INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 22, 2022 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff CPR and first aid certifications, the facility failed to have a sufficient number of staff trained in these skills on-site between January 2022 and the time of the inspection during all hours of weekly operation.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director met with Director of Support staff to discuss the requirement of having sufficient number of staff trained in CPR/First Aid on-site for all open hours. All support staff will be trained in CPR/First aid by 8/1/2022 as they are present during all open office hours. Clinical Director obtained her CPR certification on 6/13/2022 and will obtain her First Aid Certification by July 31, 2022. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
A review of the January 2021 through June 2022 fire drill logs was conducted during the onsite inspection. The facility failed to include whether the fire alarm was operative at the time of the drill during the 2021 months of January, February, March, April, May, June, July, August, September, October, November, and December.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director met with Property Manager to discuss the requirement of documenting whether the fire alarm was operative on all logs. Clinical Director added "Fire Alarm/Smoke Detector Functional" section on the Fire Drill Log prompting to answer with a Yes/No for each monthly fire drill. |
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
A review of the January 2021 through June 2022 fire drill logs was conducted during the onsite inspection. The facility failed to prepare alternate exit routes to be used during the fire drills during the 2021 months of January, February, March, April, May, June, July, August, September, October, November, and December.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director met with Property Manager to discuss the requirement of preparing alternate exit routes during fire drills. Property manager will alternate exit routes starting with July's fire drills. |
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 keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client records in two out of seven records reviewed.
Client #1 was admitted on September 7, 2021 and was discharged on January 21, 2022. There was documentation that facsimile was sent to a funding source including a discharge summary with prescribed medications on January 21, 2022.
Client #2 was admitted on September 23, 2021 and was discharge on March 9, 2022. There was documentation that facsimile was sent to a funding source including a discharge summary with prescribed medications on September 23, 2021.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director created a discharge letter to be implemented on 7/25/2022 which only includes the client's name, address, discharge status: (Successful, Unsuccessful, involuntary) and their discharge date. Clinical supervisor will conduct weekly chart audits for all discharge charts to ensure the new form is being utilized |
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 document a completed consent to release information in one out of seven records reviewed, as there was a form missing required information.
Client #2 was admitted on September 23, 2021 and was discharged on March 9, 2022. There was a consent to release form, signed and dated on October 1, 2022 for an emergency contact, but the consent did not include the specific information disclosed.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director reviewed with all staff during group supervisions the requirement to ensure that all active consents include the specific information able to be disclosed. Clinical director also added "ensuring specific information disclosed is marked on consents" on our program's chart audit sheet. Clinical Supervisor will conduct weekly audits on all client charts to ensure this expectation is being met for all existing charts and new clients moving forward. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical plant inspection, the facility failed to ensure that medications requiring refrigeration were stored appropriately, as there were food and drink in the same appliance.
The finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical director met with Medical Director to discuss the requirement of storing all medications appropriately, including ensuring that there is no food or drink in the same appliance. This information was then discussed with all medical staff. |
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 document frequency and type on the treatment plans in seven out of seven client records reviewed.
Client #1 was admitted on September 7, 2021 and was discharged on January 21, 2022. A treatment plan was completed on September 14, 2021 and November 3, 2021 that was missing documentation of frequency and type.
Client #2 was admitted on September 23, 2021 and was discharged on March 9, 2022. A treatment plan was completed on October 1, 2021 and November 23, 2021 that was missing documentation of frequency and type.
Client #3 was admitted on May 13, 2021 and was discharged on February 7, 2022. A treatment plan was completed on June 24, 2021, August 9, 2021, October 13, 2021, and December 9, 2021 that was missing documentation of frequency and type.
Client #4 was admitted on July 13, 2021 and was discharged on June 8, 2022. A treatment plan was completed on August 24, 2021, October 21, 2021, December 21, 2021, February 21, 2022, and April 21, 2022 that was missing documentation of frequency and type.
Client #5 was admitted on March 15, 2022 and was still active at the time of the inspection. A treatment plan was completed on April 7, 2022 and June 7, 2022 that was missing documentation of frequency and type.
Client #6 was admitted on January 20, 2022 and was still active at the time of the inspection. A treatment plan was completed on February 3, 2022 and March 28, 2022 that was missing documentation of frequency and type.
Client #7 was admitted on June 1, 2021 and was still active at the time of the inspection. A treatment plan was completed on July 8, 2021, September 2, 2021, November 30, 2021, January 6, 2022, March 1, 2022, and May 2, 2022 that was missing documentation of frequency and type.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical director reviewed requirement to indicate type and frequency of treatment client is receiving on all treatment plans. Clinical director added a section to treatment plans asking for the type and frequency of sessions. Clinical Supervisor will conduct weekly chart audits to ensure all existing charts meet this requirement and to ensure all charts moving forward also meet 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 within the regulatory time frames in three out seven client records reviewed.
Client #1 was admitted on September 7, 2021 and was discharged on January 21, 2022. A treatment plan was completed on November 3, 2021 and the next treatment plan update was due no later than January 3, 2022; however was no update documented in the record at the time of the inspection.
Client #2 was admitted on September 23, 2021 and was discharged on March 9, 2022. A treatment plan was completed on November 23, 2021 and the next treatment plan update was due no later than January 23, 2022; however was no update documented in the record at the time of the inspection.
Client #6 was admitted on January 20, 2022 and was still active at the time of the inspection. A treatment plan was completed on March 28, 2022 and the next treatment plan update was due no later than May 28, 2022; however was no update documented in the record at the time of the inspection.
The 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. Clinicians were reminded to utilize their client sheets as a reminder of when items are due. Clinicians were also reminded that txplans may be updated on the day they are due even if the client is not present. The expectation is that the txplan will be reviewed with the client at their next scheduled appointment. Clinical Supervisor will conduct chart audits for all clients and review to ensure this requirement is being met by 7/15/2022. Additionally, TW Ponessa will be transitioning to an EHR system in Fall of 2022 which will have electronic reminders on all paperwork due dates. It is believed this will assist in ensuring all paperwork is completed on time and within the regulatory time frames. |