INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 1, 2017 by staff from the Division of Drug and Alcohol 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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704.9(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 personnel records, supervisor notes and clinical charts, the facility failed to provide supervision of counselor assistants in accordance with the regulatory requirements in two of two counselor assistant records reviewed.
Four personnel records were reviewed on March 1, 2017, two of which were for counselor assistants. One counselor assistant, #3 had a high school diploma and the other with a qualifying bachelor's degree #4, lacking experience.
Employee #3 was hired on March 24, 2016 and would have required direct observation from March 24, 2016 through June 24, 2016, followed by close supervision June 25, 2016 through March 24, 2017. There was no documented direct observation in the personnel record nor was the facility able to provide any in the form of co-signed progress notes in clinical records. Additionally, the facility switched from weekly to monthly supervision notes on June 3, 2016.
Employee #4 was hired on January 3, 2017 and required close supervision from January 3, 2017 through July 3, 2017. Close supervision requires documentation of a minimum of one session per week of direct observation. There was no documented direct observation in the personnel record nor was the facility able to provide any in the form of co-signed progress notes in clinical records. Additionally, the facility switched from weekly to monthly supervision notes on February 3, 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning on March 6, 2017 the clinical supervisor has returned to completing weekly supervision reports on both of the counselor assistants. As of March 6, 2017 weekly meeting will be held with each of the counselor assistants to determine their needs and their progress towards becoming a counselor. In addition groups that are facilitated by the counselor assistants will continue to be observed, but the notes for these groups will also be signed by the clinical supervisor. This will continue with the two current counselor assistants until they meet the requirements of a counselor. All future counselor assistants will also be supervised in the same way. |
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
Ten client records were reviewed on March 1, 2017. The facility failed to obtain a consent to release information form for information released to a funding source in two of ten client records reviewed, specifically client records #8 and #10.
Client #8 was admitted on September 30, 2016 and discharged on December 20, 2016. The client record contained documentation indicating that the facility released patient identifying information to a funding source on November 17, 2016 and failed to obtain an informed and voluntary consent prior to the disclosure.
Client #10 was admitted into treatment on October 25, 2016 and discharged on February 28, 2017. The client record did not contain an informed and voluntary consent for the client's funding source, whom the clinical supervisor confirmed that they were billing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 4, 2017 a training was conducted with all staff to go over all clinical documentation, including releases. The proper way to complete a release was thoroughly reviewed. Staff was also made aware during this training that if there is every a question regarding the proper funding source, releases should be completed for all possible funding sources.
In addition to the training, as evaluations are completed they will be reviewed by the clinical supervisor to assure all documentation is completed properly, if any information is missing it will then be reviewed with the client during their first individual session which occurs before billing is completed. |
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
Ten client records were reviewed for client rights on March 1, 2017. The facility failed to include on the facility's Client Rights form the following verbiage: age, sex, national origin and marital status.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 2, 2017 the client's rights form was updated to include the exact verbiage: age, sex, national origin and marital status. The old form was removed from all new blank charts and replaced with the updated form. In addition all current clients will sign the new form at their next scheduled individual session. |
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
Ten client records were reviewed on March 1, 2017 for treatment and rehabilitation services.
Client #6 was admitted on April 30, 2016 and discharged on October 30, 2016. The comprehensive treatment plan was completed on April 30, 2016, and an update was due on June 30, 2016 but was not completed.
Client #8 was admitted on September 30, 2016 and discharged on December 20, 2016. The comprehensive treatment plan was completed on September 30, 2016, and an update was due on November 30, 2016 but was not completed.
Client #10 was admitted on October 25, 2016 and discharged on February 28, 2017. The comprehensive treatment plan was completed on October 25, 2016, and an update was due on December 25, 2016 but was not completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 4, 2017 a staff training was done to review all clinical documentation. During this training the timing and importance of treatment planning was reviewed. The staff were instructed on how the treatment plans are completed and the impact they have on a client's recovery so that goals are set in specific time frames. Going forward the client's who have treatment plan updates needed will be reviewed at clinical meetings before their due dates to allow enough time to have them completed. The clinical supervisor will make notation of these dates on the clinical census. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record in ten of ten records reviewed.
Ten client records were reviewed on March 1, 2017 six of which required documentation of follow up information and case consultations. Additionally, ten of the records required documentation of a record of service and progress notes.
Client #1 was admitted on October 13, 2016 and was still an active client at the time of the inspection. There was no record of service contained in the record.
Client #2 was admitted on October 17, 2016 and was still an active client at the time of the inspection. There was no record of service contained in the record.
Client #3 was admitted on October 27, 2016 and was still an active client at the time of the inspection. There was no record of service contained in the record.
Client #4 was admitted on July 12, 2016 and was still an active client at the time of the inspection. There was no record of service contained in the record.
Client #5 was admitted on June 29, 2016 and discharged on October 20, 2016. There was no record of service, case consult or follow up log contained in the record. Additionally, there were no progress notes for the months of July and August.
Client #6 was admitted on April 30, 2016 and discharged on October 30, 2016. There was no record of service, case consult or follow up log contained in the record.
Client #7 was admitted on July 23, 2016 and discharged on February 7, 2017. There was no record of service or case consult contained in the record. Additionally, there were no progress notes for the months of December or January.
Client #8 was admitted on September 30, 2016 and discharged on December 20, 2016. There was no record of service, case consult or follow up log contained in the record.
Client #9 was admitted on January 3, 2017 and discharged on January 30, 2017. There was no case consult contained in the record.
Client #10 was admitted on October 25, 2016 and discharged on February 28, 2017. There was no record of service contained in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 3, 2017 two new documents were added to blank client charts. A record of service form and a note form, the record of service form will document all sessions attended by each client and the note form will be to document any events not tracked elsewhere, such as but not limited to time missed from treatment to account for time frames with no notes.
On March 4, 2017 a staff training was conducted on all clinical documentation and charting was reviewed. The two new forms were discussed and the staff was trained on how they should be completed.
Beginning on March 6, 2017 all active client charts had record of service forms added to them and will be completed by March 31, 2017 or sooner if time allows. These charts will be reviewed by the clinical supervisor by April 7, 2017 to assure this has been completed.
All future charts will be reviewed by the clinical supervisor periodically for completeness and will then be checked again upon discharge to assure all clinical documentation is complete. |