INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 6-7, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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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, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. During the inspection, counseling sessions could be overheard in room 102 between 10am -11am on August 6-7, 2019. Clients are also able to be physically observed while in counseling sessions from the outside.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
roject Director emailed Property Maintenance on 11-6-19 and informed him of this citation. Property Maintenance has had several interactions with SUD Directors regarding this issue. Property Maintenance stated that he would try to have a temporary solution Wednesday 11/13/19. Property Maintenance is researching into the most effective method to soundproof the walls and will communicate with project director to complete this task. Property Maintenance has completed his research and ordered his materials to complete this task. The last email sent to SUD Directors stated that Property Maintenance hopes to have his materials and begin this task later this week. Property Maintenance will notify SUD Directors when this task is completed.
Property Maintenance will be putting frosted applique on the windows, but in the interim staff is instructed to keep their blinds down. Property maintenance will email SUD Directors when this task is completed at the same time as the sound barrier. Until this is completed staff of the York office have been notified with this citation and that they are to pepper appointments to avoid scheduling at the same time. Staff is placing additional sound machines in their offices and outside of their office. Staff has also moved desks around to avoid sound being heard outside of their office. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
During the inspection conducted on August 6-7, 2019, the facility was unable to provide an annual audit for the 2018 fiscal year that was completed by an independent certified public accountant.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program director will ensure that the 2019 financial audit shall be completed by an independent CPA no later than 5/1/2020. Program Director is responsible for agency-wide Annual Financial Audits for tax purposes. Program Director will add the SUD program into this financial Audit. Project Director and Clinical Supervisor will add this to the end of the calendar year tasks to ensure that it is completed. Project Director will add this to her weekly meeting agenda with the Program Director in December of each calendar year. Clinical Supervisor's monthly reports will address this area of concern to insure it is prepared for the next DDAP Audit. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
In seven out of seven client records reviewed, the facility's client rights policy failed to include documentation of all the required client rights, including, "Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record."
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Plan of Correction
The Client Rights form was revised on 11/11/19 by the Project Director and Clinical Supervisor to include the following: "Clients have the right to inspect their own records. The Program, Project or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record." This revised Client Rights form was reviewed with each York Clinician in group supervision and/or individual supervision on 11/14/19. This was updated by the Clinical Supervisor and submitted to the Project Director for approval. Each York clinician signed the policy and procedure form stating that this information was reviewed in Group Supervision ran by the Clinical Supervisor. This document will be utilized effective the date of introduction. Per TWP SUD Policy and Procedures Manual, SUD Supervisors are responsible for developing and annually updating the manual delineating policies and procedures. SUD Supervisors will circulate new or updated policies and procedures to all employees and contracted providers. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
In seven out of seven client records reviewed, the facility's client rights policy failed to include documentation of all the required client rights, including, "Clients have the right to appeal a decision limiting access to their records to the director."
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Rights form was revised on 11/11/19 by the Project Director and Clinical Supervisor to include the following: "Clients have the right to appeal a decision limiting access to their records to the director." This revised Client Rights form was reviewed with each York Clinician in group supervision and/or individual supervision on 11/13/19. This was updated by the Clinical Supervisor and submitted to the Project Director for approval. Each York clinician signed the policy and procedure form stating that this information was reviewed in Group Supervision ran by the Clinical Supervisor. This document will be utilized effective the date of introduction. Per TWP SUD Policy and Procedures Manual, SUD Supervisors are responsible for developing and annually updating the manual delineating policies and procedures. SUD Supervisors will circulate new or updated policies and procedures to all employees and contracted providers. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
In seven out of seven client records reviewed, the facility's client rights policy failed to include documentation of all the required client rights, including, "Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records."
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Rights form was revised on 11/11/19 by the Project Director and Clinical Supervisor to include the following: "Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Client Rights form was reviewed with each York Clinician in group supervision and/or individual supervision on 11/14/19 ran by the Clinical Supervisor. This was updated by the Clinical Supervisor and submitted to the Project Director for approval. Each York clinician signed the policy and procedure form stating that this information was reviewed in Group Supervision. This document will be utilized effective the date of introduction. Per TWP SUD Policy and Procedures Manual, SUD Supervisors are responsible for developing and annually updating the manual delineating policies and procedures. SUD Supervisors will circulate new or updated policies and procedures to all employees and contracted providers. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
In seven out of seven client records reviewed, the facility's client rights policy failed to include documentation of all the required client rights, including, "Clients have the right to submit rebuttal data or memoranda to their own records."
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Rights form was revised on 11/11/19 by the Project Director and Clinical Supervisor to include the following:"Clients have the right to submit rebuttal data or memoranda to their own records." This revised Client Rights form was reviewed with each York Clinician in group supervision and/or individual supervision on 11/14/19 with the Clinical Supervisor. This was updated by the Clinical Supervisor and submitted to the Project Director for approval. Each York clinician signed the policy and procedure form stating that this information was reviewed in Group Supervision. This document will be utilized effective the date of introduction. Per TWP SUD Policy and Procedures Manual, SUD Supervisors are responsible for developing and annually updating the manual delineating policies and procedures. SUD Supervisors will circulate new or updated policies and procedures to all employees and contracted providers. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
On August 6-7, 2019, a review of the facility's active and discharged client records was conducted. The facility was unable to provide a complete list of all discharged clients with their admission and discharge dates.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately following the DDAP Licensing initial inspection of 7/23/19, the Project Director and Clinical Supervisor required each SUD clinician to update a client list which was placed in a centralized location. These lists have a number of columns to provide needed checks and balances. Moreover, these client lists are reviewed in individual supervision with Clinical Supervisor and Project Director and on a random basis to ensure that they are updated in a timely manner. In January of 2020, TWP will begin to roll out Electronic Health Records that limit the potential of human error in this criteria. SUD Supervisors are responsible for the organization, and maintenance for the SUD programming in TWP Electronic Health Records. |
709.34 (a) (2) 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:
(2) Selling or use of illicit drugs on the premises.
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Observations
On August 6-7, 2019, a review of the facility's policy and procedures manual was conducted. The facility failed to address the regulation in its entirety. The policy and procedures did not address selling or use of illicit drugs on the premises.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following the initial DDAP site visit of 7/23/19, the Project Director and Clinical Supervisor located a copy of the 709.34 P&P that had been developed; yet had not been made available to staff. On 11/21/19, this document was updated by the Clinical Supervisor and approved by the Project Director to include each funding source reporting requirements. The Project Director will review 709.34 Unusual Incident policy was reviewed with the York staff at the 11/21/19 group supervision. This document will become a permanent part of the SUD policy and procedures. The group will sign on the updated policy and procedure page which will serve as documented evidence of the review and activation of this policy; which addresses: "selling or use of illicit drugs on the premises." Per TWP SUD Policy and Procedures Manual, SUD Supervisors are responsible for developing and annually updating the manual delineating policies and procedures. SUD Supervisors will circulate new or updated policies and procedures to all employees and contracted providers.
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709.34 (a) (5) 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:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
On August 6-7, 2019, a review of the facility's policy and procedures manual was conducted. The facility failed to address the regulation in its entirety. The policy and procedures did not address theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following the initial DDAP site visit of 7/23/19, the Project Director and Clinical Supervisor located a copy of the 709.34 P&P that had been developed; yet had not been made available to staff. On 11/18/19, this document was updated by the Clinical Supervisor and approved by the Project Director to include each funding source reporting requirements. The 709.34 Unusual Incident policy was reviewed with the York staff at the 11/21/19 group supervision by the Project Director. This document will become a permanent part of the SUD policy and procedures. The group will sign on the updated policy and procedure page which will serve as documented evidence of the review and activation of this policy; which addresses: "Theft, burglary, break-in or similar incident at the Project." Per TWP SUD Policy and Procedures Manual, SUD Supervisors are responsible for developing and annually updating the manual delineating policies and procedures. SUD Supervisors will circulate new or updated policies and procedures to all employees and contracted providers. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
On August 6-7, 2019, a review of the facility's policy and procedures manual was conducted. The facility failed to address the regulation in its entirety. The policy and procedures did not address implementation of a timely and appropriate corrective action plan, when indicated.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following the initial DDAP site visit of 7/23/19, the Project Director and Clinical Supervisor located a copy of the 709.34 P&P that had been developed; yet had not been made available to staff. On 11/18/19, this document was updated by the Clinical Supervisor and approved by the Project Director to include each funding source reporting requirements. The 709.34 Unusual Incident policy was reviewed with the York staff at the 11/21/19 group supervision with the Project Director. This document will become a permanent part of the SUD policy and procedures. The group will sign on the updated Policy and Procedure signature page will serve as documented evidence of the review and activation of this policy; which addresses: "Implementation of a timely and appropriate corrective actions plan, when indicated." Per TWP SUD Policy and Procedures Manual, SUD Supervisors are responsible for developing and annually updating the manual delineating policies and procedures. SUD Supervisors will circulate new or updated policies and procedures to all employees and contracted providers. |
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
On August 6-7, 2019, a review of the facility's policy and procedures manual was conducted. The facility failed to address the regulation in its entirety. The policy and procedures did not address the ongoing monitoring of the corrective action plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following the initial DDAP site visit of 7/23/19, the Project Director and Clinical Supervisor located a copy of the 709.34 P&P that had been developed; yet had not been made available to staff. On 11/18/19, this document was updated by the Clinical Supervisor and approved by the Project director to include each funding source reporting requirements. The 709.34 Unusual Incident policy was reviewed with the York staff at the 11/21/19 group supervision with the Project Director. This document will become a permanent part of the SUD policy and procedures. The group will sign in on the updated policy and procedure signature page which will serve as documented evidence of the review and activation of this policy; which addresses: "Ongoing monitoring of the corrective action Plan." Per TWP SUD Policy and Procedures Manual, SUD Supervisors are responsible for developing and annually updating the manual delineating policies and procedures. SUD Supervisors will circulate new or updated policies and procedures to all employees and contracted providers. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in three of seven clients reviewed.
Client #1 was admitted on February 12, 2019 and was an active client at the time of the inspection but did not have a psychosocial evaluation completed or available for review.
Client #2 was admitted on February 7, 2019 and was an active client at the time of the inspection, but the psychosocial evaluation was not dated by clinician.
Client #4 was admitted on October 10, 2018 and was an active client at the time of the inspection but did not have a psychosocial evaluation completed or available for review.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/6/19, the SUD Clinician's attended the 6 hour SUD P3 (that is: policy, procedure, paperwork) training to review the revised/updated SUD policy, procedures, and paperwork. These policies, procedures and paperwork are regularly referenced and reviewed in weekly group supervision; as well as in individual supervision. SUD Supervisors are responsible for individuals under their direct supervision to complete work included in their respective job descriptions in a timely manner. As of this writing, our Biopsychsocial policy stipulates that the assessments MUST be completed by the 4th session. Presently, the client caseload lists have a column indicating this/these due dates as means to safeguard this time period is observed. Client charts are regularly scrutinized in individual and/or group supervision by the Clinical Supervisor and Project Director. Random chart pulls are also conducted by both Clinical and Project Director for individuals under their supervision to review in scheduled individual supervisions. In January 2020, Electronic health records will be implemented to assist with prompt with due dates. SUD Supervisors are responsible for the organization, implementation, and maintenance for the SUD programming paperwork in TWP Electronic Health Records. |
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 a review of client records, the facility failed to document treatment and rehabilitation plan updates in four of seven client records reviewed.
Client #1 was admitted on February 12, 2019 and was an active client at the time of inspection. The client ' s initial treatment plan was completed on February 12, 2019, and a master treatment plan was completed on March 27, 2019, but there were no treatment plan updates in the client's record at the time of inspection.
Client #4 was admitted on October 10, 2018. A treatment plan update was due to be completed on April 28, 2019 but it was not completed until May 18, 2019.
Client #5 was admitted on January 3, 2018. A treatment plan update was due to be completed on June 19, 2018, but it was not completed until July 10, 2018.
Client record #6 was admitted on June 21, 2017. A treatment plan update was due to be completed on March 12, 2018, but it was not completed until June 11, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/6/19, the SUD Clinician's attended the 6 hour SUD P3 (that is: policy, procedure, paperwork) training to review the revised/updated SUD policy, procedures, and paperwork. These policies, procedures and paperwork are regularly referenced and reviewed in weekly group supervision; as well as in individual supervision. SUD Supervisors are responsible for individuals under their direct supervision to complete work included in their respective job descriptions in a timely manner. As of this writing, our TPU policy stipulates that (at a minimum) a TPU MUST be completed within every 60 day period. Presently, the client caseload lists have a column indicating this/these due dates as means to safeguard this time period is observed. Treatment Plans and TPU's are regularly scrutinized in individual and/or group supervision by the Clinical Supervisor and Project Director. Random chart pulls are also conducted by both Clinical and Project Director for individuals under their supervision to review in scheduled individual supervisions. In January 2020, Electronic health records will be implemented to assist with prompt update of treatment plans prior to the due date. SUD Supervisors are responsible for the organization, implementation, and maintenance for the SUD programming paperwork in TWP Electronic Health Records. |