INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28, 2024, 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 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:
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Plan of Correction
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709.91(b)(2)(i) 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:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project which included project policies in seven of seven records.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.91 (b) (2) (i)
INTAKE AND ADMISSION
An immediate course of action took place August 28, 2024 to update the client's Informed Consent to Participate document addressing the agency's project policies.
Policy 709.91 (b) (2) (i)
During the intake and admission session, the client will acknowledged they have been oriented and familiarized with the agency's project policies for participation.
1. The Project Facility Director will be responsible for achieving and maintaining compliance standards through their client case as well as monthly monitoring with the counseling staff to ensure clients have been familiarized with project policies.
2. For all current active clients, during their next scheduled session and within a 30 day period, the counselor will review and familiarize project policies with said client.
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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 a review of client records, the facility failed to document client orientation to the project which included hours of operation in seven of seven records.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.91 (b) (2) (ii)
INTAKE AND ADMISSION
An immediate course of action took place August 28, 2024 to update the client's Informed Consent to Participate document addressing the agency's hours of operation.
Policy 709.91 (b) (2) (ii)
During the intake and admission session, the client will acknowledged they have been oriented and familiarized with the agency's hours of operation.
1. The Project Facility Director will be responsible for achieving and maintaining compliance standards through their client case as well as monthly monitoring with the counseling staff to ensure clients have been familiarized with hours of operation.
2. For all current active clients, during their next scheduled session and within a 30 day period, the counselor will review and familiarize hours of operation with said client.
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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 a review of client records, the facility failed to document client orientation to the project which included services provided in seven of seven records.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.91 (b) (2) (iv)
INTAKE AND ADMISSION
An immediate course of action took place August 28, 2024 to update the client's Informed Consent to Participate document addressing the agency's services provided.
Policy 709.91 (b) (2) (iv)
During the intake and admission session, the client will acknowledged they have been oriented and familiarized with the agency's services provided.
1. The Project Facility Director will be responsible for achieving and maintaining compliance standards through their client case as well as monthly monitoring with the counseling staff to ensure clients have been familiarized with services provided.
2. For all current active clients, during their next scheduled session and within a 30 day period, the counselor will review and familiarize agency services provided with said client.
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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 applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in two of six records.
Client #4 was admitted on December 5, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on April 2, 2024. A treatment and rehabilitation plan update was due no later than June 2, 2024, but was not completed until June 4, 2024.
Client #6 was admitted on March 21, 2024 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on April 3, 2024. A treatment and rehabilitation plan update was due no later than June 3, 2024, but was not completed until June 18, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 15, 2023 annual inspection.
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Plan of Correction
709.93(b) Treatment and Rehabilitation Services
1) The plan of correction took place on Tuesday, September 24, 2024 regarding the comprehensive treatment and rehabilitation plans to be updated at least every 60 days that will include the following:
709.92 (b)
Treatment and rehabilitation plans shall be updated, reviewed and signed at least every 60 days by the counselor and client. However, in the event the client scheduled session falls outside of the 60 day due date, the counselor will update and sign the treatment plan by utilizing either the previous established treatment plan or previous session progress notes to update the comprehensive treatment plan. During the next scheduled client session, the comprehensive treatment plan will be reviewed, signed and a copy given to said client.
2) The Project Facility Director will be responsible for achieving and maintaining compliance standards on a monthly basis.
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