INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 24, 2018 of T. W. Ponessa, York location, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, T. W. Ponessa 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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705.21 (3) LICENSURE General req. for nonresidential facilities.
705.21. General requirements for nonresidential facilities.
The nonresidential facility shall:
(3) Comply with applicable Federal, State and local laws and ordinances.
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Observations
Based on a physical plant inspection, it was observed that in staff employee Gene's counseling office, the junction box near the ceiling is missing a cover plate. The missing junction box plate is not in compliance.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
The junction box cover plate will be replaced by the Property Maintenance person by Sept 14, 2018. The Facility director will check the office needing the cover plate on that date to ensure that it is installed. |
705.22 (3) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(3) Keep exterior exits, stairs and walkways lighted at night if in use.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure exterior stairs were lighted at night.
The stairwell that exits on to Roosevelt Avenue is only lit when manually turned on.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
At the stairwell stairs that exit onto Roosevelt Blvd, a motion detector for the light will be installed to ensure that the light will automatically come on when needed in order to exit safely. This will be completed by Sept 14, 2018 by the Property maintenance person. The Facility Director will check the stairwell on that date to ensure that the motion detector was installed and is functioning properly. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, conducted on July 24, 2018, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. The first floor group room has a door with a glass insert permitting clients to be seen during sessions. In addition, voices can be clearly heard while in the first floor group room from the adjacent counseling office.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Property Maintenance will install a covering on the glass door of the counseling room by September 14, 2018. The Property Maintenance person will also obtain 2 sound machines and place one in the counseling room and one in the adjacent counseling office by Sept 14, 2018. The sound machines will be turned on during sessions in both counseling rooms.The Facility Director will check on the installation of the glass door covering and the sound machines on Sept 14, 2018 to ensure that the door is covered and the sound machines are in place and are working properly. |
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.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure that outside steps exceeding two steps were equipped with a well secured handrail.
The outside steps of the door facing Roosevelt Avenue has a three step entrance without a hand rail.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
The Property Maintenance person will install a handrail on the 3 steps of the door facing Roosevelt Ave by Sept 14, 2018. The Facility Director will check to ensure that the handrail is installed and well secured on Sept 14, 2018. |
715.14(b) LICENSURE Urine testing
(b) A narcotic treatment program shall develop and implement policies and procedures to ensure that urine collected from patients is unadulterated. These policies and procedures shall include random observation which shall be conducted professionally, ethically and in a manner which respects patient privacy.
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Observations
During the inspection, the facility was unable to provide policy and procedures relating to this regulation.
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Plan of Correction
The Facility Director, in conjunction with the Medical Director and the Nursing Supervisor will develop the policy and procedures to ensure that the urine that is collected from clients is unadulterated, including random observation, and conducted professionally, ethically, and in a manner which respects client privacy, per Chapter 715.14(b) of the Narcotic Treatment Program regulations for Nonresidential Facilities. The Facility Director will share and review the policies and procedures for Chapter 715.14(b) by Sept 7 with the Medical Staff who will perform the urine testing initially for each prospective client and at least monthly thereafter. |
715.14(c) LICENSURE Urine testing
(c) A narcotic treatment program shall develop and implement policies and procedures to minimize misidentification of urine specimens and to ensure that the tested specimens can be traced to the donor.
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Observations
During the inspection, the facility was unable to provide policy and procedures relating to this regulation.
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Plan of Correction
The Facility Director, in conjunction with the Medical Director and the Nursing Supervisor, will develop the policy and procedures to minimize misidentification of urine specimens and to ensure that the tested specimens can be traced back to the donor, per Chapter 715.14(c) of the narcotic Treatment Program Regulations for Nonresidential Facilities. The Facility Director will share and review the policy and procedures for 715.14(c) with the medical staff by Sept 7, 2018,who will perform the urine testing initially for each prospective client and at least monthly thereafter. |
715.21 LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
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Observations
During the inspection, the facility was unable to provide policy and procedures relating to this regulation.
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Plan of Correction
The Facility Director, in conjunction with the Medical Director and the Nursing supervisor will develop the policy and procedures regarding involuntary terminations per Chapter 715.21 of the Narcotic Treatment Program Regulations for Nonresidential Facilities. Involuntary terminations will be initiated only when all other efforts to retain the client have failed. The Facility Director will share and review policy and procedures with the Medical staff and the Clinical staff by Sept 7, 2018. The policy and procedure will include informing and educating program participants as well. |
715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
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Observations
During the inspection, the facility was unable to provide policy and procedures relating to this regulation.
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Plan of Correction
The Facility Director, in conjunction with the Medical Director and the Nursing Supervisor will develop the policy and procedures regarding development and utilization of a patient grievance procedure per Chapter 715.22 of the Narcotic Treatment Program for Nonresidential Facilities by September 7, 2018. The policy and procedure will include informing and educating program participants at their next scheduled appointment with either Medical or Clinical Staff. Moving forward, participants will be informed and educated at the MAT evaluation session. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
During the inspection, the facility was unable to provide policy and procedures relating to this regulation.
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Plan of Correction
The D&A Director, in conjunction with the Medical director and the Nursing Supervisor will develop policies and procedures regarding Unusual Incidents per Chapter 715.28(a)(1-10) of the Narcotic Treatment Program Regulations for Nonresidential Facilities. The Facility Director will share and review these policies and procedures with the Medical and Clinical Staff by Sept 7, 2018. The policies and procedures will include informing and educating current program participants at their next scheduled appointment. Moving forward, participants will be informed and educated at the MAT evaluation session. |
715.28(b)(1-4) LICENSURE Unusual incidents
(b) These policies and procedures shall include the following:
(1) Documentation of the unusual incident.
(2) Prompt review and investigation.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
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Observations
During the inspection, the facility was unable to provide policy and procedures relating to this regulation.
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Plan of Correction
The Facility Director, in conjunction with the Medical Director and the Nursing supervisor will ensure that the policies and procedures for Unusual Incidents include the following per chapter 715.28(b)(1-4) of the Narcotic Treatment Program for Nonresidential Facilities:
These policies and procedures shall include:(1) Documentation of the the unusual incident (2) Prompt review and investigation(3) Implementation of a timely and appropriate corrective action plan, when indicated,a d (4) Ongoing monitoring of the corrective action plan. |