INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 21, 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 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)(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. The 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. |
705.24 (6) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on a physical plant inspection, the facility failed to provide toilet paper in the 2nd floor women's stall at all times. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Property maintenance will ensure all bathrooms have an extra supply of toilet paper at all times. This expectation was reviewed with property maintenance and support staff on 7/5/2022 |
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 July 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 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 Maintenance to discuss the requirement that all Fire Drill logs must include whether or not the fire alarm was operative. Clinical Director added a column on the Fire Drill log asking to indicate whether the fire alarm was operable. |
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 five out of six client records reviewed.Client #1 was admitted on August 4, 2021 and was discharge on February 7, 2022. A treatment plan was completed on August 26, 2021 and October 28, 2021; however there was no type and frequency documented in the record. Client #4 was admitted on October 25, 2021 and was still active at the time of the inspection. A treatment plan was completed on December 7, 2021 and April 4, 2022; however there was no type and frequency documented in the record. Client #5 was admitted on February 3, 2022 and was still active at the time of the inspection. A treatment plan was completed on April 14, 2022; however there was no type and frequency documented in the record. Client #6 was admitted on February 14, 2022 and was still active at the time of the inspection. A treatment plan was completed on April 5, 2022; however there was no type and frequency documented in the record. Client #7 was admitted on February 17, 2022 and was still active at the time of the inspection. A treatment plan was completed on April 13, 2022; however there was no type and frequency documented in the record. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director reviewed this requirement in group supervision. Clinical Director added a section on the treatment plans to indicate type and frequency of sessions. Clinical supervisor will be conduction weekly chart audits to ensure all current charts meet this expectation and ensure all clinicians are using the most recent txplan moving forward. |
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 proposed type of support services on the treatment plans in four out of six client records reviewed.Client #1 was admitted on August 4, 2021 and was discharge on February 7, 2022. A treatment plan was completed on August 26, 2021 and October 28, 2021 that did not include documented support services. Client #2 was admitted on August 23, 2021 and was discharged on June 5, 2022. A treatment plan was completed on September 28, 2021 and November 28, 2021 that did not include documented support services. Client #4 was admitted on October 25, 2021 and was still active at the time of the inspection. A treatment plan was completed on December 7, 2021 and April 4, 2022 that did not include documented support services.Client #6 was admitted on February 14, 2022 and was still active at the time of the inspection. A treatment plan was completed on April 5, 2022 that did not include documented support services.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical director reviewed requirement to indicate and document proposed types of support services on treatment plans in group supervision on 6/24/2022. Clinical supervisor will complete weekly chart audits to ensure all client charts are meeting the requirement of documenting proposed type of support services on txplans. |
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 five out seven client records reviewed.Client #2 was admitted on August 23, 2021 and was discharged on June 5, 2022. A treatment plan was completed on January 28, 2022; however there was not a new treatment plan update documented in the record at the time of the inspection. Client #3 was admitted on August 23, 2021 and was discharge on December 14, 2022. A preliminary treatment plan was completed on August 23, 2022; however there was no comprehensive treatment plan or updated treatment plan documented in the record at the time of the inspection. Client #5 was admitted on February 3, 2022 and was still active at the time of the inspection. A treatment plan was completed on April 14, 2022 and the next treatment plan was due no later than June 14, 2022; however there was no update documented in the record at the time of the inspection. Client #6 was admitted on February 14, 2022 and was still active at the time of the inspection. A treatment plan was completed on April 5, 2022 and the next treatment plan was due no later than June 5, 2022; however there was no update documented in the record at the time of the inspection. Client #7 was admitted on February 17, 2022 and was still active at the time of the inspection. A treatment plan was completed on April 13, 2022 and the next treatment plan was due no later than June 13, 2022; however there 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 in supervision on 6/24/2022. Clinicians were reminded of the importance of utilizing their client lists to show when items are due and using the "highlight" function to serve as a reminder. Clinicians were also reminded that treatment plan updates can be made when it is due even if the client is not present and reviewed at the next session. 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. |