INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 21, 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 & 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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704.12(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 #3 was hired as a counselor on December 7, 2020 and was still acting in that position.
The FTE counselor's caseload calculation is as follows: 16/40 = .40 (FTE); 16/.40 = 40, which equals to a client counselor ratio of 40:1.
Employee #4 was hired as a counselor on March 27, 2023, and was still acting in that position.
The FTE counselor's caseload calculation is as follows: 5/40 = .125 (FTE); 5/.125 = 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 Director confirmed on 6/23/2023 that all SUD clinicians were at or below the FTE regulations of 35/1. SUD Clinical Director will review staff's FTE on a month basis starting on 6/23/2023 |
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
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of seven records reviewed.
Client #2 was admitted on February 15, 2023 and was still active at the time of the inspection. The facility confirmed that it had released information to a funding source on June 14, 2023. There was no consent to release information form documented in the client record.
This was a repeat citation from the June 22, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director reviewed the requirement to obtain a consent to release information prior to releasing information. SUD clinical director reviewed with medical staff that a release of information must be obtained prior to completing a medical prior authorization. SUD Clinical Director will audit all charts to ensure all contacts have a signed consent in the chart by 6/30/2023
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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
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 #6 was admitted on September 15, 2022 and was discharged on December 27, 2022. A release of information form signed for an insurance provider dated September 15, 2022, did not indicate the specific information to be released.
Additionally, a release of information form signed September 15, 2022 for probation did not indicate the specific information to be released.
This was a repeat citation from the June 22, 2022 licensing inspection.
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 specific information being disclosed on all consents with all staff on 6/26/2023. SUD Director will audit all client charts to ensure all consents includes specific information to be disclosed by 6/30/2023. Clinical Director and supervisor will complete monthly chart audits throughout the year to ensure this issue does not occur again. |
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 three of seven client records.
Client #3 was admitted on February 1, 2023 and was still active at the time of the inspection. A release of information form signed for a friend/family member and dated March 15, 2023, did not indicate the purpose of the disclosure.
Additionally, a release of information form signed for probation and dated March 29, 2023, did not indicate the purpose of the disclosure.
Client #4 was admitted on February 8, 2023 and was still active at the time of the inspection. A release of information form signed for probation and dated February 8, 2023, did not indicate the purpose of the disclosure
Additionally, a release of information form signed for a law office and dated March 28, 2023, did not indicate the purpose of the disclosure.
Client #6 was admitted on September 15, 2022 and was discharged on December 27, 2022. A release of information form signed for an insurance provider and dated September 15, 2022, 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 6/23/2023 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 6/30/2023. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the dated signature of client in one out of seven records reviewed.
Client #2 was admitted on February 15, 2023 and was still active at the time of the inspection. A release of information, for an emergency contact, dated February 15, 2023, did not contain a client signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director reviewed the requirement to obtain the client's dated signature on consents on 6/23/2023 with all clinical staff. Ponessa's new EHR system has a function where the release of information cannot be submitted without obtaining the client's signature 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 6/30/2023. |
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 #3 was admitted on February 1, 2023 and was still active at the time of the inspection. A release of information form signed for a friend/family member and dated March 15, 2023, did not specify a consent revocation date or condition.
Additionally, a release of information form signed for probation and dated March 29, 2023, did not specify a consent revocation date or condition.
Client #4 was admitted on February 8, 2023 and was still active at the time of the inspection. A release of information form signed for probation and dated February 8, 2023,did not specify a consent revocation date or condition.
Additionally, a release of information form signed for a law office and dated March 28, 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 6/23/2023 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 6/30/2023. |