Observations
Based on a review of the facility's fire drill log from January 2020 through September 2021, the facility failed to keep a complete fire drill record to include the number of persons in the facility at the time of the drill and problems encountered during the drill from January 2020 through September 2021.These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
705.28(d)(4)
FIRE SAFETY
1. An immediate plan of action took place on Friday, October 8, 2021 updating the Fire Safety drill log for future drills to include the number of persons in the facility at the time of the drill, testing of the operative smoke detector and space to document any problems that were encountered. The updated Fire Safety drill log encompasses the following: Date, time of drill, the amount of time it took to evacuate, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and testing of the smoke detector to ensure it's operative.
2. The Project Facility Director will be responsible for achieving and maintaining compliance standards on a monthly basis.
3. The Turning Point II, Inc. has completed to Plan of Correction on October 8, 2021.
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Observations
Based on the review of client records on October 7 & 8, 2021, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in six out of seven client records reviewed.Client #1 was admitted on May 13, 2021 and was an active client at the time of the inspection. A consent to release information was signed by a witness dated May 13, 2021 for the funding source, however the client did not sign the informed and voluntary consent. The facility confirmed that the funding source was billed for services. Client #2 was admitted on July 19, 2021 and was an active client at the time of the inspection. A consent to release information was signed by a witness dated July 19, 2021 for the funding source, however the client did not sign the informed and voluntary consent. The facility confirmed that the funding source was billed for services. Client #3 was admitted on August 18, 2021 and was an active client at the time of the inspection. A consent to release information was signed by a witness dated August 18, 2021 for the funding source, however the client did not sign the informed and voluntary consent. The facility confirmed that the funding source was billed for services. Client # 4 was admitted on July 29, 2021 and was an active client at the time of the inspection. A consent to release information was signed by a witness dated July 29, 2021 for the funding source, however the client did not sign the informed and voluntary consent. The facility confirmed that the funding source was billed for services. A consent to release information was signed by a witness dated September 9. 2021 for a drug and alcohol provider and a telephone call was made to that provider on September 9, 2021.Client #6 was admitted on August 25, 2020 and was discharged on September 15, 2021. A consent to release information was signed by a witness dated August 25, 2021 for the funding source, however the client did not sign the informed and voluntary consent. The facility confirmed that the funding source was billed for services. Client #7 was admitted on January 14, 2021 and was discharged on June 8, 2021. A consent to release information was signed by a witness dated January 14, 2021 for the funding source, however the client did not sign the informed and voluntary consent. The facility confirmed that the funding source was billed for services. These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
709.28 (c) (4)
CONFIDENTIALITY
1. An immediate plan of action took place on Friday, October 8, 2021 contacting Client #1, Client #2, Client #3, Client #4, Client #6, and Client #7 via telephone regarding the need to secure a physical signature for the informed and voluntary consent to release of information for their funding source and any future source identified while the client is active with The Turning Point II, Inc. Each client was provided the option of in-person office to provide the physical written signature or confidentially mail the consent to release of information via USPS to their confirmed address that will include a self-addressed postage envelope to return confidentially to The Turning Point II, Inc.
2. The Project Facility Director will be responsible for achieving and maintaining compliance standards for each client identified in the above paragraph by securing dates and times to come in-person as well as following up with each client who chooses to receive the consent of release via USPS to confirm they received the documents, signed and have returned the documents to The Turning Point II, Inc.
3. The Turning Point II, Inc. will achieve full compliance by October 31, 2021
4. For future clients, The Turning Point II, Inc. will request all new clients to conduct the initial intake admissions session in-person to secure physical written signatures for the consent to release of information to any identified source. After the initial session and all signatures secured, the client will have the option to either continue the therapeutic process in-person or via telehealth. However, if a new client requests the initial intake admission session via telehealth, the client will be informed regarding compliance of a physical signature necessary for the consent to release of information with the option of coming into the office for an in-person review of information and physical signature or will confidentially mail via USPS with self-addressed postage envelope that must be returned to The Turning Point II, Inc. The client will have the understanding that the physical signatures are necessary for not only the funding stream authorization but any external supportive system that requires communication for coordination of treatment.
Client #1 who was admitted on May 13, 2021 was contacted via telephone to secure a date and time regarding the need to secure a physical signature for the informed and voluntary consent to release of information for their funding source and any future source identified while the client is active with The Turning Point II, Inc. Client #1 was provided the option of in-person office to provide the physical written signature or confidentially mail the consent to release of information via USPS to their confirmed address that will include a self-addressed postage envelope to return confidentially to The Turning Point II, Inc. Client #1 chose via USPS.
Client #2 who was admitted on July 19, 2021 was contacted via telephone to secure a date and time regarding the need to secure a physical signature for the informed and voluntary consent to release of information for their funding source and any future source identified while the client is active with The Turning Point II, Inc. Client #2 was provided the option of in-person office to provide the physical written signature or confidentially mail the consent to release of information via USPS to their confirmed address that will include a self-addressed postage envelope to return confidentially to The Turning Point II, Inc. Client #2 chose via USPS.
Client #3 who was admitted on Aug 18, 2021 was contacted via telephone to secure a date and time regarding the need to secure a physical signature for the informed and voluntary consent to release of information for their funding source and any future source identified while the client is active with The Turning Point II, Inc. Client #3 was provided the option of in-person office to provide the physical written signature or confidentially mail the consent to release of information via USPS to their confirmed address that will include a self-addressed postage envelope to return confidentially to The Turning Point II, Inc. Client #3 chose via USPS.
Client #4 who was admitted on July 29, 2021 was contacted via telephone to secure a date and time regarding the need to secure a physical signature for the informed and voluntary consent to release of information for their funding source, drug and alcohol coordinator of treatment and any future source identified while the client is active with The Turning Point II, Inc. Client #4 was provided the option of in-person office to provide the physical written signature or confidentially mail the consent to release of information via USPS to their confirmed address that will include a self-addressed postage envelope to return confidentially to The Turning Point II, Inc. Client #4 chose to come in-person Monday October 18, 2021.
Client #6 who was admitted on Aug 25, 2021 was contacted via telephone to secure a date and time regarding the need to secure a physical signature for the informed and voluntary consent to release of information for their funding source and any future source identified while the client is active with The Turning Point II, Inc. Client #6 was provided the option of in-person office to provide the physical written signature or confidentially mail the consent to release of information via USPS to their confirmed address that will include a self-addressed postage envelope to return confidentially to The Turning Point II, Inc. Client #6 chose via USPS.
Client #7 who was admitted on January 14, 2021 was contacted via telephone to secure a date and time regarding the need to secure a physical signature for the informed and voluntary consent to release of information for their funding source and any future source identified while the client is active with The Turning Point II, Inc. Client #7 was provided the option of in-person office to provide the physical written signature or confidentially mail the consent to release of information via USPS to their confirmed address that will include a self-addressed postage envelope to return confidentially to The Turning Point II, Inc. Client #7 chose via USPS.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to develop a written plan providing for intake and admission which includes requirements for completion of treatment. These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
709.91 (a) (3)
INTAKE AND ADMISSION
1. An immediate course of action took place Friday October 8, 2021 to complete the policy addressing requirements for completion of treatment.
Policy 709.91 (a) (3)
During the intake and admission session, the client will identify treatment goals and objectives to accomplish through the therapeutic process in effort to achieve successful completion of treatment. The goals and objectives identified will be personal and unique to each individual client.
During the therapeutic process, the counselor and client will randomly review the initial goals and objectives to acknowledge progress or any areas to address and improve.
As the client progresses toward achieving their goals and objectives toward a successful completion of treatment, the counselor will discuss the termination process and aftercare plan of action to ensure recovery success for the client.
2. The Project Facility Director will be responsible for achieving and maintaining compliance standards through their client case as well as having monthly meetings with the counseling staff to discuss individual client progress and areas to address in effort for the client to improve to achieve their goals and objectives for completion of treatment.
3. For current active clients, in the next scheduled session, the counselor will discuss with each individual goals and objectives in effort to achieve completion of treatment. For future clients, goals and objectives will be identified during the initial session regarding completion of treatment.
4. The Turning Point II, Inc. has written the policy for requirements for completion of treatment and secured within the policy and procedure handbook.
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