INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 12, 2016 by staff from the Division of Drug and Alcohol 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:
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Plan of Correction
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records on July 12, 2016, the facility failed to document an annual performance evaluation in three of six applicable personnel records.
Employee # 1 was hired as the CEO on August 10 2005. An annual performance evaluation was due to be completed by September 2015 and was not completed at the time of the inspection.
Employee # 2 was hired as the Drug & Alcohol Director July 10, 2010. An annual performance evaluation was to be completed by August 2015 and was not completed at the time of the inspection.
Employee # 3 was hired as the Clinical Supervisor on September 9, 2013. An annual performance evaluation was to be completed by October 2015 and was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee # 1(CEO) will have her annual performance review completed by the President of TW Ponessa Counseling Services, Inc. by 8-1-16.
Employee # 2 (D&A Director) will have her annual performance review completed by the Project Director(CEO) by 7-31-16. Employee # 3 (Clinical Supervisor) will have his annual performance review completed by the Facility Director(D&A Director)by 7-31-16. Moving forward, the Project Director will ensure that her performance review and the Facility Director's performance review are completed by August 1 of each year. The Facility Director will ensure that the performance review for the Clinical Supervisor is completed by August 1 of each year. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of ten client records on July 12, 2016, the facility did not receive the required physician signature on the Individual treatment and rehabilitation plan and subsequent plans as required for reimbursement under the medical assistance program in three client records.
Client #1 was admitted on March 4, 2016 and is still an active client. Client #1's individual treatment and rehabilitation plan was developed and signed on April 29, 2016 and did not have a physician signature.
Client #2 was admitted on November 18, 2015 and is still an active client. Client #2's individual treatment and rehabilitation plan was developed on January 20, 2016 and updates of March 20, 2016 and May 20, 2016 did not have a physician signature.
Client #4 was admitted on November 11, 2015 and was discharged on May 11, 2016. Client #4's individual treatment and rehabilitation plan was developed on March 2, 2016 and update of May 2, 2016 did not have a physician signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will meet with all clinical staff by 7-29-16 to review the policy/requirement requiring that all treatment plans, including the Initial Treatment Plan, the Master Treatment Plan, and all Treatment Plan Updates , are signed by the Medical Director within 1 week of creating the treatment plan. The Medical Director will sign all treatment plans for the active clients by 7-29-16. Moving forward,the Facility Director will ensure that at least 5 random chart reviews per therapist are conducted each month to ensure compliance. |