INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 24, 2017 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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709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on a conversation with facility staff on July 24, 2017, the facility failed to have an efficient record keeping system in place.
Prior to the review the facility was notified informing them to have available during the licensing inspection a list of both active and discharge clients. The facility reported that a counselor resigned without notice in November 2016. The facility was unable to provide a list of the clients assigned to the former counselor's caseload, indicating that then-active clients were either transferred to other facilities, or were discharged from treatment. The facility was also unable to provide a list of clients discharged from that former counselor's caseload prior to their resignation. After approximately 1 hour and 20 minutes, the facility provided a list of five active clients that may have been assigned to the former counselor.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
n 8/1/17, the Facility Director reviewed with clinical staff the process for maintaining an up to date list of active and discharged clients. Client lists are to be submitted to the Facility Director by the 15th of each month. Failure to do so may result in disciplinary action, according to the agency's progressive disciplinary policy. Moving forward, the Facility Director will then develop a master list of admissions and discharges. The Facility Director will also coordinate with the Support Staff Coordinator on an ongoing basis to ensure proper storage and accessibility of discharged charts with her staff. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
A licensing renewal inspection was conducted on July 24, 2017. Based on a review of the facility's administrative documentation, the facility failed to develop policies and procedures that specifically addressed the following unusual incidents:
1)Physical assault or sexual assault by staff or a client.
2)Selling or use of illicit drugs on the premises.
3)Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in treatment or, when known by the facility, for ambulatory services.
4)Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
5)Theft, burglary, break-in or similar incident at the facility.
6)Event at the facility requiring the presence of police, fire, or ambulance personnel.
7)Fire or structural damage to the facility.
8)Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will revise the current Reporting of Unusual Incidents policy and procedures to include the 8 areas documented in the citation. This will be completed by September 5, 2017 and submitted to the Project Director for approval. The new policy and procedures will be disseminated to staff and reviewed in staff meetings by the Facility Director by September 8, 2017.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
A licensing renewal inspection was conducted on July 24, 2017. Based on a review of the facility's administrative documentation, the facility's policies and procedures for responding to incidents failed to include the provision of ongoing monitoring of the corrective action plan.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Ongoing monitoring of the policies and procedures for unusual Incidents will be specified and written into the Reporting of Unusual Incidents policy by September 5, 2017 and disseminated to staff by September 8, 2017. Moving forward, it is the responsibility of the Facility Director to ensure that all recommended and appropriate follow up occurs. Further, it is the responsibility of the Facility Director to develop a plan of action for the implementation of recommendations and for ongoing monitoring of the Plan of Correction. |
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
Six client records were reviewed on July 24, 2017. The facility failed to document a treatment plan update at least every 60 days for client records # 4, 5, and 6.
Client # 4 was admitted into treatment on 5/12/16 and was discharged on 2/20/17. A comprehensive treatment plan was completed for the client on 6/20/16. The first treatment plan update documented in the client's record was completed on 12/15/16.
Client # 5 was admitted into treatment on 2/12/16 and was discharged on 10/12/16. The last treatment plan update documented in the client's record, completed on 9/15/16, did not document the signature of a counselor.
Client # 6 was admitted into treatment on 12/2/15 and was discharged on 1/12/17. The last treatment plan update documented in the client's record was completed on 7/20/16.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director met with the clinical staff on August 3, 2017 to review the policy/requirement requiring that the Master Treatment Plan is updated within 60 days of executing the Master Treatment Plan. Moving forward, the Facility Director will ensure that at least 5 random chart reviews per therapist are conducted each month to ensure compliance of this requirement. Additional training will be conducted by the Facility Director if necessary, pending the results of the chart reviews. |
709.93(a) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Six client records were reviewed on July 24, 2017. The facility failed to document a complete client record for client records # 4 and 5.
Client # 4 was admitted into treatment on 5/12/16 and was discharged on 2/20/17. A discharge summary was not documented in the client's record.
Client # 5 was admitted into treatment on 2/12/16 and was discharged on 10/12/16. A discharge summary was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director met with clinical staff on 8/1/17 to review the policy/regulation/procedures for completion of client records when discharging a client, particularly completion of the discharge summary. Moving forward, the Facility Director will ensure that all discharged charts are reviewed for accuracy and completion of paperwork requirements prior to processing for storage in order to ensure compliance of this requirement. Additional training will be conducted if necessary, pending the results of the chart reviews.
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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
Personnel records were reviewed for the completion of CPR certification training on July 20, 2017. The facility failed to ensure that at least one person certified in CPR skills was onsite during all hours of the facility's operation.
The facility's hours of operation are Monday - Thursday, 8 am - 8 pm, and Friday, 8 am - 5 pm. The facility failed to provide documention that verified that at least one CPR certified staff person was onsite for the following hours of operation:
- Monday 5 pm - 8 pm
- Tuesday 5 pm - 8 pm
- Wednesday 4:30 pm - 8 pm
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
It is the responsibility of the Facility Director to ensure that adequate CPR coverage is available during hours of operation. CPR certification will be offered to additional staff by September 8, 2017 to close the gap in coverage. Moving forward, the Facility Director will monitor the schedules of CPR trained staff and the hours of operation to ensure adequate coverage. More staff will receive training as soon as possible if a gap in coverage occurs.
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