INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 2016 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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records on July 8, 2016, the facility failed to document an annual performance evaluation in three of four applicable personnel records.
Employee # 1 was hired as the CEO on August 10 2005. An annual performance evaluation was due to be completed by September 2015 and was not completed at the time of the inspection.
Employee # 2 was hired as the Drug & Alcohol Director July 10, 2010. An annual performance evaluation was to be completed by August 2015 and was not completed at the time of the inspection.
Employee # 3 was hired as the Clinical Supervisor on September 9, 2013. An annual performance evaluation was to be completed by October 2015 and was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee # 1(CEO) will have her annual performance review completed by the President of TW Ponessa Counseling Services, Inc. by 8-1-16.
Employee # 2 (D&A Director) will have her annual performance review completed by the Project Director(CEO) by 7-31-16. Employee # 3 (Clinical Supervisor) will have his annual performance review completed by the Facility Director(D&A Director)by 7-31-16. Moving forward, the Project Director will ensure that her performance review and the Facility Director's performance review are completed by August 1 of each year. The Facility Director will ensure that the performance review for the Clinical Supervisor is completed by August 1 of each year.
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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 ten client records on July 8, 2016, the facility failed to provide services according to the individual treatment and rehabilitation plan in client records, #1, 2 and 10.
Client #1 was admitted to treatment on August 27, 2015 and is still an active client. The treatment plan dated September 23, 2015 and subsequent updates stated that the client was to receive individual counseling sessions weekly. Client #1 was seen 2/29/16 in February, twice in March, once in April, twice in May, and three times in June.
Client #2 was admitted to treatment on February 25, 2016 and is still an active client. The treatment plans dated April 7 and June 7, 2016 stated that the client was to receive individual counseling sessions weekly. Client #2 was seen three times in April, four times in May and only one time in June.
Client #10 was admitted to treatment on March 13, 2015 and discharged on June 3, 2016. Client #10's treatment plan dated March 31, 2015 and all subsequent plans stated that the client was to receive individual counseling sessions weekly. Client #10 was not seen from December 15, 2015 until April 12, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will review the policy/requirement for providing services in according to the individual treatment plan with staff by 7-29-16. The discharge policy will be reviewed during this time as well. During ongoing supervision sessions, staff will also receive further training on techniques and procedures to help motivate and better engage clients in treatment. Moving forward, at least 5 charts per therapist will be reviewed randomly on a monthly basis by the Facility Director to ensure compliance with this requirement. |