INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28, 2018 of T. W. Ponessa, Harrisburg 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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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Client records number one through seven, inclusive, contained consent to release information forms that allowed for the release of information that exceeds what is permissible under 4 Pa. Code 255.5 (b).
The consent to release information forms to the third party payors, allowed for the release of the following items:
(a) Psychiatric evaluation
(b) Psychosocial history
(c) Medication regime
(d) discharge summary
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Plan of Correction
The consent form from the third party payor has been discontinued and pulled from both the hard copy versions and electronic versions. The Facility Director replaced the non-compliant form with the TW Ponessa Authorization for Disclosure of Health Information form which is 4 PA Code 255.5 (b) compliant, effective July 27, 2018. The clinical and support staff was informed by the Facility Director of this change on that date. The clinical staff was also directed by the Facility Director to have ongoing clients sign the appropriate compliant TW Ponessa release at the next scheduled appointment. Clinical charts will be randomly pulled at the rate of 5 per week by the Facility Director to ensure compliance with replacing the release. Full compliance with ongoing clients is expected by Sept 27, 2018. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to ensure that there was documentation of written acknowledgment by the client that they had been made aware of their rights in client record numbers two and five.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All charts will be checked by the Facility Director by 8-31-18 to ensure that the Client Rights form is signed by the client and filed in the clinical chart. If there are any Client Rights forms missing, the therapist will review the Client Rights with the client. This includes the 2 missing forms in the charts that were pulled for the inspection.
Moving forward, charts will be monitored by the therapist and the Facility Director on a weekly basis to ensure that a signed Client Rights form is present in the clinical chart. |
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. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on review of seven client records, the facility failed to document a consent to treat in six of the records reviewed.
Client # 1 was admitted on 3/13/18 and was active at the time of the inspection.
Client #2 was admitted on 11/3/17 and discharged on 1/16/18.
Client #4 was admitted on 10/24/17 and discharged on 4/10/18.
Client #5 was admitted on 5/4/18 and was active at the time of the inspection.
Client #6 was admitted on 2/28/18 and was active at the time of the inspection.
Client #7 was admitted on 3/6/18 and was active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All charts will be checked by the Facility Director by 8-31-18 to ensure that the Consent to Treatment form is signed by the client and filed in the clinical chart. If there are any Consent to Treatment forms missing, the therapist will review the Consent to Treatment form with the client. This includes the 5 missing forms in the active charts that were pulled for the inspection.
Moving forward, charts will be monitored by the therapist and the Facility Director on a weekly basis to ensure that a signed Consent to Treatment form is present in the clinical chart.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to provide documentation verifying that counseling services were provided in accordance with the clients' individual treatment plan all seven records reviewed.
Client #1 was admitted on March 13, 2018 and was still an active client at the time of the inspection. The individual treatment plan, dated April 20, 1018, indicated the client was to receive bi-weekly individual therapy sessions. The client's record of services had no entries indicating that the client attended, was a no show or cancelled treatment sessions between May 1, 2018 and June 4, 2018. Additionally there were no progress notes in the client record for those sessions.
Client #2 was admitted on November 3, 2017 and discharged on January 16, 2018.. The individual treatment plan, dated November 9, 2017, indicated the client was to receive weekly individual therapy sessions. The client's record of services had no entries indicating that the client attended, was a no show or cancelled treatment sessions between November 10, 2017 to November 28, 2017 and December 8, 2017 to December 20, 2017. Additionally there were no progress notes in the client record for those sessions.
Client #3 was admitted on October 17, 2017 and discharged on January 17, 2018. The individual treatment plan, dated November 9, 2017, indicated the client was to receive weekly individual therapy sessions. The client's record of services had no entries indicating that the client attended, was a no show or cancelled treatment sessions between November 10, 2017 to December 2, 2017. Additionally there were no progress notes in the client record for those sessions.
Client #4 was admitted on October 24, 2017 and discharged on April 10, 2018. The individual treatment plan, dated November 8, 2017, indicated the client was to receive weekly individual therapy sessions. The client's record of services had no entries indicating that the client attended, was a no show or cancelled treatment sessions between November 16, 2017 to November 26, 2017, November 28, 2017 to December 10, 2017, and December 21, 2017 to January 7, 2018. Additionally there were no progress notes in the client record for those sessions.
Client #5 was admitted on May 4, 2018 and was active at the time of the inspection. The individual treatment plan, dated May 7, 2018, indicated the client was to receive weekly individual therapy sessions. The client's record of services had no entries indicating that the client attended, was a no show or cancelled treatment sessions between May 22, 2018 to June 4, 2018, June 12, 2018 to June 24, 2018 and June 26, 2018 to July 8, 2018. Additionally there were no progress notes in the client record for those sessions.
Client #6 was admitted on February 2, 2018 and was active at the time of the inspection. The individual treatment plan, dated April 9, 2018, indicated the client was to receive bi-weekly individual therapy sessions. The client's record of services had no entries indicating that the client attended, was a no show or cancelled treatment sessions between March 10, 2018 to April 1, 2018 and May 4, 2018 to June 20, 2018. Additionally there were no progress notes in the client record for those sessions.
Client #7 was admitted on March 6, 2018 and was active at the time of the inspection. The individual treatment plan, dated March 27, 2018, indicated the client was to receive bi-weekly individual therapy sessions. The client's record of services had no entries indicating that the client attended, was a no show or cancelled treatment sessions between April 11, 2018 to May 3, 2018 and May 25, 2018 to June 10, 2018. Additionally there were no progress notes in the client record for those sessions.
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Plan of Correction
The Facility Director will educate the Clinical staff during the next weekly supervision regarding the requirements as outlined in Chapter 709.92(c) of Treatment and Rehabilitation Services. Counseling services are to be scheduled in accordance with the individual treatment plan. Documentation of barriers affecting this goal shall be recorded in the record of service, eg missed appointments, hospitalization of the client, etc. At least 5 client records will be checked randomly each week by the Facility Director to ensure compliance. |