INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 8, 2015 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff.
The findings include:
The SRFSR was reviewed on June 8, 2015 for staff compliance with required HIV/AIDS and TB/STD training. One out of one staff for which the training was due, specifically record # 3, did not receive the training within the required timeframe. Employee # 3 accepted the position of clinical supervisor on September 9, 2013. Training was due by September 9, 2014. HIV/AIDS training was not completed until November 14, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The D&A Director is responsible for ensuring that all new clinical staff receive the 4 hour TB/STD training and the 6 hour HIV training within one year of hire. Moving forward, the D&A Director will review all staff training plans at least once per quarter for timely compliance with this regulation. If an outside DDAP approved TB/STD and/or HIV training is unavailable within the one year of hire, the D&A Director will conduct these trainings utilizing DDAP approved curriculum with the appropriate staff in order to ensure compliance with this regulation. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include proposed types of supportive services in seven of twelve client records reviewed.
The findings include:
Twelve client records were reviewed for comprehensive treatment plans, which included support services on June 8, 2015. Seven out of twelve client records lacked documentation of a treatment plan that included a proposed type of support service, specifically client records # 2, 4, 5, 6, 7, 8, and 9.
The comprehensive treatment plan for client #2 was documented on August 27, 2014; however it did not include a proposed type of support service for client #2.
The comprehensive treatment plan for client #4 was documented on May 11, 2015; however it did not include a proposed type of support service for client #4.
The comprehensive treatment plan for client #5 was documented on February 16, 2015; however it did not include a proposed type of support service for client #5.
The comprehensive treatment plan for client #6 was documented on March 6, 2015; however it did not include a proposed type of support service for client #6.
The comprehensive treatment plan for client #7 was documented on February 13, 2015; however it did not include a proposed type of support service for client #7.
The comprehensive treatment plan for client #8 was documented on April 30, 2015; however it did not include a proposed type of support service for client #8.
The comprehensive treatment plan for client #9 was documented on February 16, 2015; however it did not include a proposed type of support service for client #9.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the D&A Director to ensure that the Master Treatment Plan for each client include a treatment goal for support services. Staff attended supervision on 6-17-15 during which they were informed of the requirement to include an objective in which the client is recommended to obtain recovery support and/or community support for identified areas of need for services outside the treatment setting. The treatment plans for client records 2,4,5,6,7, and 8 have been updated to include a goal recommending support. Client record # 9 was a closed chart. Moving forward, treatment plans will be reviewed monthly by the D&A Director or the Clinical Supervisor to monitor compliance with this requirement. |
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 the review of client records the facility failed to ensure that a complete record was documented in three of thirteen client records reviewed.
The findings include:
Five client records were reviewed for documentation of a follow-up attempt on June 8, 2015. The facility failed to document a follow-up attempt in three out of five discharged records, specifically client records #2, 9, and 12.
Client #2 was admitted on 6/2/14 and discharged on 1/9/15. As of the date of inspection, there was no documentation of a follow-up attempt for client #2.
Client #9 was admitted on 1/22/15 and discharged on 4/15/15. As of the date of inspection, there was no documentation of a follow-up attempt for client #9.
Client #12 was admitted on 8/5/14 and discharged on 3/10/15. As of the date of inspection, there was no documentation of a follow-up attempt for client #12.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the D&A Therapists and ultimately the D&A Director to ensure that therapists' discharged clients receive a follow-up call within 30 days of discharge. Staff attended supervision on 6-17-15 during which they were informed/reminded of the requirement to complete and document a call or attempted call within 30 days of discharge. Staff for records 2,9,and 12 were directed by the D&A Director to make a follow-up call to those clients. Moving forward, discharged charts will be placed by the therapists in a separate locked filing cabinet to await follow up calls by the discharging therapist. The cabinet will be checked weekly by the D&A Director. Charts for clients who are due for their follow up call will be pulled and given to the discharging therapist for follow up. After documentation of the follow up call, the chart will be returned to the D&A Director for review and then filed as a completed discharged chart. |