INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 12, 2014 by staff from the Division of Drug and Alcohol 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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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to include the type of treatment and rehabilitation services in seven of ten client records.
The findings include:
Ten client records requiring the completion of comprehensive treatment plans were reviewed on June 12, 2014. The facility failed to identify the type of counseling services to be provided on treatment plans contained in client records # 4, 5, 6, 7, 8, 9 and 10.
The facility director confirmed the findings.
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Plan of Correction
The clinical staff was informed of the requirement to include the type of treatment on each treatment plan at a meeting on 6-18-14. The treatment plans for client records #4,5,6,7,8,9 were corrected by the treating clinician on 6-20-14 to include the type of treatment. Moving forward, treatment plans will be reviewed monthly by the D&A Director or the Clinical Supervisor to monitor compliance with this requirement. |
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 every 60 days in three of ten records.
The findings include:
Ten records requiring treatment plan updates were reviewed on June 12, 2014. The facility failed to ensure that treatment plans were updated at least every 60 days in client records # 3, 8 and 10.
Client # 3 was admitted to the outpatient program on September 16, 2013 and was discharged on March, 17, 2014. The client's last treatment plan update was completed on December 26, 2013. The facility failed to complete the treatment plan update that was due on or by February 24, 2014.
Client # 8 was admitted to the outpatient program on November 29, 2013 and was discharged on April 11, 2014. The record included treatment plan updates that were completed on January 16, 2014 and April 11, 2014. The facility failed to complete the treatment plan update that was due on or by March 17, 2014.
Client #10 was admitted to the outpatient program on October 24, 2013 and was discharged on April 3, 2014. The record included treatment plan updates that were completed on November 26, 2013 and February 6, 2014. The facility failed to complete the treatment plan update that was due on or by January 25, 2014.
The facility director confirmed the findings.
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Plan of Correction
The requirement to complete and document treatment plan updates every 60 days was reviewed with the clinical staff at a meeting on 6-18-14. Moving forward, treatment plans will be reviewed monthly by the D&A director or the Clinical Supervisor to monitor compliance with this requirement. |
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 client records, the facility failed to ensure that treatment services were provided according to the frequency specified on the treatment plans in three of ten client records reviewed.
The findings included;
Ten client records with comprehensive treatment plans that required weekly sessions were reviewed on June 12, 2014. The facility failed to ensure that treatment services were provided as stated on the treatment plans in client records # 1, 5 and 6.
Client #1 was admitted to the outpatient program on October 14, 2013. The client's treatment plan dated March 20, 2014 specified that individual counseling sessions were to be conducted weekly. The facility conducted individual sessions with the client on 4/15/14, 5/8/14 and 5/19/14 with no other sessions scheduled or conducted before, between or after those dates.
Client #5 was admitted to the outpatient program on October 24, 2013 and was discharged on May 2, 2014. The client's treatment plan dated February 21, 2014 specified that individual counseling sessions were to be conducted weekly. The facility conducted individual sessions with the client on 2/21/14, 3/7/14, 3/20/14, 4/3/14 and 5/1/14 with no other sessions scheduled or conducted before, between or after those dates.
Client # 6 was admitted to the outpatient program on November 11, 2013. The client's treatment plan dated April 10, 2014 specified that individual counseling sessions were to be conducted weekly. The facility conducted individual sessions with the client on 5/4/14 and 6/5/14 with no other sessions scheduled or conducted before, between or after those dates.
The facility director confirmed the findings.
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Plan of Correction
The clinical staff was informed of the requirement to provide treatment services according to the frequency specified on the treatment plan at a meeting on 6-18-14. Moving forward, clinicians will ensure that clients are scheduled according to the treatment plan. All gaps in treatment that occur due to the client being unavailable will be documented in the record of service;eg vacations, medical issues. Every attempt will be made to reschedule the client within the prescribed timeframe for no-shows and cancellations, including offerring them an appointment with another clinician if necessary. This will be documented in the record of service as well. Compliance with this requirement will be monitored by the D&A Director or Clinical Supervisor on a monthly basis. |