INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 23, 2022 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 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 nine personnel records, the facility failed to maintain documentation that counselor assistants received direct observation of the provision of counseling services as part of their close supervision, in two of two applicable records.Employee # 8 was hired as a high school level counselor assistant by the facility on July 1, 2021 and has remained in that position. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision. Employee # 6 was hired by the facility on August 17, 2020 and promoted to the position of counselor assistant on December 17, 2021. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
on 3/9/2022, Clinical Supervisor reviewed the supervision notes and specifically documented the type of direct supervision that was conducted for staff #8 and staff # 6
To ensure that this does not reoccur in the future, clinical supervisor will randomly audit staff files to ensure that the supervision notes remain in compliance and include both direct and indirect supervision documentation. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of ten personnel records, the facility failed to provide documentation that counselor assistants documented to the facility director that they are working toward counselor status upon completion of each calendar year in two of two applicable records. Employee # 6 was hired by the facility on November 5, 2018 and promoted to the position of counselor assistant on November 14, 2019.Employee # 7 was hired by the facility on February 11, 2019 and promoted to the position of counselor assistant on December 13, 2019.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The documentation of the counselor assistants working toward the position of the counselor was included in the supervision notes. In order to comply with the DDAP standards, employee #6 and 7 will write a formal letter to the facility director each calendar year that states that they are working toward counselor status. This letter will be signed off by both the staff and the director by 3/30/2022.
To ensure that this does not reoccur in the future, clinical supervisor will audit the files of the counselor assistants in February of each calendar year to ensure that the letter is updated in the staff files. |
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
Based on a review of nine personnel records, the facility failed to ensure that staff received at least four hours of TB/STD training and six hours of HIV/AIDS training within the regulatory time frame in one applicable record.Employee # 3 was hired by the facility as a counselor on March 3, 2020 and has remained in that position. The employee was due to have the TB/STD and HIV/AIDS training no later than March 3, 2021 and the Plan of Correction from a previous citation indicated they would be completed by June 30, 2021. However, the trainings were not completed until January 24, 2022 and February 18, 2022, respectively. This is a repeat citation from the March 18, 2021 licensure renewal inspection. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee # 3 has taken the required trainings on 1/24/22 and on 2/18/22. Employee #3 was late taking the training due to scheduling conflicts and training availability.
To ensure that this does not reoccur in the future, clinical supervisor will review training needs in monthly supervision sessions with all counselors to ensure that counselors receive the required trainings in the designated time frame to comply with DDAP regulations. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1. Employee #11 was hired as a counselor on June 22, 2020 and was still acting in that position. Employee #11 was reported to have 15 hours per week devoted to their 15 clients on their caseload.The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.The FTE counselor ' s caseload calculation is as follows: 15/40 = 0.375(FTE); 15/0.375 = 40, which equals to a client/counselor ratio of 40:1.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee # 11 was a full time employee until 1/17/2022 when her hours were reduced to part time. The facility was working toward providing a smooth transition of her clients to other staff members. Employee #11 will reduce her caseload to 12 clients by 3/30/2022 which will then provide the client/counselor ratio to 32
The caseload calculation will be as follows: 15/40 = 0.375(FTE); 12/0.375 = 32, which equals to a client/counselor ratio of 32:1. This will keep employee #11 below the regulation limit of 35/1.
To ensure that this does not occur in the future, clinical supervisor will review caseload ratios in monthly supervision sessions to ensure the employees remain in compliance. |
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on a physical plant inspection on February 23, 2022, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as two trash receptacles outside of the lower level entrance were uncovered.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The uncovered garbage containers that were seen outside of the facility were not owned by the facility but were owned by another department in the same building.
On 3/1/2022, facility director spoke with the other facility and asked that they no longer store their garbage containers outside uncovered.
To ensure that this does not reoccur in the future, facility director will monitor the outside property daily to ensure that the garbage containers are either covered or removed. |
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
Based on a review of ten personnel files, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one record reviewed.Employee #8 was hired as a counselor assistant on July 1, 2021 and was due to be trained in the use of fire extinguishers by July 8, 2021; however, fire safety training was not documented as complete until August 26, 2021.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During a file audit, it was noticed by the clinical supervisor that employee #8 did not have it documented that he was instructed in the use of fire extinguishers during his week of hire. On August 26th, 2021 clinical supervisor conducted the training and documented it in the employee file.
To ensure that this does not occur in the future, clinical supervisor will review files for new hires within the first week of their employment to ensure that documentation of the fire extinguisher training is included in the file. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from April 2021 through December 2021, the facility failed to prepare alternate exit routes as the same exit route was documented in each drill.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
on 3/10/2022, A fire drill was conducted with 6 participants using an alternative exit strategy.
To ensure that this does not reoccur in the future, a staff training was held on 3/9/2022 which informed the staff of the need to utilize an alternative exit strategy several times per year. Clinical Supervisor will audit the fire drill form quarterly to ensure alternative routes are being used throughout the year. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
The facility failed to document that the annual report for 2021 was made available to the public.This is a repeat citation from the March 18, 2021 licensure renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical director will add the following information to the TPALs website by 4/10/2022. An annual report which includes but is not limited to, a statement disclosing the names of officers, directors, and principle shareholders.
To ensure this does not occur in the future, the clinical director and facility director will meet annually to ensure that the information is listed on the website. If it is not listed on the website for any technical reasons, the facility director will create an add in the paper to make the information available to the public. |
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
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 that included reference to the drug and alcohol treatment activities for both 2020 and 2021. The Plan of Correction from the previous licensing inspection indicated that the 2020 financial audit would be completed by May 30, 2021.This is a repeat citation from the March 18, 2021 licensure renewal inspection. The findings were discussed with project staff during the licensing process.
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Plan of Correction
The project CFO has requested an exception from the annual audit which was accepted by DDAP and granted on 2/14/2022. Project CFO has tax forms available on site to be reviewed when next inspection takes place.
To ensure that this does not reoccur, project CFO and clinical director will meet semi-annually to ensure that the proper documents are available to comply with the exception. The semi annual meeting will take place on 6/15/2022. |
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 nine client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information prior to disclosing information in one record reviewed. Client #1 was admitted to the Outpatient Activity on August 2, 2021 and discharged on December 14, 2021. The record contained documentation of contact with a treatment provider on September 30, 2021, to whom the informed and voluntary consent to release information form was not signed by the client until October 4, 2021.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/16/2022, clinical supervisor will conduct a staff meeting to discuss releases and consent forms. Counselors will be re-trained on releases specifically that they cannot speak with any other provider without already having a signed consent in the EHR.
To ensure that this does not reoccur, the clinical supervisor will randomly audit files to monitor releases. Any new hires will be trained on obtaining releases within their first week of employment. New hires will also attend a DDAP confidentiality training within their first year of employment. |
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 a review of nine client records, the facility failed to ensure that consent to release information forms included the purpose of disclosure in eight records reviewed.Client #1 was admitted to the outpatient activity on August 2, 2021 and was discharged December 14, 2021. The record contained a consent to release information form to a family member signed by the client on August 2, 2021, that was missing the purpose of disclosure.Client #2 was admitted to the outpatient activity on March 22, 2021 and was discharged on April 27, 2021. The record contained consent to release information forms to treatment providers signed by the client on March 31, 2021, April 1, 2021, and April 16, 2021, that were missing the purpose of disclosure. Client #3 was admitted to the outpatient activity on June 25, 2021 and was discharged on December 25, 2021. The record contained a consent to release information form to a treatment provider signed by the client on June 25, 2021, that was missing the purpose of disclosure. Client #5 was admitted to the outpatient activity on August 3, 2021 and was active at the time of the inspection. The record contained a consent to release information form to a probation officer signed by the client on August 3, 2021, that was missing the purpose of disclosure. Client #6 was admitted to the outpatient activity on June 3, 2021 and was active at the time of the inspection. The record contained a consent to release information form to a treatment provider signed by the client on June 3, 2021, that was missing the purpose of disclosure. Client #7 was admitted to the partial activity on December 20, 2021 and was active at the time of the inspection. The record contained a consent to release information form to a court signed by the client on December 23, 2021, that was missing the purpose of disclosure. Client #8 was admitted to the partial activity on January 14, 2022 and was active at the time of the inspection. The record contained consent to release information forms to a probation officer and treatment provider signed by the client on January 20, 2022, that were missing the purpose of disclosure. Client #9 was admitted to the partial activity on December 20, 2021 and was active at the time of the inspection. The record contained two consent to release information forms to treatment providers signed by the client on December 20, 2021 and December 21, 2021 that were missing the purpose of disclosure. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The release form has been updated on 3/9/2022 to include the following statement. "The purpose of this release is for continuity of care" The release form then proceeds to inform the client that the release allows the agency to inform the listed individual or agency of the client's diagnosis, attendance information, cooperation with treatment recommendations, prognosis, and relapse.
Counselors will replace current release forms with the new forms by having their clients sign the updated forms for all current releases by 5/14/2022. The newly signed updated forms will be uploaded to the EHR record.
To ensure that this does not reoccur, the release form has been updated on the EHR record so that every release in the future will list the purpose for the disclosure. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure that clients received individual counseling twice a week in two of three records reviewed.Client # 7 was admitted on December 20, 2021 and was active at the time of the inspection. For the week of January 24-28, 2022, there were no documented individual sessions. During the week of February 7-11, 2022, there was only one documented individual session. Client #8 was admitted on January 14, 2022 and was active at the time of the inspection. For each week between January 24, 2022 and February 19, 2022, there was only one documented individual session. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
on 3/9/2022, a meeting was held with the staff to discuss that PHP clients will be seen by a counselor for an individual session 2x per week. The staff was informed at this meeting that an individual with a CRS does not count for the second individual session. Counselors will clearly document the contents of the sessions.
To ensure that this does not reoccur, clinical supervisor will review PHP client's treatment attendance on a weekly basis to ensure that they are receiving individual sessions with their counselor 2x per week. |