INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on 8/20/2015 and 8/21/2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Greater Philadelphia Asian Social Service Center - Asian Outpatient Counseling Service 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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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
Based on a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of four personnel records reviewed.
The findings include:
Four counselor personnel records were reviewed on 8/21/2015. The facility failed to ensure that employee # 6 met the experiential requirements for the position of counselor.
Employee # 6 was hired as a bachelor's level counselor on 1/27/2015. Employee # 6 did not meet the qualifications for the position of counselor as they did not have any documented clinical experience in a health or human service agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor Qualifications: The staff employee #6 at GPASS did not meet the qualifications as a counselor was replaced. He was a fee for service worker. He is working at another agency full time. A new experienced counselor with a Masters Degree in Psychology replaced him.
The Executive Director will oversee all new staff and credentials and keep the staff files locked in the Executive Directors room. The Executive Director will oversee all staff records until a HR staff person is hired. This will be effective as of 9/10/2015. The CEO and/or COO will oversee the Executive Director completes this assignment.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of fire extinguishers upon employment in one of six personnel records reviewed.
The findings include:
Six personnel records requiring documentation of fire extinguisher training were reviewed during the renewal inspection on 8/21/2015. The facility failed to document the completion of fire extinguisher training upon employment in personnel record # 7.
Employee # 7 was hired on 6/16/2015 as a counselor assistant. Employee # 7 completed the fire extinguisher training on 6/29/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Extinguisher Training: A new hire at GPASS will be provided fire extinguisher training within the first 7 days of hire according to the State Regulations. The Executive Director is a trained fire fighter and will be responsible for the training of staff or will designate a Fire Captain to be responsible. The Fire Captain or the Executive Director will see that this is done and two instruction sheets will be given to employee. One sheet will be signed by the employee with all the instructions on the use of a fire extinguisher, as well as where to go during a fire drill and put in the staff file. This procedure was initiated as of 8/21/15. The Executive Director will be responsible to see that this is done and placed in the staff file until a HR staff person is hired.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent that includes all of the required content required by regulation.
The findings include:
42 CFR, Part 2, Subpart C, subsection 2.31(a)(2) states that a consent under these regulations must include the name or title of the individual or the name of the organization to which the disclosure is made.
Ten client records requiring informed and voluntary consent to release information forms were reviewed on 8/20/2015 - 8/21/2015. The facility failed to document all of the required content on the informed and voluntary consent to release information forms in client records # 2, 5, 6 and 8.
Client # 2 was admitted on 3/4/2015 and was still an active client at the time of the inspection. Client # 2's informed and voluntary consent to release information form dated 3/4/2015 for the purpose of recovery support did not list the agency or person to whom the disclosure is authorized.
Client # 5 was admitted on 2/27/2015 and discharged on 6/1/2015. Client # 5's informed and voluntary consent to release information form dated 3/11/2015 for the purpose of recovery support did not list the agency or person to whom the disclosure is authorized.
Client # 6 was admitted on 1/23/2015 and discharged on 4/10/2015. Client # 6's informed and voluntary consent to release information forms both dated 1/23/2015 for the purpose of recovery support and emergency contact did not list the agency or person to whom the disclosure is authorized.
Client # 8 was admitted on 2/13/2015 and discharged on 5/18/2015. Client # 8's informed and voluntary consent to release information forms both dated 2/13/2015 for the purpose of recovery support and emergency contact did not list the agency or person to whom the disclosure is authorized.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Confidentiality: Voluntary consent forms in many individual charts did not list who the consented release of information was to go to. The individual signed the form and it was witnessed but the name of the organization and the person and title that was to receive the information was not present. As of 9/16/15 the Clinical supervisor will be responsible to check that this procedure is corrected during weekly chart audits. Client #2 consent form was corrected/updated by the clinical supervisor on 9/15/15 the client was instructed not to sign anything that was not completely filled out in the future. The clinical supervisor may designate an assistant to also review the charts. The clinical supervisor will overseeing that all the proper information is filled out and none of the forms are blank by taking random charts during the monthly chart review.
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of two client records.
The findings include:
Two client records requiring written notification to the client of the facility's decision to involuntarily terminate the client's treatment were reviewed on 8/20/2015. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the facility in client record # 1.
Client # 1 was admitted into treatment on 3/2/2015 and was involuntarily terminated from the facility on 7/8/2015. There was no documentation of written notification of the facility's decision to involuntarily terminate the client's treatment as of the on-site inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Notification of Termination: in the event that an individual is discharged from treatment for failure to comply with the rules and regulations of the treatment center a letter of termination will be sent to the individual in the event that the individual did not sign a termination slip at the program. This will be in effect 9/16/15. The Clinical Supervisor will assign a staff person to oversee the discharge was handled properly and the Clinical Supervisor will be responsible to oversee the staff assigned to the task is doing the job properly when he is doing weekly chart checks. A letter was sent out to client #1 about treatment termination on 9/16/15 and a copy placed in the chart.
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715.6(a)(1)(i)-(iii) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program
(1) A medical director shall be a physician and shall have obtained one of the following:
(i) Three years documented experience in the provision of services to persons who are addicted to alcohol or other drugs, including at least 1 year of experience in the treatment of narcotic addiction with a narcotic drug.
(ii) Certification in addiction medicine by the American Society of Addiction Medicine.
(iii) A certificate of added qualifications in addiction psychiatry by the American Board of Psychiatry and Neurology, Inc.
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Observations
Based on a review of personnel records, the facility failed to ensure that the medical director met the qualifications for the position in one of one personnel record reviewed.
The findings include:
The personnel record for the medical director was reviewed on 8/21/2015. The facility failed to provide documentation that employee # 9, the medical director, met one of the three experiential requirements for the position.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Physician staffing: GPASS has a waiver from the State to be able to provide Suboxone medication to individuals at GPASS. The Executive Director Requested that the State rescinds the Suboxone waver as it was never initiated at GPASS. The Executive Director of GPASS Spoke to a Drug & Alcohol Licensing Specialist on 8/24/15 requesting that the waver be rescinded. We are sending any individuals that are requesting the use of Suboxone to Castor Medical Center that will provide the medication in their office. We requested that the waver be rescinded. GPASS agrees that no medication shall be dispensed at the facility.
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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
Based on a review of client records, the facility failed to document a treatment plan update at least every 60 days in three of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on 8/20/2015 - 8/21/2015. The facility failed to document a treatment plan update at least every 60 days in client records # 2, 5 and 8.
Client # 2 was admitted on 3/4/2015 and was still an active client at the time of the inspection. The client's last treatment plan was completed on 6/19/2015.
Client # 5 was admitted on 2/27/2015 and discharged on 6/1/2015. The client's last treatment plan was completed on 3/30/2015.
Client # 8 was admitted on 2/13/2015 and discharged on 5/18/2015. The client's last treatment plan was completed on 3/16/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will appoint a staff person to randomly review on a weekly basis active charts for an updated Treatment/Recovery plan. If an individual stops coming to treatment for 30 days they will be discharged on the 31 day and a notice of the discharge will be mailed to the individual's residence listed in their file. This will take effect on 9/16/15 and will be overseen by a designee and/or the Clinical Supervisor during random weekly chart checks.
Client #2 had a revised Treatment / Recovery plan done and it's noted that it was a late entry.
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709.17(a)(1) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
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Observations
Based on a review of administrative documentation, the facility failed to comply with the directive issued by the Department requiring the facility to develop and implement policies and procedures for the reporting of unusual incidents.
The findings include:
As per the directive within Chapter 709 Subchapter C enacted on 10/18/2014, the facility was required to develop and implement policies and procedures for the reporting of unusual incidents. The facility's administrative records were reviewed for documentation of policies and procedures for the reporting of unusual incidents on 8/21/2015. As of the date of the inspection, the facility has not developed policies and procedures for the reporting of unusual incidents to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Revocation of license: A policy and procedure for the implementation of reporting of unusual incidents. GPASS has a policy and procedure for reporting unusual incidents for CBH and DBH but did not list the State as required by the deputy director. This was an oversight in listing all agencies. A policy was written on 8/21/15 and approved by the board of directors. A copy of the Licensing Alert from the Deputy Secretary for Quality Assurance was also added to the policy and procedure manual along with a copy of the incident report form provided by the State. The Executive Director will oversee the clinical director maintains compliance of the requirements for reporting incidents. A staff meeting will be held on 9/11/15 with the Clinical Supervisor and the policy and form will be reviewed by the clinical team.
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