INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25 - 26, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Turning Point II 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 and a plan of correction is due on November 27, 2007.
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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 reviews of personnel records, employee #5 did not receive documented supervision for a counselor assistant. Employee # 5 had documented clinical actions in a client chart on 8/11/07, demonstrating that the employee was engaged in clinical activity. The facility had designated this employee as an intern, but they failed to treat this person as a counselor assistant.
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Plan of Correction
The facility designated a part-time employee with appropriate credentials as an intern for completion of Master's degree requirements. This employee performed some supervised duties relative to a Counselor Assistant position without proper documentation of that supervision. Procedures have been put in place that require all future bona fide interns be classified as Counselor Assistants and be supervised and that such supervision be properly documented. Project/Facility Director will insure that this guideline is followed. |
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 personnel records reviewed, the facility failed to obtain STD/TB training for all employees. Employee # 1 has not received STD/TB training.
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Plan of Correction
Based on personnel records reviewed, the facility failed to obtain STD/TB training for all employees. Personnel identified did not receive the required training due to schedule conflicts and/or extraordinary travel requirements when certified sessions were scheduled. The personnel identified shall complete the mandated training sessions, based on current regional availability, by March 30, 2008. Mandated training will be scheduled for deficient employees by the Project/Facility Director. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on review of the client records it was determined that the facility failed to document consistently informed and voluntary consents to release information forms. In client record # 2, two forms had other checked off for information to be shared, but failed to document what the information was. In client record # 3, a consent to release form failed to include a purpose that was consistent with the release. On a social security release of information form, the purpose for the release was not clearly defined.
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Plan of Correction
Information categories designating "other" were mistakenly checked due to human error on some Consent to Release forms. All current client Consent to Release records have been reviewed and/or corrected as of 11/15/07. Project/Facility Director will conduct staff training and continuously monitor client records to determine that the facility maintains client information forms in a consistent, complete and correct manner. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on review of client records it was determined that the facility failed to document the drug and alcohol history. Drug and alcohol histories in client records failed to include a progression of the clients substance use/abuse, as it relates to the client's lengths and patterns of substance use, in four out of four client records, # 1, 2, 3, and 4.
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Plan of Correction
Client "drug and alcohol histories" failed to include an adequately in-depth progression of the clients' substance use/abuse patterns. Project/Facility Director will conduct staff training and monitor future client drug and alcohol histories to determine that the facility maintains expanded information in an acceptable manner. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on review of client records it was determined that the facility failed to document the complete personal histories. Personal histories were documented between two forms, which failed to include the complete histories. In client record # 1, the family, legal,educational and employment history were not complete. In client record # 2 the family, employment, educational and recreational histories were not completed. In client record # 3 the family, employment, educational, and sexual histories were not complete. In client record # 4 the family, employment, educational, recreational, and sexual histories were not complete.
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Plan of Correction
Personal history records were documented between two forms which, when reviewed individually, failed to include a complete history. Project/Facility director will amalgamate the current forms to form one comprehensive document. Project/Facility Director will conduct staff training to insure familiarity and compliance with the combined form by 12/30/07. |
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
Based on review of the client records it was determined that the facility failed to review the client's progress on treatment plan updates. Treatment plan updates failed to include an assessment of progress in relationship to the previously stated comprehensive treatment plan goals and objectives stated in three out of three client records reviewed, # 1, 2, and 3.
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Plan of Correction
Client progress in relation to stated goals and objectives was not adequately reviewed and updated for all clients on treatment plan updates. A structured documentation procedure for recording and dating, client progress in relation to prior goals/objectives has been instituted. Staff training will conducted by 12/30/07 to ensure continued compliance; compliance will be overseen by the Project/Facility Director. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
The facility failed to meet the requirement for this regulation as noted on the staffing form completed by the Project Director. The form reflected a client census of 38 for outpatient counseling. The maximum capacity authorized by the Department for this activity is 35.
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Plan of Correction
The recorded caseload of 38 clients occurred as a variance for a two (2) week period just prior to the Survey Visit. Several new clients were added to the caseload in anticipation of pending discharges, thus creating a temporarily elevated caseload above the 35 client authorized capacity. Project/Facility Director will request a new Department authorized caseload of 42 by 1/30/08 in order to prevent future occurrence of this situation. |