INITIAL COMMENTS
|
This report is a result of an on-site licensure inspection conducted on July 22-23, 2019, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. 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.
|
Plan of Correction
|
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
|
Observations
During the inspection conducted on July 23, 2019, the facility was unable to provide an annual audit for the 2018 fiscal year that was completed by an independent certified public accountant.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program director will ensure that the 2019 financial audit shall be completed by an independent CPA no later than 5/1/2020. Program Director is responsible for agency-wide Annual Financial Audits for tax purposes. Program Director will add the SUD program into this financial Audit. Project Director and Clinical Supervisor will add this to the end of the calendar year tasks to ensure that it is completed. Project Director will add this to her weekly meeting agenda with the Program Director in December of each calendar year. Clinical Supervisor's monthly reports will address this area of concern to insure it is prepared for the next DDAP Audit. |
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
The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one of seven client records reviewed on July 22 - 23, 2019.
Client record #2 included a letter sent to probation on April 22, 2019, however there was no release of information form for probation in the client record at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 9/6/19, the SUD Clinician's attended the 6 hour SUD P3 (that is: policy, procedure, paperwork) training to review the revised/updated SUD policy, procedures, and paperwork. These policies, procedures and paperwork are regularly referenced/reviewed in weekly group supervision; as well as in individual supervision conducted by the SUD Supervisors. Fully executed valid signed consents are a regular and ongoing topic in group and individual supervision. The assigned clinician to this client chart received weekly individual supervision and was required to attend a confidentiality training. Due to continuous record keeping error, this person is no longer employed with this agency. Continued compliance will be monitored through regular random chart audits by SUD Supervisors and reviewed in individual supervision as needed. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one of seven client records reviewed on July 22 - 23, 2019.
Client record #2 contained a release of information form to an insurance company that was signed by the client on April 4, 2019. The release form did not state the specific information that was disclosed to the insurance company.
|
Plan of Correction
On 9/6/19, the SUD Clinician's attended the 6 hour SUD P3 (that is: policy, procedure, paperwork) training to review the revised/updated SUD policy, procedures, and paperwork. These policies, procedures and paperwork are regularly referenced and reviewed in weekly group supervision; as well as in individual supervision conducted by SUD Supervisors. Fully executed valid signed consents are a regular and ongoing topic. The assigned clinician to this client chart received weekly individual supervision and was required to attend a confidentiality training. Due to continuous record keeping error, this person is no longer employed with this agency. Continued compliance will be monitored through regular random chart audits by SUD Supervisors and reviewed in individual supervision as needed. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
|
Observations
In seven out of seven client records reviewed, the facility's client rights policy failed to include documentation of all the required client rights, including, "Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record."
These findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The Client Rights form was revised on 11/11/19 by the Project Director and Clinical Supervisor to include the following: "Clients have the right to inspect their own records. The Program, Project or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record." This revised Client Rights form was reviewed with each Lancaster Clinician in group supervision and/or individual supervision on 11/13/19 conducted by the clinical supervisor. This was updated by the Clinical Supervisor and submitted to the Project Director for approval. Each Lancaster clinician signed the policy and procedure form stating that this information was reviewed in Group Supervision. This document will be utilized effective the date of introduction. Per TWP SUD Policy and Procedures Manual, SUD Supervisors are responsible for developing and annually updating the manual delineating policies and procedures. SUD Supervisors will circulate new or updated policies and procedures to all employees and contracted providers.
|
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
|
Observations
In seven out of seven client records reviewed, the facility's client rights policy failed to include documentation of all the required client rights, including, "Clients have the right to appeal a decision limiting access to their records to the director."
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Client Rights form was revised on 11/11/19 by the Project Director and Clinical Supervisor to include the following: "Clients have the right to appeal a decision limiting access to their records to the director." This revised Client Rights form was reviewed with each Lancaster Clinician in group supervision and/or individual supervision on 11/13/19 conducted by the Clinical Supervisor. This was updated by the Clinical Supervisor and submitted to the Project Director for approval. Each Lancaster clinician signed the policy and procedure form stating that this information was reviewed in Group Supervision. This document will be utilized effective the date of introduction. Per TWP SUD Policy and Procedures Manual, SUD Supervisors are responsible for developing and annually updating the manual delineating policies and procedures. SUD Supervisors will circulate new or updated policies and procedures to all employees and contracted providers. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
|
Observations
In seven out of seven client records reviewed, the facility's client rights policy failed to include documentation of all the required client rights, including, "Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records."
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Client Rights form was revised on 11/11/19 by the Project Director and Clinical Supervisor to include the following: "Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Client Rights form was reviewed with each Lancaster Clinician in group supervision and/or individual supervision on 11/13/19 conducted by the Clinical Supervisor. This was updated by the Clinical Supervisor and submitted to the Project Director for approval. Each Lancaster clinician signed the policy and procedure form stating that this information was reviewed in Group Supervision. This document will be utilized effective the date of introduction. Per TWP SUD Policy and Procedures Manual, SUD Supervisors are responsible for developing and annually updating the manual delineating policies and procedures. SUD Supervisors will circulate new or updated policies and procedures to all employees and contracted providers. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
|
Observations
In seven out of seven client records reviewed, the facility's client rights policy failed to include documentation of all the required client rights, including, "Clients have the right to submit rebuttal data or memoranda to their own records."
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Client Rights form was revised on 11/11/19 by the Project Director and Clinical Supervisor to include the following:"Clients have the right to submit rebuttal data or memoranda to their own records." This revised Client Rights form was reviewed with each Lancaster Clinician in group supervision and/or individual supervision on 11/13/19 with the Clinical Supervisor. This was updated by the Clinical Supervisor and submitted to the Project Director for approval. Each Lancaster clinician signed the policy and procedure form stating that this information was reviewed in Group Supervision. This document will be utilized effective the date of introduction. Per TWP SUD Policy and Procedures Manual, SUD Supervisors are responsible for developing and annually updating the manual delineating policies and procedures. SUD Supervisors will circulate new or updated policies and procedures to all employees and contracted providers.
|
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.
|
Observations
On July 22-23, 2019, a review of the facility ' s active and discharged client records was conducted. The facility was unable to provide a complete list of all discharged clients with their admission and discharge dates.
|
Plan of Correction
Immediately following the DDAP Licensing initial inspection of 7/23/19, the Project Director and Clinical Supervisor required each SUD clinician to update a client list which was placed in a centralized location. These lists have a number of columns to provide needed checks and balances. Moreover, these client lists are reviewed in individual supervision with Clinical Supervisor and Project Director and on a random basis to ensure that they are updated in a timely manner. In January of 2020, TWP will begin to roll out Electronic Health Records that limit the potential of human error in this criteria. SUD Supervisors are responsible for the organization, and maintenance for the SUD programming in TWP Electronic Health Records.
|
709.34 (a) (2) 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:
(2) Selling or use of illicit drugs on the premises.
|
Observations
On July 22-23, 2019, a review of the facility ' s policy and procedures manual was conducted. The facility failed to address the regulation in its entirety. The policy and procedures did not address selling or use of illicit drugs on the premises.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Following the initial DDAP site visit of 7/23/19, the Project Director and Clinical Supervisor located a copy of the 709.34 P&P that had been developed; yet had not been made available to staff. On 11/18/19, this document was updated by the Clinical Supervisor and approved by the Project Director to include each funding source reporting requirements. The 709.34 Unusual Incident policy was reviewed with the Lancaster staff at the 11/20/19 group supervision with the Clinical Supervisor. This document will become a permanent part of the SUD policy and procedures. The group will sign on the updated policy and procedure page which will serve as documented evidence of the review and activation of this policy; which addresses: "selling or use of illicit drugs on the premises." Per TWP SUD Policy and Procedures Manual, SUD Supervisors are responsible for developing and annually updating the manual delineating policies and procedures. SUD Supervisors will circulate new or updated policies and procedures to all employees and contracted providers. |
709.34 (a) (5) 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:
(5) Theft, burglary, break-in or similar incident at the facility.
|
Observations
On July 22-23, 2019, a review of the facility ' s policy and procedures manual was conducted. The facility failed to address the regulation in its entirety. The policy and procedures did not address theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Following the initial DDAP site visit of 7/23/19, the Project Director and Clinical Supervisor located a copy of the 709.34 P&P that had been developed; yet had not been made available to staff. On 11/18/19, this document was updated by the Clinical Supervisor and approved by the Project Director to include each funding source reporting requirements. The 709.34 Unusual Incident policy was reviewed with the Lancaster staff at the 11/20/19 group supervision conducted by the Clinical Supervisor. This document will become a permanent part of the SUD policy and procedures. The group will sign on the updated policy and procedure page which will serve as documented evidence of the review and activation of this policy; which addresses: " Theft, burglary, break-in or similar incident at the Project." Per TWP SUD Policy and Procedures Manual, SUD Supervisors are responsible for developing and annually updating the manual delineating policies and procedures. SUD Supervisors will circulate new or updated policies and procedures to all employees and contracted providers. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
|
Observations
On July 22-23, 2019, a review of the facility ' s policy and procedures manual was conducted. The facility failed to address the regulation in its entirety. The policy and procedures did not address implementation of a timely and appropriate corrective action plan, when indicated.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Following the initial DDAP site visit of 7/23/19, the Project Director and Clinical Supervisor located a copy of the 709.34 P&P that had been developed; yet had not been made available to staff. On 11/18/19, this document was updated by the Clinical Supervisor and approved by the Project Director to include each funding source reporting requirements. The 709.34 Unusual Incident policy was reviewed with the Lancaster staff at the 11/20/19 group supervision conducted by the Clinical Supervisor. This document will become a permanent part of the SUD policy and procedures. The group will sign on the updated Policy and Procedure signature page will serve as documented evidence of the review and activation of this policy; which addresses: "Implementation of a timely and appropriate corrective actions plan, when indicated." Per TWP SUD Policy and Procedures Manual, SUD Supervisors are responsible for developing and annually updating the manual delineating policies and procedures. SUD Supervisors will circulate new or updated policies and procedures to all employees and contracted providers. |
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
On July 22-23, 2019, a review of the facility ' s policy and procedures manual was conducted. The facility failed to address the regulation in its entirety. The policy and procedures did not address the ongoing monitoring of the corrective action plan.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Following the initial DDAP site visit of 7/23/19, the Project Director and Clinical Supervisor located a copy of the 709.34 P&P that had been developed; yet had not been made available to staff. On 11/18/19, this document was updated by the Clinical Supervisor and approved by the Project director to include each funding source reporting requirements. The 709.34 Unusual Incident policy was reviewed with the Lancaster staff at the 11/20/19 group supervision conducted by the Clinical Supervisor.. This document will become a permanent part of the SUD policy and procedures. The group will sign in on the updated policy and procedure signature page which will serve as documented evidence of the review and activation of this policy; which addresses: "Ongoing monitoring of the corrective action Plan." Per TWP SUD Policy and Procedures Manual, SUD Supervisors are responsible for developing and annually updating the manual delineating policies and procedures. SUD Supervisors will circulate new or updated policies and procedures to all employees and contracted providers. |
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
The facility failed to update treatment and rehabilitation plans in two of seven client records reviewed.
Client #2 was admitted on May 21, 2018. A treatment plan update was due to be completed on June 22, 2019, but it was not completed until July 1, 2019.
Client #3 was admitted on June 24, 2018. A treatment plan update was due to be completed on June 7, 2019, but it was not completed until June 16, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 9/6/19, the SUD Clinician's attended the 6 hour SUD P3 (that is: policy, procedure, paperwork) training to review the revised/updated SUD policy, procedures, and paperwork. These policies, procedures and paperwork are regularly referenced and reviewed in weekly group supervision; as well as in individual supervision. SUD Supervisors are responsible for individuals under their direct supervision to complete work included in their respective job descriptions in a timely manner. As of this writing, our TPU policy stipulates that (at a minimum) a TPU MUST be completed within every 60 day period. Presently, the client caseload lists have a column indicating this/these due dates as means to safeguard this time period is observed. Treatment Plans and TPU's are regularly scrutinized in individual and/or group supervision by the Clinical Supervisor and Project Director. Random chart pulls are also conducted by both Clinical and Project Director for individuals under their supervision to review in scheduled individual supervisions. In January 2020, Electronic health records will be implemented to assist with prompt update of treatment plans prior to the due date. SUD Supervisors are responsible for the organization, and maintenance for the SUD programming paperwork in TWP Electronic Health Records. |