INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 7-8, 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.The facility has designated its training year as January 1, 2022, through December 31, 2022. Employee #3 was hired as a counselor on November 5, 2003, and was still in the position at the time of the onsite inspection. Review of this employee's training certificates verified that only 24 hours of training were documented during the 2022 training year. Employee #6 was hired as a counselor on May 28, 2019, and was still in the position at the time of the onsite inspection. Review of this employee's training certificates verified that only 20 hours of training were documented during the 2022 training year.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
SUD Clinical Director reviewed the requirements to complete 25 hours of training per year on 6/14/2023.The requirement to obtain a certificate of completion and training feedback form for all training was also reviewed. SUD Clinical Director will review all trainings on a quarterly basis with each clinician to review the number of training hours still needed for the year beginning 6/16/2023. During this time, all completed trainings will be reviewed to ensure the presence of a certificate and training feedback form. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility's work week. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.Employee #2 was hired as a clinical supervisor on May 2, 2022 and was still acting in that position. The FTE counselor's caseload calculation is as follows: 4 /40 = .1 (FTE); 4/.1 = 40, which equals to a client counselor ratio of 40:1.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
SUD Clinical Director will be submitting an Exemption request by 6/30/2023 to allow SUD Clinical supervisor to complete her ongoing counseling services with two long-term clients. If this exemption request is not granted, these clients will be transferred to another clinician so that SUD Clinical Supervisor does not have any clients by 7/30/2023. |
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
Based on a review of client records, the facility failed to obtain informed and voluntary consent, in writing, which includes specific information disclosed in one of seven client records. Client #1 was admitted on January 17, 2023 and was still active at the time of the inspection. A release of information form signed for a friend/family member and dated January 17, 2023, did not indicate the specific information to be released. This finding was reviewed with facility staff during the licensing inspection
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Plan of Correction
Clinical Director reviewed the requirement to document the specific information to be disclosed on all releases of information on 6/14/2023 with all clinical staff. Ponessa's new EHR system has a function where the release of information cannot be submitted without documenting the specific information to be disclosed on all consents moving forward. SUD Clinical director and SUD clinical supervisors will complete chart audits on all charts to ensure all consents have this information clearly documented on 6/23/2023. |
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 to obtain informed and voluntary consent, in writing, which includes the purpose of disclosure in two of seven client records. Client #1 was admitted on January 17, 2023 and was still active at the time of the inspection. A release of information form signed for a friend/family member and dated January 17, 2023, did not indicate the purpose of the disclosure.Client #6 was admitted on March 16, 2023 and was discharged on May 22, 2023. A release of information form signed for an insurance provider and dated March 16, 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
Clinical Director reviewed the requirement to document the purpose of disclosure on all releases of information on 6/14/2023 with all clinical staff. Ponessa's new EHR system has a function where the release of information cannot be submitted without documenting the purpose on all consents moving forward. SUD Clinical director and SUD clinical supervisors will complete chart audits on all charts to ensure all consents have this information clearly documented on 6/23/2023. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consent, in writing, which includes the date, event or condition upon which the consent will expire, in two of seven client records. Client #1 was admitted on January 17, 2023 and was still active at the time of the inspection. A release of information form signed for a friend/family member and dated January 17, 2023, did not specify a consent revocation date or condition. Client #6 was admitted on March 16, 2023 and was discharged on May 22, 2023. A release of information form signed for an insurance provider and dated March 16, 2023, did not specify a consent revocation date or condition. These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Clinical Director reviewed the requirement to document the date, event or condition upon which the consent will expire on all releases of information on 6/14/2023 with all clinical staff. Ponessa's new EHR system has a function where the release of information cannot be submitted without documenting the date, event or condition upon which the consent will expire to ensure this is completed on all consents moving forward. SUD Clinical director and SUD clinical supervisors will complete chart audits on all charts to ensure all consents have this information clearly documented 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 four out of six applicable records reviewed.Client #2 was admitted on October 27, 2022 and was still active at the time of the inspection. A comprehensive treatment plan update was completed on December 6, 2022 and the next update was due no later than February 6, 2023; however, the next update was completed on March 9, 2023.Client #3 was admitted on October 6, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on October 20, 2022 and the next update was due no later than December 20, 2022; however, the next update was completed on December 22, 2022. Additionally, the next treatment plan update was to be completed not later than February 22, 2023; however the next update was completed March 2, 2023. Client #4 was admitted on August 1, 2022 and was still active at the time of the inspection. A treatment plan update was completed on October 19, 2022 and the next update was due no later than December 19, 2022; however, the next update was completed on December 21, 2022. Client #5 was admitted on January 13, 2023 and was discharged on May 24, 2023. A comprehensive treatment plan was completed on March 2, 2023 and the next update was due no later than May 2, 2023; however, the next update was completed on May 25, 2023.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 for all clients and review to ensure this requirement is being met by 7/15/2023. |