INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 12 through 13, 2018 of T. W. Ponessa And Associates Counseling Services, Inc., by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on observation during the physical plant inspection conducted on July 13, 2018, the facility failed to ensure that the lids to the dumpster closed so as to prevent the penetration of insects and rodents. The dumpster lids when closed, did not completely cover the container. An approximate one inch gap was noted where rodents and insects could obtain access to the container.
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Plan of Correction
The gap in the dumpster lid will be corrected/repaired by the Property Maintenance person by Sept 7, 2018.The Facility Director will follow up to ensure that it is completed by that date. The lid will be checked by the Property Maintenance person on a monthly basis to ensure that it fits correctly. The Facility Director will follow up with the Property Maintenance person to ensure it is being checked monthly. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection conducted on July 13, 2018, it was observed that counselor room 214 had windows with no window treatments, thus allowing unobstructed visual access.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A window blind will be installed by September 7, 2018 in Room 214 by the Property Maintenance person. The Facility Director will follow up to ensure that the blind is installed by that date. |
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 ensure that the consent forms for the release of information to third party payors complied with the limitations of 4 Pa. Code 255.5 (b) in nine of nine records reviewed.
Client record #'s one through nine, inclusive contained consent to release information forms that allowed for the release of (a) Psychiatric evaluation, (b) Psychosocial history, (c) Medication regime and the (d) discharge summary to third party payors.
This exceeds what is permissible under 4 Pa. Code 255.5 (b).
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Plan of Correction
The consent form from the third party payor has been discontinued and pulled from both the hard copy and electronic versions. The Facility director replaced the non-compliant payor form with the TW Ponessa Authorization for Disclosure of Health Information, which is 4 PA Code 255.5 (b) compliant, effective July 27, 2018. The clinical and support staff was informed by the Facility Director of this change on that date. The clinical staff was also directed by the Facility Director to have ongoing clients sign the appropriate compliant TW Ponessa release at the next scheduled appointment. Clinical charts will be randomly pulled at the rate of 5 per week by the Facility Director to ensure compliance with replacing the release. Full compliance with new clients is current. Full compliance with ongoing clients is expected by 9/27/18. |
715.14(b) LICENSURE Urine testing
(b) A narcotic treatment program shall develop and implement policies and procedures to ensure that urine collected from patients is unadulterated. These policies and procedures shall include random observation which shall be conducted professionally, ethically and in a manner which respects patient privacy.
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Observations
During the inspection, the facility was unable to provide policy and procedures relating to this regulation.
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Plan of Correction
The Facility Director, in conjunction with the Medical Director and Nursing Supervisor will develop the policy and procedures to ensure that urine collected from clients is unadulterated, including random observation, and conducted professionally, ethically, and in a manner which respects client privacy, per Chapter 715.14 (b) of the Narcotic Treatment Program Regulations for Nonresidential Facilities. The Facility Director will share and review the The Policy and Procedures for 715.14 by Sept 7, 2018 with the Medical Staff who will perform the Urine testing initially for each prospective client and at least monthly thereafter. |
715.14(c) LICENSURE Urine testing
(c) A narcotic treatment program shall develop and implement policies and procedures to minimize misidentification of urine specimens and to ensure that the tested specimens can be traced to the donor.
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Observations
During the inspection, the facility was unable to provide policy and procedures relating to this regulation
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Plan of Correction
The Facility Director, in conjunction with the Medical Director and the Nursing Supervisor, will develop the policy and procedures to minimize misidentification of urine specimens and to ensure that the tested specimens can be traced back to the donor, per Chapter 71514 (c) of the Narcotic Treatment Program Regulations for Nonresidential Facilities. The Facility Director will share and review the Policy and Procedures for 715.14(c) by September 7, 2018 with the medical staff who will perform the Urine testing initially for each prospective client and at least monthly thereafter. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
During the review of two Suboxone client records, the facility failed to provide two and a half hours of psychotherapy per month for one of the clients. During the past 3 months, client #1 received zero to 60 minutes of therapy each month.
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Plan of Correction
The Facility Director, in conjunction with the Medical Director and Nursing Supervisor will develop the policy and procedures to address compliance with Chapter 715.19(1) of the Narcotic Treatment Program Regulations for Nonresidential Facilities. This regulation addresses the required frequency of psychotherapy services. The Facility Director will share and review policy and procedure with the Medical staff, Clinical staff during clinical supervision by September 7, 2018. Clinical charts for all participants will be reviewed weekly by the Facility Director and/or the Medical Staff to ensure compliance. |
715.21 LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
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Observations
During the inspection, the facility was unable to provide policy and procedures relating to this regulation.
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Plan of Correction
The Facility Director, in conjunction with the Medical Director and the Nursing Supervisor, will develop the policy and procedures regarding involuntary terminations per Chapter 715.21 of the Narcotic Treatment Program Regulations for Nonresidential Facilities. Involuntary terminations will be initiated only when all other efforts to retain the client have failed. The Facility Director will share and review policy and procedures with the Medical Staff and the Clinical Staff by Sept 7, 2018. The policy and procedure will include informing and educating program participants by September 7, 2018. |
715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
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Observations
During the inspection, the facility was unable to provide policy and procedures relating to this regulation.
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Plan of Correction
The Facility Director, in conjunction with the Medical Director and the Nursing Supervisor, will develop the policy and procedures regarding development of and utilization of a patient grievance procedure per Chapter 715.22 of the Narcotic Treatment Program Regulations for Nonresidential Facilities by 9-7-18. The policy will be reviewed with staff by 9-14-18.
Client records will be reviewed on a bi-weekly basis by the D&A Director to ensure that clients are educated regarding the grievance policy and procedures. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
During the inspection, the facility was unable to provide policy and procedures relating to this regulation.
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Plan of Correction
The D&A Director, in conjunction with the Medical Director and the Nursing Supervisor will develop policies and procedures regarding Unusual Incidents per Chapter 715.28(a)(1-10) of the Narcotic Treatment Program Regulations for Nonresidential Facilities. The Facility Director (D&A Director) will will share and review these policies and procedures with the Medical Staff and the Clinical Staff by Sept 7,2018. The policy and procedure will include informing and educating program participants by September 7, 2018 and on an ongoing basis.
Procedures will include making reports to the appropriate authorities in a timely manner.
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715.28(b)(1-4) LICENSURE Unusual incidents
(b) These policies and procedures shall include the following:
(1) Documentation of the unusual incident.
(2) Prompt review and investigation.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
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Observations
During the inspection, the facility was unable to provide policy and procedures relating to this regulation.
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Plan of Correction
The Facility Director, in conjunction with the Medical Director and the Nursing Supervisor,will ensure that the policies and procedures for Unusual Incidents include the following per Chapter 715.28(b)(1-4) of the narcotic treatment Program for Nonresidential Facilities:
These policies and procedures shall include the following: (1) Documentation of the unusual incident. (2) Prompt review and investigation. (3) Implementation of a timely and appropriate corrective action plan, when indicated. (4) Ongoing monitoring of the corrective action plan. |
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 seven client records, the facility failed to provide documentation verifying that counseling services were provided in accordance with the clients' individual treatment plan in four of seven records reviewed.
Client #4 was admitted on October 16, 2017 and was still an active client at the time of the inspection. The individual treatment plan, dated November 13, 2017, indicated the client was to receive weekly individual therapy sessions. The client's record of services had no entries indicating that the client attended, was a no show or cancelled treatment sessions between November 4th, 2017 - November 19th, 2017, December 7th, 2017 - December 20, 2017, December 29, 2017 - January 15, 2018, February 27, 2018 - March 21, 2018, March 23, 2018 - April 11, 2018 and April 13, 2018 - May 7, 2018. Additionally there were no progress notes in the client record for those sessions.
Client #5 was admitted on February 14, 2018 and was still an active client at the time of the inspection. The initial treatment plan, dated March 13, 2018, indicated the client was to receive weekly therapy sessions. The client's record of services had no entries indicating that the client attended, was a no show or cancelled treatment sessions between May 22, 2018 and June 4, 2018. According to the progress note from May 21, 2018, the client was scheduled for an appointment on May 28, 2018. This date is a nationally recognized holiday and no services were provided on that day. The session was not rescheduled in accordance with the treatment plan.
Client #6 was admitted on February 20, 2018 and was discharged on May 11, 2018 with a readmit date of June 13, 2018. The initial treatment plan, dated, February 29, 2018, indicated the client was to receive biweekly individual therapy sessions. The client's record of services had no entries indicating that the client attended, was a no show or cancelled treatment sessions between March 2, 2018 - April 10, 2018. A session was scheduled during this time but was cancelled by the counselor, according to facility. There was no documentation in the client's record of the cancellation or an attempt to reschedule client to meet the requirements of the treatment plan.
Client #7 was admitted on November 10, 2017 and was still an active client at the time of the inspection. The initial treatment plan, dated November 1, 2017, indicated biweekly therapy sessions. The client's record of services had no entries indicating that the client attended, was a no show or cancelled treatment sessions between February 23, 2018 - March 14, 2018. Additionally there were no progress notes in the client record for those sessions.
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Plan of Correction
The Facility Director will educate the Clinical staff during supervision regarding the requirements as outlined in Chapter 709.92(c) of Treatment and Rehabilitation Services. Counseling services are to be scheduled in accordance with the individual treatment plan. Documentation of barriers affecting this goal shall be recorded in the record of service, eg missed appointments, hospitalization of the client, etc. At least 5 client records will be checked randomly each week by the Facility Director to ensure compliance. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report completed by the facility, and an interview with the facility director on July 13, 2108 , the facility exceeded their approved capacity of 100. At the time of the inspection the number of active clients was 119.
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Plan of Correction
On August 28,2018, the Facility Director submitted to DDAP (Licensing) a request for a capacity increase to 125, from the capacity of 100, which is in effect with the current license. Confirmation was received from DDAP on Aug 30, 2018 that the capacity request was received. |