INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11, 2011 by staff from the Division of Drug and Alcohol 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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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on review of administrative documentation, the facility's policy and procedures, and an interview with the facility director, the facility failed to document an overall plan for addressing the facility training needs.
The findings include:
The policy and procedure manual was reviewed on August 8, 2011. According to the policy and procedure manual, "The project director is responsible for developing the upcoming agency training plan by the close of January 31 of the New Year." An interview with the facility director on 8/8/2011 at 3:30 p.m. confirmed that the overall training plan was not documented at the time of the inspection.
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Plan of Correction
The Project Director, in conjunction with the Facility Director, will develop the upcoming annual agency training plan by January 31 of the new training year. The training year is the calendar year.
The Facility Director will collect and review the training needs assessment forms from agency personnel by December 31 of each year. With input from the Facility Director, the Project Director will develop the Annual Training Plan for the new training year. The Project Director will ensure that the Annual Training Plan is completed by January 31 by adding it to her annual work plan/task manager reminder for January. The Annual Training Plan for 2011 will be completed by 9-23-11. |
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 personnel records, a review of the facility summary report, and a conversation with the facility director, the facility failed to provide documentation of HIV/AIDS and TB/STD training for one of three employee records.
The findings include:
Three personnel records were reviewed on August 8, 2011. The facility summary report was reviewed on August 8, 2011. Three personnel were required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required TB/STD training for personnel record # 3.
Employee # 3 is a support staff member who was hired on 1/23/2009. TB/STD training was to be completed within two years of hire, by 1/23/2011. The facility failed to provide documentation of TB/STD training.
The facility director confirmed this finding.
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Plan of Correction
All support staff will have 4 hours of training for TB/STD's and 6 hours of HIV training within the first 2 years of hire. The Facility Director will develop and maintain a spreadsheet of new support staff hires affecting the D&A Program. Information regarding dates of hire will be obtained from the Administrative Coordinator. The Facility Director will notify the Administrative Coordinator via email, when these trainings are available in the community. Support staff will register for and attend the available trainings. Utilizing the DOH Licensing approved curriculum for TB/STD's and HIV, in-house trainings will be scheduled and conducted by medical staff if support staff is unable to attend the outside trainings in the mandated time frame. The Facility Director will follow up with the Administrative Coordinator on a monthly basis to ensure that training for support staff is monitored in a timely manner. Employee number 3 will register for and attend the next required trainings that is available to her. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Thirteen months of fire drill logs were reviewed on August 9, 2011. The facility only used an alternate exit in one of the thirteen months reviewed. April 14, 2011 documented a blocked exit. Twelve months documented the use off all exits. The facility director confirmed this finding.
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Plan of Correction
Fire drills will be conducted by the Facility Director and/or the Director of Maintenance on a monthly basis. Once every 3 months, monthly fire drills will include the simulation of 1 or more unavailable exits due to a fire, necessitating the use of an alternate exit, beginning in September 2011.
Fire drills will be scheduled in advance on a quarterly basis by the Facility Director and the Director of Maintenance. (This information will not be disseminated to staff; it is for QA purposed only). The Facility Director will ensure that fire drills include at least 1 unavailable exit for each location at least once every 3 months by auditing the fire drill logs each month for compliance. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills are conduct on different times of the day.
The findings include:
The fire drill record was reviewed on August 9, 2011. There were no fire drills documented for the evening hours of operations from July 2010 through July 2011. All other drills were conducted on either the morning or afternoon shifts. The following months were reviewed July 2010, August 2010, September 2010, October 2010, November 2010, December 2010, January 2011, February 2011, March 2011, April 2011, May 2011, June 2011 and July 2011. The facility's hours are Monday through Thursday 8 a.m. - 8 p.m., Friday 8 a.m. - 5 p.m., and Saturday 9 a.m. to 2:00 p.m. The facility director was interviewed on August 9 2011 and she confirmed that there were no documented drills after 5:30 p.m.
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Plan of Correction
Fire drills will be conducted by the Facility Director and/or the Director of Maintenance on a monthly basis at various times of the day, including evenings (after 5:00 pm) beginning in September 2011.
Fire drills will be scheduled in advance on a quarterly basis by the Facility Director and the Director of Maintenance. (This information will not be disseminated to staff; it is for QA purposed only). The Facility Director will ensure that fire drills are conducted at various times of the day for each location by auditing the fire drill logs each month for compliance. |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of the 2010 annual report and an interview with the facility director, the governing body failed to make available to the public an annual report which included a statement disclosing the names of officers, directors and principal shareholders, as required by regulation.
The findings include:
The 2010 annual report was reviewed on August 8, 2011. According to documentation presented, on July 21, 2011, the facility made available to the public the 2010 annual report. The 2010 annual report did not include a statement disclosing the names of officers, directors and principal shareholders.
On August 8, 2011 facility director was interviewed. The facility director confirmed that a statement disclosing the names of officers, directors and principal shareholders had not been included in the annual report.
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Plan of Correction
The Facility Director will ensure that the Annual Report will include a statement disclosing the names of officers, directors, and principle shareholders. At present, Thomas W. Ponessa, President, is the sole officer of T.W. Ponessa and Associates Counseling Services, Inc. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on a review of administrative policies and an interview with the facility director, the project failed to demonstrate that the project director assisted the governing body in formulating project goals and objectives for the 2011/2012 fiscal year.
The findings were:
A review of administrative documentation and conversation with the facility director on August 8, 2011 confirmed that the project director did not assist nor present to the governing body the project goals and objectives for the fiscal year of July 1, 2011 to June 30, 2012. The documentation of the 2011/2012 goals and objectives was completed by the facility director and not the project director. The goals and objectives for 2011/2012 were not presented to the governing body for approval.
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Plan of Correction
The Project Director, in conjunction with the Facility Director, will assist the Governing Body with the formulation of the project goals and objectives for each fiscal year (July 1 to June 30). The goals and objectives will be presented to the governing body for approval. (2011/2012 goals and objectives have been approved by the Facility Director and the Governing Body.)Utilizing the written quarterly reports for the previous 4 quarters, the Project Director will assist the President (Governing Body) in developing the project goals and objectives by July 1 for the upcoming fiscal year. The finalized goals and objectives will be presented to the President by July 15 of the new fiscal year. The Project Director will ensure the report is completed in the identified time frame by utilizing her annual work plan/task manager reminder for June.
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement and an interview with the facility director, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
The findings include:
The letters of agreement were reviewed on August 8, 2011. There was no documentation of a 24-hour emergency medical coverage agreement with a licensed hospital of physician.
The facility director was interviewed and confirmed there was no documentation of a 24- hour emergency medical coverage available.
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Plan of Correction
The Facility Director will obtain a written agreement with a hospital(s) in the Harrisburg area to provide 24 hour medical and psychiatric coverage. Letters of agreement will be resent to The Harrisburg Hospital and sent to Holy Spirit Hospital. The Facility Director will research the name of the appropriate person at each facility and address and send the letter to that person by Sept 30, 2011.If the letter has not been signed and returned by the hospital by October 15, 2011, the Facility Director will appear in person to speak to the appropriate hospital personnel directly. To ensure ongoing 24 hour coverage, the Facility Director will request a condition that the agreement remains in effect until and unless either party terminates it, thus eliminating the need to send the letter of agreement for approval every 2 years.
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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to document annual performance evaluations as required by agency policy and regulation in one of two personnel records.
The findings include:
Two personnel records were reviewed on August 9, 2011. Both personnel records were required to include documentation of annual performance evaluations. Per agency policy, performance evaluations are conducted at least annually on the employee's anniversary date. An employee evaluation for the year of 2011 was not documented in employee record # 2.
Employee # 2 was hired on 4/6/2009. The employee was promoted to facility director on 7/19/2010. The last employee performance evaluation was documented on 4/19/2010. A performance evaluation was due by 4/19/2011.
An interview was conducted with the facility director confirmed that an annual evaluation for the 2011 year had not be completed.
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Plan of Correction
The Facility Director will notify the Project Director of the upcoming due date of the annual performance evaluation one month prior to the anniversary date of the Facility Director.
The Human Resources Director will notify the Project Director,(who is responsible for compliance with this regulation), of the due date of the Facility Director's upcoming performance evaluation at the beginning of July each year. The Project Director will ensure that the performance evaluation is completed in a timely manner by utilizing her calendar task manager reminder. The 2011 performance evaluation will be completed by September 23, 2011.
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