. Clinical supervisor will monitor that the treatment plans are being completed during supervision sessions and case consultations. Client's will randomly be reviewed during staff meetings held every Wednesday at 12:00p.m. |
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
During a review of records on March 12, 2019, the facility failed to develop an individual treatment or rehabilitation plan with the client in three out of seven records. Client #3 was admitted on July 16, 2018 and was current at the time of the inspection. Client #3 had no individual treatment plans documented in their record at the time of the inspection. Client #6 was admitted on July 24, 2018 and was discharged on January 16, 2019. Client #6 had a treatment plan dated September 21, 2018, which was only initialed by the client on January 2, 2019. There was no record of service or progress note that correlated with that date. The counselor never signed the treatment plan. Client #6 had a treatment plan dated November 22, 2018 which was initialed by the counselor. There was no record of service or progress note which correlated to that date. The treatment plan was never signed by the client.Client #7 was admitted on May 24, 2018 and was discharged on January 6, 2019. Client #7 had the second page of an initial treatment plan dated May 24, 2018 which was signed by the client and counselor and had a record of service corresponding to that date. The client had no other treatment plans documented at the time of inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A staff training is to be held on 4/3/19 to review clinical documentation which will specify treatment planning. Staff will be educated on the importance of treatment planning and the impact it serves on client progress in treatment.
Staff members will be educated on the proper way to develop a treatment plan and the importance of working together with the client to develop this plan. Client will sign the plan and counselor will consistently monitor the progress throughout client's treatment.
Preliminary treatment plans will be developed during the initial evaluation and will be signed by the client. Counselors/counselor assistants will upload and save the treatment plans and updated treatment plans on the electronic health record system as well as have a copy in the client file.
The electronic health record system automatically creates a detailed record of service of each appointment kept or not kept by the client to eliminate potential error for appointment dates and times.
Clinical supervisor will monitor that the treatment plans are being completed during supervision sessions and case consultations. Client's will randomly be reviewed during staff meetings held every Wednesday at 12:00p.m. |
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
During review of records on March 12, 2019, the facility failed to document type and frequency of treatment and rehabilitation services in three out of seven records. Clients # 1, 3, 5, 6 and 7 had no type and frequency of treatment and rehabilitation services documented during the inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
During the staff meeting on 4/3/19 on clinical documentation, clinical supervisor will inform the project director,counselors, and counselor assistants that when treatment plans are being developed on the electronic health record system, there is a section to be filled out on the treatment plan which includes the type and frequency of treatment that the particular client is receiving. Counselors will fill out this section during every treatment plan update.
If the type or frequency of a client's treatment changes at any time, clinical supervisor will note these changes during case consultations. The counselor will then update the changes on the treatment plan.
In addition, the electronic health record system record of service includes the type of treatment being given each time a client presents.
Finally, Clinical supervisor will consistently monitor client health records randomly to ensure staff is following through with the changes. |
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
During a review of records on March 12, 2019, the facility failed to review, and update treatment and rehabilitation plans every sixty days. Client #1 was admitted on August 15, 2018 and was still active at the time of the inspection. Client # 1 had a treatment plan dated October 14, 2018 and then not another treatment plan until February 22, 2019. There was one treatment plan in the record that contained no dates or signatures. Client # 2 was admitted on September 21, 2018 and had a treatment plan dated September 21, 2018 then not another treatment plan until March 12, 2019. Client # 3 was admitted on July 16, 2018 and was still active at the time of the inspection. Client #3 had no documented treatment plans. Client #4 was admitted on November 7, 2017 and was discharged on May 11, 2018. Client #4 had a treatment plan dated November 7, 2017. Client #4 had no other documented treatment plans. Client #6 was admitted on July 24, 2018 and was discharged on January 16, 2019. Client #6 had a treatment plan dated September 21, 2018 which was initialed by the client on January 2, 2019. The counselor never signed off on the treatment plan. There was no corresponding record of service or progress note for that date. Client #6 had a treatment plan dated November 22, 2018 which was initialed on January 2, 2019 by the counselor. The client never signed the treatment plan. There was no corresponding record of service or progress note for that date. Client #7 was admitted on May 24, 2018 and had the second page of an initial treatment plan dated May 24, 2019 which was signed off on by both the client and counselor. There were no other documented treatment plans at the time of inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A staff training is to be held on 4/3/19 to review clinical documentation which will specify treatment planning. Staff will be educated on the importance of treatment planning and the impact it serves on client progress in treatment.
Staff members will be educated on the proper way to develop a treatment plan, time frames and the importance of working together with the client to develop this plan. Client will sign the plan and counselor will consistently monitor the progress throughout client's treatment.
Each time that a treatment plan is developed, the electronic health record system will alert the counselor that a treatment plan will be due 30 days after a treatment plan has been developed. This will allow the counselor ample amount of time to update the treatment plan with the client.
The electronic health record system automatically creates a detailed record of service of each appointment kept or not kept by the client to eliminate potential error for appointment dates and times. The system will also save an electronic version of the treatment plan in addition to the paper treatment plan that will be filed.
Clinical supervisor will monitor that the treatment plans are being completed during supervision sessions and case consultations. Client's will randomly be reviewed during staff meetings held every Wednesday at 12:00p.m
Finally, all discharged client files will be given to the clinical supervisor for review. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
During a review of records on March 12, 2019, the facility failed to have a record of services documented for two out of seven clients.Client #2 was admitted on September 21, 2018 and was active at the time of the inspection. There was no documented record of services for Client #2. Client #4 was admitted on November 7, 2017 and was discharged on May 11, 2018. There was no documented record of services for Client #4. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Project Director has purchased THERANEST which is an electronic health record system. The agency is currently utilizing this system and has a documented record of service for each client that is receiving treatment. This system records every client appointment to include a record a service, type, and frequency of treatment that a client is receiving. Utilizing this system eliminates any potential errors in documenting dates and times of service.
Additionally, if a client chooses this option, they will automatically receive a mobile text reminder 24 hours prior to their individual appointments with a counselor. |