INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, 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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704.11(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 the review of personnel records, the project failed to ensure that employee #7 received a minimum of six hours of HIV/AIDS and at least four hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum within the first year of employment.Employee #7 was hired as a counselor on March 3, 2020 and was due to have the communicable disease trainings no later than March 3, 2021; however, there was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.The findings were discussed with project staff during the licensing process.
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Plan of Correction
Employee # 7 will complete a DDAP approved HIV and STD training by 6/30/2021. Employee # 7 will register for the next available training. If there is no training by 6/30/2021. TPALS will contact a contracted trainer to train employee #7 on site by 6/30/2021
To ensure this does not reoccur in the future, clinical supervisor will review trainings needs in monthly supervision sessions with all counselors to ensure the counselors receive required trainings in the designated time frame to comply with DDAP regulations. |
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 governing body failed to 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.The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project CEO will add the following information to the TPALS website by 4/30/2021 which will be readily 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.
To ensure that this deficiency does not reoccur, the project CEO and clinical supervisor will meet annually to review the website to ensure that the information regarding the officers, directors, and principal shareholders is accurate. |
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. The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project CEO will contract with CPA to conduct 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. This will be completed by 5/30/2021.
In order to ensure this does not reoccur in the future, CEO and clinical supervisor will schedule an annual financial meeting to discuss CPA contract and ensure that the audit has been completed each year. |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.Client #3 was admitted on November 17, 2020 and was an active client at the time of the inspection. It was documented in the records that there was communication between the client ' s paramour and facility staff on December 15, 2020; however, there was not valid release of information form signed by the client prior to the disclosure. The findings were discussed with project staff during the licensing process.
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Plan of Correction
On 5/18/2021, a staff training has been scheduled to address the fundamentals of client confidentiality. Clinical Supervisor will address the client release protocols to all staff. The training will include informing the staff that ALL releases must have a client signature that is signed and dated on the date the release is obtained. That signature may be either hand written or electronic.
The release that was obtained from client #3 to speak with the paramour was not signed and dated due to client receiving telehealth services. The staff has obtained a new release from the client with an electronic signature and date.
To ensure this does not reoccur, all existing staff will be properly trained on how to document releases. Additionally, any new hires will attend a training on documenting releases within their first week of employment. This training will be conducted by the on site clinical supervisor.
Further, Clinical Supervisor will randomly audit files to ensure that the releases are being filled out correctly by all staff. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of seven client records reviewed.Client #1 was admitted on May 1, 2020 and was discharged on June 29, 2020. A release of information form to the client ' s employer, signed and dated by a witness on May 14, 2020, allowed for the release of diagnosis, information about attendance or lack thereof at treatment sessions, cooperation with treatment program and prognosis, all of which exceeds the limits established by 4 Pa. Code 255.5.The findings were discussed with project staff during the licensing process.
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Plan of Correction
On 5/18/2021, a staff training has been scheduled to address the fundamentals of client confidentiality. Clinical Supervisor will review the appropriate disclosures as stated by Pa. Code 255.5. to all clinical staff. Clinical staff will all be provided a copy of Pa code 255.5 to keep in their offices for quick reference.
To ensure this does not reoccur, all existing staff will be properly trained on disclosure and given the desk reference. Clinical Supervisor will give a brief training to new hires during their first week of employment and provide them with a the desk reference of PA code 255.5. Further, any new hires will attend a DDAP approved confidentiality training within their first year of employment.
Lastly, Clinical Supervisor will randomly audit files to ensure that the releases are being filled out correctly by all staff. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated client signature in three of seven client records reviewed.Client #1 was admitted on May 1, 2020 and was discharged on June 29, 2020. Four release of information forms, one to the funding source, one to a family member, one to an employer and one to a recovery home, were signed and dated by a witness; however, they did not have a dated client signature.Client #2 was admitted on May 18, 2020 and was discharged on January 20, 2021. Three release of information forms, one to the emergency contact, one to the funding source and one to another treatment facility, were signed and dated by a witness; however, they did not have a dated client signature.Client #4 was admitted on July 30, 2020 and was an active client at the time of the inspection. Two release of information forms, one to the funding source and the other to an emergency contact, were signed and dated by a witness; however, they did not have a dated client signature.The findings were discussed with project staff during the licensing process.
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Plan of Correction
Due to COVID and telehealth, TPALS staff signed releases for the clients "COVID 19 exempt". After reviewing the DDAP regulations for telehealth releases, A staff training was held on 3/24/2021 by clinical supervisor informing the staff to ensure that telehealth client's electronically sign their names on release forms on the date that the release is obtained.
Client # 2 and Client # 4 have been contacted by their primary counselor and new releases have been obtained with an electronic signature and date.
Further, to ensure this does not reoccur in the future, clinical supervisor will randomly audit files to ensure releases are being obtained correctly with client signatures and dates. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records, the project failed to offer a copy of client consents to the client in seven of seven client records reviewed. Client #1 was admitted on May 1, 2020 and was discharged on June 29, 2020. There was no indication that the client was offered a copy of the four release of information forms documented in the client record.Client #2 was admitted on May 18, 2020 and was discharged on January 20, 2021. There was no indication that the client was offered a copy of the three release of information forms documented in the client record.Client #3 was admitted on November 17, 2020 and was an active client at the time of the inspection. There was no indication that the client was offered a copy of the three release of information forms documented in the client record.Client #4 was admitted on July 30, 2020 and was an active client at the time of the inspection. There was no indication that the client was offered a copy of the two release of information forms documented in the client record.Client #5 was admitted on August 12, 2020 and was discharged on March 5, 2021. There was no indication that the client was offered a copy of the four release of information forms documented in the client record.Client #6 was admitted on August 24, 2020 and was an active client at the time of the inspection. There was no indication that the client was offered a copy of the three release of information forms documented in the client record.Client #7 was admitted on June 16, 2020 and was discharged on January 18, 2021. There was no indication that the client was offered a copy of the three release of information forms documented in the client record.The findings were discussed with project staff during the licensing process.
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Plan of Correction
On 5/18/2021, a staff training has been scheduled to address the fundamentals of client confidentiality to comply with 709.28. Clinical Supervisor will address the client release protocols to all staff.
On 4/8/2021, a tab has been added to the electronic release form to include an indication that client has been offered a copy of the release. The release will either state "refused" or "accepted" at the bottom of the form.
The active clients mentioned in the citation have been contacted and offered a copy of the release forms. All clients refused and it has been documented.
In order to prevent reoccurrence, clinical supervisor will review new intakes and also randomly audit files monthly to ensure proper documentation remains in place. |
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
Based on the review of client records, the project failed to obtain written acknowledgement that the project may not discriminate in the provision of services on the basis of creed, ethnicity and handicap in seven of seven client records reviewed.Client #1 was admitted on May 1, 2020 and was discharged on June 29, 2020. Client #2 was admitted on May 18, 2020 and was discharged on January 20, 2021. Client #3 was admitted on November 17, 2020 and was an active client at the time of the inspection. Client #4 was admitted on July 30, 2020 and was an active client at the time of the inspection. Client #5 was admitted on August 12, 2020 and was discharged on March 5, 2021. Client #6 was admitted on August 24, 2020 and was an active client at the time of the inspection. Client #7 was admitted on June 16, 2020 and was discharged on January 18, 2021. The findings were discussed with project staff during the licensing process.
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Plan of Correction
on 4/8/2021, The CEO has updated the client's rights form to comply with 709.30. It was added to the electronic health record system.
To address this issue with existing clients, all counselors will review the newly developed client's rights form with their active clients and have the client sign, date, and acknowledge that they have been offered a copy of the new form.
All new clients will be provided this form during their initial intake which will be performed by a counselor. The counselors will ensure that the client will sign, date, and acknowledge that they have been offered a copy of this form all during the intake process.
To prevent the issue from reoccurrence, Clinical Supervisor will review new intakes to ensure the new form is being utilized, additionally, clinical supervisor will randomly audit active clients throughout the year to ensure all proper forms are documented and saved in the EHR system. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on the review of client records, the project failed to obtain written acknowledgement that the clients were informed of the right to inspect their own records, that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental and that the reason for removing sections shall be documented in the record in seven of seven client records reviewed. Client #1 was admitted on May 1, 2020 and was discharged on June 29, 2020. Client #2 was admitted on May 18, 2020 and was discharged on January 20, 2021. Client #3 was admitted on November 17, 2020 and was an active client at the time of the inspection. Client #4 was admitted on July 30, 2020 and was an active client at the time of the inspection. Client #5 was admitted on August 12, 2020 and was discharged on March 5, 2021. Client #6 was admitted on August 24, 2020 and was an active client at the time of the inspection. Client #7 was admitted on June 16, 2020 and was discharged on January 18, 2021. The findings were discussed with project staff during the licensing process.
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Plan of Correction
on 4/8/2021, The CEO has updated the client's rights form to comply with 709.30. The updated form was added to the electronic health record system on 4/8/2021.
To address this issue with existing clients, all counselors will review the newly developed client's rights form with their active clients and have the client sign, date, and acknowledge that they have been offered a copy of the new form.
All new clients will be provided this form during their initial intake which will be performed by a counselor. The counselors will ensure that the client will sign, date, and acknowledge that they have been offered a copy of this form all during the intake process.
To prevent the issue from reoccurrence, Clinical Supervisor will review new intakes to ensure the new form is being utilized, additionally, clinical supervisor will randomly audit active clients throughout the year to ensure all proper forms are documented and saved in the EHR system. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on the review of client records, the project failed to obtain written acknowledgement that clients were informs that clients have the right to appeal a decision limiting access to their records in seven of seven client records reviewed. Client #1 was admitted on May 1, 2020 and was discharged on June 29, 2020. Client #2 was admitted on May 18, 2020 and was discharged on January 20, 2021. Client #3 was admitted on November 17, 2020 and was an active client at the time of the inspection. Client #4 was admitted on July 30, 2020 and was an active client at the time of the inspection. Client #5 was admitted on August 12, 2020 and was discharged on March 5, 2021. Client #6 was admitted on August 24, 2020 and was an active client at the time of the inspection. Client #7 was admitted on June 16, 2020 and was discharged on January 18, 2021. The findings were discussed with project staff during the licensing process.
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Plan of Correction
on 4/8/2021, The CEO has updated the client's rights form to comply with 709.30. The updated form was added to the electronic health record system on 4/8/2021.
To address this issue with existing clients, all counselors will review the newly developed client's rights form with their active clients and have the client sign, date, and acknowledge that they have been offered a copy of the new form.
All new clients will be provided this form during their initial intake which will be performed by a counselor. The counselors will ensure that the client will sign, date, and acknowledge that they have been offered a copy of this form all during the intake process.
To prevent the issue from reoccurrence, Clinical Supervisor will review new intakes to ensure the new form is being utilized, additionally, clinical supervisor will randomly audit active clients throughout the year to ensure all proper forms are documented and saved in the EHR system. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on the review of the unusual incident reports, the project failed to notify the Department within three business days of an unusual incident involving the death, or serious injury due to trauma, suicide, medication error or unusual circumstances.The project was notified on June 7, 2020 that one of their active clients was deceased; however, there is not documentation that this was reported the Department within the regulatory timeframe.The findings were discussed with project staff during the licensing process.
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Plan of Correction
On 4/14/2021, A staff meeting has been scheduled to review 709.34, reporting of unusual incidents. Clinical Supervisor will review with staff what constitutes as an unusual incident to include the death, or serious injury due to trauma, suicide, medication error or unusual circumstances of a client. Counselors will be informed at this meeting to report any unusual incident to the acting supervisor immediately. The clinical supervisor on site will report the unusual incident to DDAP within 1-3 days. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on the review of client records, the project failed to ensure that intake procedures included documentation of the disclosure to the client of the criteria for admission, treatment, completion and discharge in seven of seven client records reviewed.Client #1 was admitted on May 1, 2020 and was discharged on June 29, 2020. Client #2 was admitted on May 18, 2020 and was discharged on January 20, 2021. Client #3 was admitted on November 17, 2020 and was an active client at the time of the inspection. Client #4 was admitted on July 30, 2020 and was an active client at the time of the inspection. Client #5 was admitted on August 12, 2020 and was discharged on March 5, 2021. Client #6 was admitted on August 24, 2020 and was an active client at the time of the inspection. Client #7 was admitted on June 16, 2020 and was discharged on January 18, 2021. The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project Director created an Orientation form that includes; Intake procedures shall include documentation of: (2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following: (ii)criteria for admission, treatment, completion, and discharge.
The orientation form has been added to in the intake procedure and will be signed by the client. The client will be offered a copy of the form. The counselor will document whether the client accepts or refuses a copy of the form. To ensure that all clients receive this form, clinical supervisor will randomly audit files to ensure the form has been signed and offered to every client. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on the review of client records, the project failed to ensure that intake procedures and client orientation included documentation of familiarization with the hours of operation in seven of seven client records reviewed.Client #1 was admitted on May 1, 2020 and was discharged on June 29, 2020. Client #2 was admitted on May 18, 2020 and was discharged on January 20, 2021. Client #3 was admitted on November 17, 2020 and was an active client at the time of the inspection. Client #4 was admitted on July 30, 2020 and was an active client at the time of the inspection. Client #5 was admitted on August 12, 2020 and was discharged on March 5, 2021. Client #6 was admitted on August 24, 2020 and was an active client at the time of the inspection. Client #7 was admitted on June 16, 2020 and was discharged on January 18, 2021. The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project Director created an Orientation form that includes; Intake procedures shall include documentation of: (2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following: (ii) Hours of operation.
The orientation form has been added to in the intake procedure and will be signed by the client. The client will be offered a copy of the form. The counselor will document whether the client the accepts or refuses a copy of the form. To ensure that all clients receive this form, clinical supervisor will randomly audit files to ensure the form has been signed and offered to every client. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on the review of client records, the project failed to ensure that intake procedures and client orientation included documentation of familiarization with the fee schedule in seven of seven client records reviewed.Client #1 was admitted on May 1, 2020 and was discharged on June 29, 2020. Client #2 was admitted on May 18, 2020 and was discharged on January 20, 2021. Client #3 was admitted on November 17, 2020 and was an active client at the time of the inspection. Client #4 was admitted on July 30, 2020 and was an active client at the time of the inspection. Client #5 was admitted on August 12, 2020 and was discharged on March 5, 2021. Client #6 was admitted on August 24, 2020 and was an active client at the time of the inspection. Client #7 was admitted on June 16, 2020 and was discharged on January 18, 2021. The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project Director created an Orientation form that includes; Intake procedures shall include documentation of: (2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following: (ii)fee schedule.
The orientation form has been added to in the intake procedure and will be signed by the client. The client will be offered a copy of the form. The counselor will document whether the client accepts or refuses a copy of the form. To ensure that all clients receive this form, clinical supervisor will randomly audit files to ensure the form has been signed and offered to every client. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on the review of client records, the project failed to ensure that intake procedures and client orientation included documentation of familiarization with the services provided in seven of seven client records reviewed.Client #1 was admitted on May 1, 2020 and was discharged on June 29, 2020. Client #2 was admitted on May 18, 2020 and was discharged on January 20, 2021. Client #3 was admitted on November 17, 2020 and was an active client at the time of the inspection. Client #4 was admitted on July 30, 2020 and was an active client at the time of the inspection. Client #5 was admitted on August 12, 2020 and was discharged on March 5, 2021. Client #6 was admitted on August 24, 2020 and was an active client at the time of the inspection. Client #7 was admitted on June 16, 2020 and was discharged on January 18, 2021. The findings were discussed with project staff during the licensing process.
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Plan of Correction
Project Director created an Orientation form that includes; Intake procedures shall include documentation of: (2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following: (ii)services provided.
The orientation form has been added to in the intake procedure and will be signed by the client. The client will be offered a copy of the form. The counselor will document whether the client accepts or refuses a copy of the form. To ensure that all clients receive this form, clinical supervisor will randomly audit files to ensure the form has been signed and offered to every client. |