INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 14, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, T. W. Ponessa and Associates Counseling Services, Inc. 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:
|
Plan of Correction
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
The facility has designated its training year as January 1, 2022, through December 31, 2022.
Employee #3 was hired as a counselor on October 19, 2020 and was still in the position at the time of the onsite inspection. Review of this employee's training certificates verified that only 17 hours of training were documented during the 2022 training year.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
SUD Clinical Director reviewed the requirements to complete 25 hours of training per year on 6/15/2023 with all clinicians and clinical supervisor. The requirement to obtain a certificate of completion and training feedback form for all training was also reviewed. SUD Clinical Director will review all trainings on a quarterly basis beginning 6/19/2023 with each clinician to review the number of training hours still needed for the year. During this time, all completed trainings will be reviewed to ensure the presence of a certificate and training feedback form. SUD Clinical Director reviewed all trainings for the 2023 year and confirmed all trainings so far have a training certificate and training feedback form on 6/15/2023. |
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.
|
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.
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.
Employee #4 was hired as a counselor on September 26, 2016 and was still acting in that position.
The FTE counselor's caseload calculation is as follows: 38/40 = .95 (FTE); 35/.95 = .3684, which equals to a client counselor ratio of 37:1.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
SUD Clinical Direcor reviewed the FTE regulation with all staff. Clinical director reviewed all clinician's FTE ratios and confirmed that as of 6/15/2023, all clinicians had rations at or below the regulation limit of 35/1. SUD clinical director will keep ongoing documentation of clinician ratios to ensure they are within regulation limits beginning on 6/15/2023. Director will utilize the formula provided in the FTE DDAP Alert 04/2023 |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a physical plant inspection, the facility failed to prohibit heaters in the facility that are not permanently mounted or installed. A portable space heater observed in room #104.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
SUD Clinical Director reviewed physical plan standards with all clinical and non-clinical staff on 6/15/2023 emphasizing that no portable heaters are to be in the facility at any time. SUD Clinical Director ensured all space heaters were removed from the premises on 6/15/2023. Director will begin quarterly site walkthroughs beginning 6/15/2023 to ensure this does not happen again. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
|
Observations
Based on a physical plant inspection, the facility failed to maintain the grounds in a safe manner. It was observed by DDAP staff that the first floor exit on the Rooseevelt Street side of the building requires but does not have a handrail.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Ponessa Behavioral Health's property maintenance team will install a handrail on the Roosevelt Ave side of the building to ensure safety in emergency situations. These handrails will be installed by 7/30/2023. |
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of six applicable records reviewed.
Client #1 was admitted on September 26, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on October 28, 2022 and the next update was due no later than December 28, 2022; however, the next update was completed on May 18, 2023.
Client #3 was admitted on February 20, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 7, 2023 and the next update was due no later than May 7, 2023; however, the next update was completed on May 18, 2023.
Client #4 was admitted on September 15, 2022 and was still active at the time of the inspection. A treatment plan update was completed on December 1, 2022 and the next update was due no later than February 1, 2023; however, the next update was completed on May 30, 2023.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Clinical director reviewed will all clinicians the requirement to complete all txplan updates within 60 days in supervision on 6/15/2023. Clinicians were reminded of the importance of utilizing their client lists to show when items are due and using the "highlight" function to serve as a reminder. Clinicians were also educated on the "inactive treatment plan widget" in the EHR system. Clinicians were also reminded that treatment plan updates can be made when it is due even if the client is not present and reviewed at the next session. Clinicians were also reminded that the clinician can sign off on a treatment plan before it is reviewed with the client. Clinicians were reminded that the start date of the treatment plan is reflected by the date of their signature. Clinical Supervisor will conduct chart audits for all clients and review to ensure this requirement is being met by 7/15/2023. |