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 February 4-5, 2020. Based on the findings of the on-site inspection, Tpals Turning Point Alternative Living Solutions 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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704.9(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
During a review of staff records on February 4-5, 2020, the facility failed to provide adequate supervision to a counselor assistant with a high school diploma. A counselor assistant with a high school diploma 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.
Staff #6 was hired as a counselor assistant on February 15, 2019. Staff #6 only had documentation of weekly supervision for the first two months with no direct observation, then monthly supervision for the next ten months.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/10/20. A plan has been put in to place regarding 704.9.
Clinical Supervisor will appropriately document all scheduled supervision sessions.
A supervision plan to meet 704.9 will be developed for each new hire and placed in their file within the first week of employment.
Staff #6 will return to weekly supervision until September 30th 2020 to ensure appropriate supervision documentation is in place.
Project Director will review staff files quarterly throughout the year to ensure that appropriate documentation is in place.
Additionally, group supervision takes place every Wednesday at 12pm which will be appropriately documented and supervised by project director.
Project Director will review staff files quarterly throughout the year to ensure that this deficiency does not recur.
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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 staff records on February 4-5, 2020, the facility failed to have staff persons and volunteers 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.
Staff #5 was hired as a counselor assistant on November 5, 2018. Staff #5 had no documentation of TB/STD training as of the date of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/12/2020, Clinical Supervisor has contracted with a DDAP approved trainer to schedule both HIV and TB/STD training for all staff members who have have not yet received the training.
The HIV training has been scheduled for Monday April 13, 2020
The TB/STD training has been scheduled for Tuesday April 14th 2020.
Clinical Supervisor will utilize this contracted trainer for all future staff who have difficulty scheduling a DDAP training due to limited availability. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
During a review of staff records on February 4-5, 2020, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
Staff #3 was hired on November 18, 2019 as a counselor. Staff #3 had a fire extinguisher training certificate, however there was no documented date when this training was completed.
Staff #6 was hired on February 15, 2019 as a counselor assistant. There was no documentation that Staff #6 had received fire extinguisher training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff members all receive fire extinguisher training within the first week of employment to comply with regulations.
Clinical Supervisor will appropriately document the fire extinguisher training for all staff within the first week that they are hired. Clinical Supervisor will document the date that the staff received the training.
Beginning on 2/10/2020, Project Director will review staff files on a quarterly basis to oversee Clinical Supervisor's documentation and ensure the dates have been documented appropriately throughout the year. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
During a review of staff records on February 4-5, 2020, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
Staff #6 was hired on February 15, 2019 as a counselor assistant. Staff #6 had no documentation that they were trained to perform assigned tasks during emergencies.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All personnel are trained to perform assigned tasks during emergencies to comply with 705.28 during the first week of their employment.
Beginning on 2/10/20, Clinical Supervisor will appropriately document the assigned tasks during emergencies for all staff members.
Beginning on 2/10/2020, Project Director will review staff files throughout the year on a quarterly basis to oversee Clinical Supervisor's documentation ensuring that this error does not recur.
On 3/1/20, A staff needs checklist will be developed to include assigned tasks during emergencies. The checklist will be placed in staff files and will be initialed by Clinical Supervisor upon date of completion. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
During an inspection and review of records on February 4-5, 2020, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 2/11/20. The Project Director has reviewed and signed the updated policy and procedure manual which delineates project policies and procedures to comply with 709.23.
CEO will oversee the project policy and procedure manual to ensure these regulations remain in place for the future if any changes are made. |
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
During an inspection and review of records on February 4-5, 2020, 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 which include reference to the drug and alcohol treatment activities.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
CEO has submitted to file an exception from the annual audit of activities associated with the project's drug and alcohol abuse services. The facility is waiting on the results of the exemption.
Additionally, CEO has placed phone calls to several independent certified public accountants during the month of February 2020 and is waiting to contract with an accountant for the future.
Project director will quarterly review the status with CEO and ensure that this deficiency will not recur the future. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
During an inspection and review of records on February 5, 2020, the unusual incidents policies and procedures failed to include implementation of a timely and appropriate corrective action plan, when indicated.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
On 2/10/2020, the policy and procedure for the unusual incidents documentation has been modified to include the following:
DOCUMENTATION REQUIREMENTS
1. All staff members are required to report any of the above incidents, immediately upon becoming aware of them, to their immediate supervisor.
2. The department supervisor will complete an investigation, to determine any known causes and supporting testimony (which may be collected in writing from other parties) and will prepare the DDAP required form (HD1062F), within 12 hours of being notified, and forward to the CEO for review and submission to DDAP within 72 hours, as required by regulation.
3. The CEO will identify any causal or contributing factors related to policy or procedures at TPALS and will develop an appropriate corrective action plan.
4. Upon completing the investigation, the CEO or designee will proscribe the corrective plan requirements including time-frame and personnel responsible for completion.
5. The CEO will monitor the corrective action plan on a quarterly basis to ensure the plan remains in place.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
During an inspection and review of records on February 5, 2020, the unusual incidents policies and procedures failed to include ongoing monitoring of the corrective action plan.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 2/10/20 The following addition has been added to the unusual incident policy and procedure statement with the exact verbiage:
"#5.The CEO will monitor the corrective action plan on a quarterly basis to ensure the plan remains in place." |