INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 20-21, 2017 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:
|
Plan of Correction
|
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.
|
Observations
Nine client records were reviewed on July 20-21, 2017. The facility failed to obtained a valid consent to release form in client record, #1.
Client #1 was admitted into treatment on 11/10/16 and was still active in treatment. A consent to release to the client ' s funding source, dated 11/30/16 exceeded 4 PA Code 255.5 (b) by allowing the facility to release the following information: psychiatric evaluation, medication regime, psychosocial history, and discharge summary. Additionally, the facility failed to obtained a consent to release for the client ' s health insurance company, which is another funding source for the client.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Facility Director met with clinical staff on 8-2-17 to review 709.28(c) Confidentiality regulation/policy. The Facility Director reviewed the agency's Release of Information form and how to complete it properly for each type of entity e.g. funding sources, insurance companies, case managers, attorneys. The requirement to complete a new Consent to Release if a funding source changes or is added was also emphasized. Moving forward, the Facility Director will ensure that at least 5 random chart reviews per therapist are conducted by the Facility Director or Clinical Supervisor each month to ensure compliance. Additional training will be conducted by the Facility Director if necessary, pending the results of the chart reviews. |
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.
|
Observations
A licensing renewal inspection was conducted on July 20-21, 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.
|
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. |
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.
|
Observations
A licensing renewal inspection was conducted on July 20-21, 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.
|
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. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
|
Observations
Two client records were reviewed for the Buprenorphine activity on July 20-21, 2017. For client records # 1 and 2, the facility failed to document that the female patient had been fully informed of the possible risk to an unborn child from continued use of illicit drugs and from use of, or withdrawal from, a narcotic drug administered in treatment.
Client # 1, a female patient, was admitted into treatment on 11/10/16 and was still active in treatment. The client received an initial prescription for Buprenorphine on 2/22/17.
Client # 2, a female patient, was admitted into treatment on 2/23/17 and was still active in treatment. The client received an initial prescription for Buprenorphine on 3/29/17.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Medical Director will update the Buprenorphine intake paperwork packet to include full written disclosure of the possible risk to the unborn child from continued use of illicit drugs and from use of or withdrawal from Buprenorphine prescribed by our medical department for Suboxone maintenance treatment. The packet will be updated by September 5, 2017. Moving forward, at the Buprenorphine intake appointment, the nursing supervisor will ensure that the required client sign-off is completed as well as verbal communication by the nursing staff of these risks. The prescribing psychiatrist will also verbally inform the client of such risks at the Buprenorphine intake appointment. The Medical Director is ultimately responsible to ensure that compliance with this standard is maintained. |
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.
|
Observations
Nine client records were reviewed on July 20-21, 2017. The facility failed to document a treatment plan update at least every 60 days for client records # 1, 2, 6, and 7.
Client # 1 was admitted into treatment on 11/10/16 and was still active in treatment. The last treatment plan update documented in the client's record was completed on 5/11/17.
Client # 2 was admitted into treatment on 2/23/17 and was still active in treatment. A comprehensive treatment plan was completed for the client on 3/13/17. The first treatment plan update documented in the client's record was dated for 5/12/17. However, the signatures documented on the treatment plan indicated that the treatment plan was signed by the counselor and medical director on 3/12/17. The treatment plan was then signed by the client on 3/18/17. The next treatment plan update documented in the client's record was completed on 7/13/17.
Client # 6 was admitted into treatment on 10/27/16 and was discharged on 2/21/17. A comprehensive treatment plan was completed for the client on 11/2/16. A subsequent treatment plan update was due to be completed for the client by 1/2/17, and one was not documented in the client's record.
Client # 7 was admitted into treatment on 2/21/17 and was discharged on 7/12/17. A comprehensive treatment plan was completed for the client on 4/12/17. A subsequent treatment plan update was due to be completed for the client by 6/12/17, and one was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Facility Director met with the clinical staff on August 2, 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. |