INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 28, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, GPASS- Asian Outpatient Counseling Service was found to be not 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
On September 28, 2016 ten personnel records were reviewed. Four personnel records were required to have documentation of their qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel records #7 and 8.
Employee # 7 was hired as a counselor on August 8, 2016. Employee #7 has an Associates Degree in Applied Science which is not a qualifying degree.
Employee # 8 was hired as a counselor on June 13, 2016. Employee #8 has an Bachelors Degree in Art Education which is not a qualifying degree.
These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
9/6/16: HR Director and Clinical Supervisor met with Employee #7 to educate her on standards 704.4 and 704.12
Employee #7 was notified her of the change in employment status to satisfy the standard requirements. At the time of the meeting with employee #7 a new job description and training plan was signed. Employee #7 was also informed of the new supervision schedule with immediate supervisor to reflect the changes.
9/6/16: HR Director and Clinical Supervisor met with Employee #8 to educate her on standards 704.4 and 704.12
Employee #8 was notified her of the change in employment status to satisfy the standard requirements. At the time of the meeting with employee #8 a new job description and training plan was signed. Employee #8 was also informed of the new supervision schedule with immediate supervisor to reflect the changes.
Program Director will be responsible for monitoring the supervision and training requirements of all Assistant Counselors to ensure that all requirements are met.
To ensure this deficiency does not occur again, prior to scheduling interviews for clinical employment at GPASS the HR Director will refer to Chapter 704. Staffing Requirements to verify that the prospective candidate meets qualification for clinical positions at GPASS.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report, a review of staff records and a conversation with the project director, the facility failed to ensure that staff person #10 received the required trainings.
Employee #10, a counselor assistant, was hired on June 16, 2015 and was required to obtain 6 hours of HIV/Aids training and 4 hours of TB/STD training by June 16, 2016. These trainings were not documented as of the date of the inspection..
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Employee #10: 704.11 (c) 6hr HIV/AIDS scheduled for November 14, 2016. Training will be facilitated internally.
10/18/16: Facility Director added an addendum to P&P Manual (Policy #2000-Orientation and Training) to include an outline of the 6 hour training curriculum to meet all 704.11 requirements.
Training for Communicable Disease HIV/AIDS (6Hrs) was added to the training schedule for 11/14/16 and 5/29/16.
To prevent this deficiency in the future Communicable Disease HIV/AIDS (6hrs) training will be added to GPASS Annual Training Schedule ongoing annually.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on September 28, 2016 the facility failed to keep the facility free of hazards.
The threshold leading from the second floor, rear group room had been damaged and a repair was attempted that left exposed nails protruding through the wood facing toward the room which presented a tripping and injury hazard.
This information was reviewed with the facilty staff during the licensing inspection.
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Plan of Correction
The area identified as a hazard was corrected on 9/29/16 by facility maintenance. The area was measured for fitting and a metal threshold was purchased and installed to ensure safety and free from hazard 705.2. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential 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 September 28, 2016 the facility failed to ensure privacy of counseling sessions.
The counseling office on the first floor, in the middle hall, near the exit door had a window which allowed unobstructed visual access from the hallway into the room.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 9/29/16 deficiency was corrected by facility maintenance to meet standard 709.28. The window was painted to prevent unobstructed visual access into the office. |
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 on September 28, 2016, the facility failed to document an informed and voluntary consent in the following client records.
Client #5 was admitted on 7/6/2016 and was still an active client at the time of the inspection. On a consent form dated 7/6/16 the facility failed to document the specific information to be released, the purpose for the information to be released, or agency/person to whom the information was to be released.
Client #8 was admitted on 11/2/15 and was discharged on 2/23/16. On a consent form dated 11/2/15 the facility failed to document the client name, the agency/person to whom the information was to be released or the date of the client's signature.
This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
On 10/4/16 all clinical staff was trained (in-service) by Clinical Supervisor on release of information packets and proper completion of consents.
To ensure that this deficiency does not occur again as of 10/17/16 counselors are required to bring two clinical charts to scheduled supervision for clinical audit as a part of supervision. Supervisors will audit all clinical forms for in search of proper completion and compliance of all clinical forms in the charts. In addition, quarterly the Program Director and Clinical Supervisor will randomly select clinical charts to audit for on-going compliance. |