INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25, 2017 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Personnel records were reviewed for the completion of CPR certification training on July 20, 2017. The facility failed to ensure that at least one person certified in CPR skills was onsite during all hours of the facility's operation.
The facility's hours of operation are Monday - Thursday, 8 am - 8 pm, and Friday, 8 am - 5 pm. The facility failed to provide documention that verified that at least one CPR certified staff person was onsite for the following hours of operation:
- Tuesday 4 pm - 8 pm
- Thursday 3 pm - 8 pm
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
It is the responsibility of the Facility Director to ensure that adequate CPR coverage is available during hours of operation. CPR certification will be offered to additional staff by September 8, 2017 to close the gaps in coverage. Moving forward, the Facility Director will monitor the schedules of CPR trained staff and the hours of operation to ensure adequate coverage. More staff will receive training as soon as possible if a gap in coverage occurs. |
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
Seven client records were reviewed on July 25, 2017. The facility failed to obtain an informed and voluntary consent in client records, #5 and 6.
Client # 5 was admitted into treatment on 6/8/17 and was still active in treatment. A consent to release information to a county probation office, signed and dated on 6/22/17, did not specify the information to be disclosed.
Client # 6 was admitted into treatment on 5/25/17 and was still active in treatment. Documentation in the client's record indicates the facility forwarded a letter to a public defender on 7/6/17, reporting the client's presence in treatment and diagnosis. A consent to release information to this public defender was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director met with clinical staff on 8-2-17 to review the Confidentiality regulations/policies. The Facility Director reviewed the agency's Release of Information form and how to complete it properly for each type of entity e.g. funding sources, insurance companies, case managers, attorneys. The requirement to complete a new Consent to Release if a funding source changes or is added was also emphasized. Moving forward, the Facility Director will ensure that at least 5 random chart reviews per therapist are conducted by the Facility Director or Clinical Supervisor each month to ensure compliance. Additional training will be conducted by the Facility Director if necessary, pending the results of the chart reviews. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
A licensing renewal inspection was conducted on July 25, 2017. Based on a review of the facility's administrative documentation, the facility failed to develop policies and procedures that specifically addressed the following unusual incidents:
1)Physical assault or sexual assault by staff or a client.
2)Selling or use of illicit drugs on the premises.
3)Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in treatment or, when known by the facility, for ambulatory services.
4)Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
5)Theft, burglary, break-in or similar incident at the facility.
6)Event at the facility requiring the presence of police, fire, or ambulance personnel.
7)Fire or structural damage to the facility.
8)Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will revise the current Reporting of Unusual Incidents policy and procedures to include the 8 areas documented in the citation. This will be completed by September 5, 2017 and submitted to the Project Director for approval. The new policy and procedures will be disseminated to staff and reviewed in staff meetings by the Facility Director by September 8, 2017.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
A licensing renewal inspection was conducted on July 25, 2017. Based on a review of the facility's administrative documentation, the facility's policies and procedures for responding to incidents failed to include the provision of ongoing monitoring of the corrective action plan.
This finding was reviewed with facility staff during the licensing process
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Plan of Correction
Ongoing monitoring of the policies and procedures for unusual Incidents will be specified and written into the Reporting of Unusual Incidents policy by September 5, 2017 and disseminated to staff by September 8, 2017. Moving forward, it is the responsibility of the Facility Director to ensure that all recommended and appropriate follow up occurs. Further, it is the responsibility of the Facility Director to develop a plan of action for the implementation of recommendations and for ongoing monitoring of the Plan of Correction. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Seven client records were reviewed on July 25, 2017. The facility failed to document that an individual treatment and rehabilitation plan was developed with the client for client records # 1, 4, 5, and 7.
Client # 1 was admitted into treatment on 11/14/16 and was still active in treatment. The individual treatment and rehabilitation plan documented in the client's record was completed on 2/27/17. The client's record did not include documentation that the treatment plan was developed with the client.
Client # 4 was admitted into treatment on 12/15/16 and was discharged on 7/10/17. The individual treatment and rehabilitation plan documented in the client's record was completed on 2/16/17.
Client # 5 was admitted into treatment on 6/8/17 and was still active in treatment. The individual treatment and rehabilitation plan documented in the client's record was completed on 7/13/17.
Client # 7 was admitted into treatment on 5/22/17 and was still active in treatment. The individual treatment and rehabilitation plan documented in the client's record was completed on 6/13/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director met with clinical staff on 8-1-17 to review the policy/requirement for timely completion of and proper documentation of treatment plans, including the Initial Treatment Plan, the Master Treatment Plan, and Treatment Plan Updates in the progress note. Moving forward, the Facility Director will ensure that at least 5 random chart reviews per therapist are conducted each month to ensure compliance of this requirement. Additional training will be conducted if necessary, pending the results of the chart reviews. |