INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1-2, 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:
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Plan of Correction
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705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. It was observed by DDAP staff that the urinal in the mens lavatory on the second floor was leaking water when it was flushed.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Ponessa Behavioral Health had a plummer come out to resolve the issue where the urinal in the mens lavatory on the second floor leaked water when flushed. This issue was resolved as of 6/9/2023 |
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.
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Observations
Based on a physical plant inspection, the facility failed to prevent use of portable heaters that are not permanently mounted or installed. A portable space heater was observed, by DDAP staff, in room #304. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
SUD Clinical Director will review physical plan standards with all clinical and non-clinical staff on 6/26/2023 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 6/2/2023. Director will complete quarterly walkthroughs beginning on 6/26/2023 to ensure this violation 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.
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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 emergency exit steps on the Forster street side of the building did not have a handrail.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Ponessa Behavioral Health's property maintenance team will install a handrail on the Forster Street side of the building to ensure safety in emergency situations. These handrails will be installed by 6/30/2023. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed obtain informed and voluntary consent, in writing, which includes the purpose of disclosure in four of seven client records. Client #3 was admitted on December 17, 2022 and was still active at the time of the inspection. A release of information form signed for a treatment provider and dated December 7, 2022, did not indicate the purpose of the disclosure.Client #4 was admitted on March 10, 2023 and was still active at the time of the inspection. A release of information form signed for a non-treatment provider dated April 17, 2023, did not indicate the purpose of the disclosure.Client #6 was admitted on December 5, 2022 and was discharged on March 23, 2023. A release of information form signed for a pharmacy and dated December 12, 2022, did not indicate the purpose of the disclosure.Additionally, a release of information form signed for a family member/friend and dated December 6, 2022, did not indicate the purpose of the disclosure. Client #7 was admitted on March 17, 2023 and discharged on April 28, 2023. A release of information form signed for an insurance provider and dated March 17, 2023, did not indicate the purpose of the disclosure. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
DDAP requirements to clearly document the purpose on all Releases of Information was reviewed with all clinical staff on 6/5/2023. Ponessa Behavioral Health has started using an EHR system that does not allow the completion of a release of information without indicating the purpose of the consent to ensure consistency across all programs. SUD Clinical Supervisor and SUD Clinical Director will complete chart audits on 6/19/2023 to ensure all charts are in compliance by 6/23/2023. |
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.
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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 27, 2022 and was still active at the time of the inspection. A treatment plan update was completed on February 13, 2023 and the next update was due no later than April 13, 2023; however, the next update was completed on April 19, 2023.Client #3 was admitted on December 17, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on December 29, 2022 and the next update was due no later than February 29, 2023; however, the next update was completed on April 26, 2023.Client #4 was admitted on March 10, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 20, 2023 and the next update was due no later than May 20, 2023; however, the next update was completed on May 22, 2023.This was a repeat citation from the June 21, 2022 licensing inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical director reviewed will all clinicians the requirement to complete all txplan updates within 60 days in supervision on 6/5/2023. 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 ongoing for all active and new clients and review to ensure this requirement is being met by 7/15/2023. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information within thirty days of discharge, as per the facility ' s policy, in one of three applicable client record. Client #5 was admitted on August 11, 2022 and was discharged on December 22, 2022. There was no documentation of a follow-up contact in this client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical director reviewed will all clinicians the requirement to complete a follow up with all discharged clients within 30 days of discharge on 6/5/2023. Clinicians were reminded that this communication must be clearly documented in the client's chart and can be done via phone call or letter. SUD clinical supervisor and SUD clinical director will complete chart audits on all discharged charts to ensure the presence of a follow up letter prior to processing the discharge starting on 6/19/2023. Follow up letter was sent to client #5 on 6/19/23 |